Beacon International
Detail
Evidence of Insurance Effective Date —Insurance hereunder is effective on the later of:
The moment the Scheme Administrator receives the Application and correct Premium if Application and payment is made online or by facsimile; or
11:59pm US Eastern Standard Time on the date the Scheme Administrator receives the Application and correct Premium if Application and payment is made by mail; or
The moment the Participating Member departs from his/her Home Country; or
11:59pm US Eastern Standard Time on the date requested on the Application; and
Evidence of Insurance Termination Date — Insurance hereunder terminates on the earlier of:
11:59pm US Eastern Standard Time on the last day of the period for which Premium has been paid; or
11:59pm US Eastern Standard Time on the date requested on the Application; or
The moment of the Participating Member’s arrival upon return to his/her Home Country (unless the Participating Member has started a Benefit Period or is eligible for Home Country Coverage or Visits).
Termination of Coverage for Participating Member — Coverage and Benefits for the Participating Member under this insurance will terminate effective at 11:59 PM, EST, on the earliest of the following dates:
The next day following the end of the period for which Premium has been fully and timely paid; or
The termination date as shown on the Proof of Insurance Coverage Page or Evidence of Insurance; or
The date the Master Policy is terminated; or
The date the Participating Member first fails to meet or no longer meets the eligibility requirements for this insurance as set forth in the Master Policy and outlined in the Evidence of Insurance; or
The date the Scheme Administrator and/or Underwriters, at its sole option, elects to cancel from the Beacon/Axis Series Group Insurance Plan (sometimes referred to herein as "this insurance plan" or "the plan") all Participating Members of the same sex, age, class or geographic location as the Participating Member, provided the Scheme Administrator gives no less than thirty (30) days advance written notice by mail to the Participating Member's last known place of residence or mail - forwarding address of its intent to exercise such option with or in conjunction and the express written consent of Underwriters; or
The cancellation date specified by the Scheme Administrator and/or Underwriters pursuant to Section 15.1, above; or
The cancellation date specified by the Participating Member, or upon return to Home Country; or
The date specified by the Scheme Administrator and/or Underwriters in any notice of cancellation, forfeiture or rescission issued pursuant to or as a result of the circumstances described in Sections 7, 12, 15 and above, or Section 16 below, or as otherwise permitted by the Terms of this insurance. Coverage for the Participating Member shall remain in full force and effect unless terminated pursuant to the provisions of this section, except as otherwise provided in the Master Policy or the Evidence of Insurance.
TERMINATION OF MASTER POLICY —The Master Policy can be terminated at any time by Underwriters or the Master Policyholder by giving at least thirty (30) days written notice to the other, thus providing the same such notice to the Scheme Administrator and to the Participating Member. Such termination will have no effect on the Evidence of Insurance prior to the date of the termination, or on eligible coverage or
benefits under this insurance accrued prior thereto. No Evidence of Insurance will be issued, or Extensions accepted after the date the Master Policy is terminated.
POLICY DEFINITIONS — Certain words and phrases used in the Master Policy and the Evidence(s) of Insurance issued by the Master Policy are defined below. Other words and phrases may be defined elsewhere in the Master Policy or Evidence(s) of Insurance issued by the Master Policy, which would include where they are first used.
Accident: A sudden, unintentional and Unexpected occurrence caused by external, visible means and resulting in physical Injury to the Participating Member.
Act of Terrorism: An act, which would include, but is not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes, which would include the intention to influence any government and/or to put the public, or any section of the public, in fear.
Acute Onset of a Pre-existing Condition: An Unexpected outbreak or recurrence of a Pre-existing Condition, that occurs Unexpectedly and without advance warning, either in the form of Physician recommendation or symptoms that have caused a prudent person to seek medical attention prior to the outbreak or recurrence. Treatment must be obtained within twenty-four (24) hours of the sudden and Unexpected occurrence of pain.
AIDS: Acquired Immune Deficiency Syndrome, as the term is defined by the United States Centers for Disease Control and Prevention.
Amateur Athletics: An amateur or other non-professional sporting, recreational or athletic activity that is organized, sponsored and/or sanctioned, and/or involves regular or scheduled practices, games and/or competitions. This definition does not include athletic activities that are non-contact and engaged in by the Participating Member solely for recreational, entertainment or fitness purposes.
Application: The fully answered and signed individual or Family Application/Enrollment form submitted by or on behalf of the Participating Member for acceptance into, Extension of coverage under or reinstatement in this insurance plan, which, by this reference, shall be incorporated in and become a part of the Master Policy and/or Evidence of Insurance. Any insurance agent/broker assigned to or assisting with the Application is the representative of the applicant/Participating Member and is not an agent or representative for or on behalf of the Scheme Administrator, Underwriters, and/or the Master Policyholder.
ARC Syndrome: AIDS related complex, as that term defined by the United States Centers for Disease Control and Prevention.
Beneficiary: The person(s), executers, or administrators entitled to receive payment of benefits.
Coinsurance: The payment by or obligations of the Participating Member for payment of Eligible Medical Expenses at the percentage specified in the Schedule of Benefits/Limits contained herein and exclusive of the Deductible.
Coronavirus Disease 2019 (COVID-19): An infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[6] The disease was first identified in December 2019 in Wuhan, the capital of China's Hubei province, and has since spread globally, resulting in the ongoing 2019–20 coronavirus pandemic. Common symptoms include fever, cough, and shortness of breath. Other symptoms may include muscle pain, sputum production, diarrhea, sore throat, loss of smell, and abdominal pain. While the majority of cases result in mild symptoms, some progress to viral pneumonia and multi-organ failure.
Coverage Period: The period beginning on the Effective Date of Coverage of the Evidence of Insurance and ending on the earliest of the following dates: (i) the termination date specified in the Proof of Insurance Coverage Page, or (ii) the termination date as determined in accordance with Section 15 above. The Coverage Period of Insurance can be no less than five (5) days and no more than three-hundred-sixty-four(364) days.
Covered Transplant: A transplant involving the heart, heart/lung, lung, kidney, kidney/pancreas, liver, and allogenic or autologous bone marrow.
Custodial Care: Those types of care or services, wherever furnished and by whatever name called, that are designed primarily to assist an individual.
Death: Complete and irreversible cessation of life.
Deductible: The dollar amount of Eligible Medical Expenses specified on the Proof of Insurance of Coverage Page, that the Participating Member must pay per Period of Insurance prior to receiving benefits under this insurance, and exclusive of Coinsurance.
Dental Treatment: Treatment or supplies relating to the care, maintenance, or repair of teeth, gums, or bones supporting the teeth, which would include dentures and preparation for dentures.
Dependent Child; Children: A Participating Member who is less than eighteen (18) years of age at the time of Application and shares the Participating Members home for at least half the year (if divorced, the Dependent Child may live with former Spouse); and must not provide more than one-half of his/her own support (scholarships excluded); or must be less than twenty-six (26) years of age at the time of Application, and a full-time student and claim the Participating Members residence as his/her official residence while away at school; and must not provide more than one-half of his/her own support (scholarships excluded); and must be the Participating Members biological, step or legally adopted Child.
Disabled: A person who has a congenital or acquired mental or physical defect that interferes with normal functioning of the body, system or the ability to be self-sufficient.
Durable Medical Equipment (DME): Consists of a standard basic Hospital bed and/or a standard basic wheelchair.
Educational Care: Care for restoration (by education or training) of a person's ability to function in a normal or near-normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy, and speech therapy.
Effective Date of Coverage: The date the Participating Member initially obtains coverage under the Beacon/Axis Series family of Insurance plans and maintains continuous unbroken coverage thereafter; this date is indicated on the Proof of Insurance Coverage Page provided after the Application for insurance.
Eligible Medical Expenses: Expenses for Injuries, Illnesses and cost incurred by a Participating Member in which all Terms, Conditions and Limits of the Evidence of Insurance have been met in full. Eligible Medical Expenses will not be determined until the Scheme Administrator has received and reviewed the Complete Proof of Claim. Eligible Medical Expenses are subject the Limits, Deductibles and Coinsurance set forth on the Participating Members Proof of Insurance Coverage Page, Schedule of Benefits and Evidence of Insurance.
Emergency: A medical condition manifesting itself by acute signs or symptoms that could reasonably result in placing the Participating Member's life or limb(s) in danger if medical attention is not provided within twenty-four (24) hours.
Epidemic: An outbreak of disease that spreads quickly and affects many individuals at the same time.
EST: US Eastern Standard Time.
Evidence of Insurance (EOI): The document issued by the Master Policyholder to the Participating Member, which describes and provides an outline and evidence of eligible coverages and benefits payable to or for
the benefit of the Participating Member under the Master Policy, and which includes the Participating Member's Application and any Riders attached thereto.
Expenses Incurred: Expenses rendered by a Participating Member that have or may not yet have been paid by the responsible parties.
Experimental: Any Treatment that includes completely new, untested drugs, procedures or services, or the use of which is for a purpose other than the use for which they have previously been approved; new drug procedure or service combinations; and alternative therapies that are not generally accepted standards of current medical practice.
Extended Care Facility: An institution, or a distinct part of an institution, that is licensed as a Hospital, Extended Care Facility or Rehabilitation Care facility by the state or country in which it operates; is regularly engaged in providing twenty-four (24) hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; maintains a daily record on each patient; provides each patient with a planned program of observation prescribed by a Physician; provides each patient with active Treatment of an Illness or Injury. Extended Care Facility does not include a facility primarily for rest, the aged, Substance Abuse, Custodial Care, nursing care, or for care of Mental or Nervous Disorders or the mentally incompetent.
Extension of Coverage: When a Participating Member continues coverage under the Beacon/Axis Series Group Insurance Plan beyond the Coverage Period indicated on the Proof of Insurance Coverage Page received at the initial purchase of Participating Members Insurance Policy. At the end of each Coverage Period, a Participating Member is generally invited to continue his/her coverage.
Family: A Participating Member and his/her Spouse (see definition of Spouse) who is covered as a Participating Member under this insurance plan and his/her Dependent Child(ren) (see definition of Dependent Child; Children) who are under the age of eighteen (18) and covered as Participating Members under this insurance plan.
HIV Positive: Laboratory evidence defined by the United States Centers for Disease Control and Prevention as being positive for Human Immunodeficiency Virus infection.
Home Country: The country of which the Participating Member is a citizen, national or maintains his/her residence or usual place of abode; or the country of which the Participating Member is the possessor of a validly issued passport. US citizens will have the US as their Home Country regardless of where they are. Home Health Care Agency: A public or private agency or one of its subdivisions, which operates pursuant to law; and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation and Treatment prescribed by a Physician.
Home Nursing Care: Services, provided by a Home Health Care Agency and supervised by a Registered Nurse, that are directed toward the personal care of a patient, provided always that such care is in lieu of Medically Necessary Inpatient care.
Hospice: An institution that operates as a Hospice; is licensed by the state or country in which it operates; and operates primarily for the reception, care and palliative control of pain for terminally ill persons who have, as certified by a Physician, a life expectancy of not more than one-hundred-eighty (180) days.
Hospital: An institution that operates as a Hospital pursuant to law; is licensed by the state or country in which it operates; operates primarily for the reception, care, and Treatment of sick or injured persons as Inpatients; provides twenty-four(24)hour nursing service by Registered Nurses on duty or call; has a staff of one or more Physicians available at all times; provides organized facilities and equipment for diagnosis and Treatment of acute medical, surgical or mental/nervous conditions on its premises; and is not primarily a long-term care facility, Extended Care Facility, Nursing, rest, Custodial Care, or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.
Hospitalization or Hospitalized: Confined and/or treated in a Hospital as an Inpatient.
Illness: A sickness, disorder, Illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. Illness does not include learning disabilities, or attitudinal or disciplinary problems.
Infectious or Contagious Disease: Any disease capable of being transmitted from an infected person, animal or species to another person, animal, or species by any means.
Injury: Unexpected and unforeseen harm to the body caused by an accident that requires medical treatment.
Inpatient: A person who is an overnight resident patient of a Hospital, using and being charged for room and board.
Intensive Care Unit: A Cardiac Care Unit or other unit or area of a Hospital that meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations for Special Care Units.
Investigational: Treatment that includes drugs, procedures or services that are still in the clinical stages of evaluation and not yet released for distribution by the US Food and Drug Administration.
Loss of Limb: Definite diagnosis of the complete severance of one or more limbs at or above the wrist or ankle joint as the result of an accident.
Loss of Sight: Loss means; entire and irrecoverable Loss of Sight in one or both eyes as the result of an accident.
Master Policyholder: The Beacon/Axis Series Group Insurance Trust (Anguilla).
Maximum Limit: The cumulative total dollar amount of benefit payments and/or reimbursements available to a Participating Member under this insurance during the Participating Member’s period of coverage. When the Maximum Limit is reached, no further benefits, reimbursements or payments will be available under this insurance.
Medically Necessary; Medical Necessity: A Treatment or supply that is necessary and appropriate for the diagnosis or Treatment of an Illness or Injury based on generally accepted standards of current medical practice as determined by the Scheme Administrator. By way of example but not limitation, a Treatment or supply will not be considered Medically Necessary or a Medical Necessity if it is provided or obtained only as a convenience to the Participating Member or his/her provider; and/or if it is not necessary or appropriate for the Participating Member's Treatment, diagnosis or symptoms; and/or if it exceeds (in scope, duration or intensity) that level of care that is needed to provide safe, adequate, and appropriate diagnosis or Treatment.
Medical Research: Research conducted to aid and support the body of knowledge in the field of medicine. Medical research can be divided into two general categories: the evaluation of new treatments for both safety and efficacy in what are termed clinical trials, and all other research that contributes to the development of new treatments. The latter is termed pre-clinical research if its goal is specifically to elaborate knowledge for the development of new therapeutic strategies.
Mental or Nervous Disorders: A mental, nervous or emotional Illness that generally denotes an Illness of the brain with predominant behavioral symptoms; or an Illness of the mind or personality, evidenced by abnormal behavior; or an Illness or disorder of conduct evidenced by socially deviant behavior. Mental or Nervous Disorders include, without limitation, psychosis; depression; schizophrenia; bipolar affective disorder; and those psychiatric Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association. Mental or Nervous Disorder does not include learning disabilities, or attitudinal or disciplinary problems. For purposes of this insurance, Mental or Nervous Disorder does not include Substance Abuse.
Mortal Remains: The bodily remains or ashes of a Participating Member.
Newborn: An infant from the moment of birth through the first thirty-one (31) days.
Outpatient: A person who receives Medically Necessary Treatment by a Physician or other healthcare provider that does not require an overnight stay in a Hospital.
Pandemic: An outbreak of a disease that occurs over a wide geographic area and affects an exceptionally high proportion of the population.
Participating Member: The person(s) named as the Participating Member(s) on the Proof of Insurance Coverage Page.
Participating Organization: A business, society or association that has purchased medical coverage for a group of individuals.
Physician: A duly licensed practitioner of the medical arts. A Physician must be currently licensed by the state or country in which the services are provided, and the services must be within the scope of that license.
Pre-existing Condition: Any Illness, Injury or Mental or Nervous Disorder that, with reasonable medical certainty, existed on or at any time prior to the Effective Date of Coverage, whether or not previously manifested or symptomatic, diagnosed, treated or disclosed on the Application or on any Claim Form or otherwise, which would include any chronic, subsequent or recurring complications, or consequences associated therewith or arising or resulting therefrom.
Pre-notification; Pre-notify: A general determination of Medical Necessity, made in reliance and based upon the completeness and accuracy of the information provided at the time thereof. Pre-notification is not an assurance, authorization, verification of coverage, verification of benefits or guarantee of payment. See Section 24 above, for further details.
Pregnancy; Pregnant: The process of growth and development within a woman's reproductive organs of a new individual from the time of conception through the phases where the embryo grows, and the fetus develops to birth.
Premium: The Premium payments required to effectuate and maintain the Participating Member's insurance coverage and benefits under this insurance, in the amounts and at the times established by the Scheme Administrator in its sole discretion from time to time.
Principal Sum: The benefit based upon the attained age of the Participating Member and is a Sub-Limit (see Sub-Limit definition) of the policy maximum.
Professional Athletics: A sport activity, which would include practice, preparation and actual sporting events, for any individual or organized team that is a member of a recognized professional sports organization, is directly supported or sponsored by a professional team or professional sports organization, is a member of a playing league that is directly supported or sponsored by a professional team or professional sports organization; or has any athlete receiving for his/her participation, any kind of payment or compensation, directly or indirectly, from a professional team or professional sports organization.
Proof of Insurance Coverage Page: The Proof of Insurance Coverage Page is issued by the Scheme Administrator to the Participating Member contemporaneously with the Evidence of Insurance (and/or upon Extension hereof) evidencing the Participating Member's insurance coverage under the Master Policy as evidenced by the Evidence of Insurance, which Proof of Insurance Coverage Page shall be incorporated in and become a part of the Master Policy. The Proof of Insurance Coverage Page serves as a descriptive document highlighting the coverage limits, Deductible(s), coverage dates, optional Riders, and the name of Participating Member for all Evidence of Insurance issued by the Scheme Administrator on behalf of the Master Policyholder and Underwriters.
Rare Conditions/Defects: Conditions/defects which affect a small number of people compared to the general population and, because they are rare, can present challenges with regards to diagnosis, Treatment, and prevention. A condition/defect is considered to be rare when it affects 1 person in 2,000 or fewer.
Registered Nurse: A graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters "R.N." after his or her name.
Rehabilitation Care: Care for restoration (by education or training) of a person's ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy, and speech therapy.
Relative: A parent, guardian, Spouse, son, daughter, or immediate Family member of the Participating Member.
Rider: Any exhibit, schedule, attachment, amendment, endorsement or other document attached to, issued in connection with, or otherwise expressly made a part of or applicable to, the Master Policy, the Evidence of Insurance, or the Application, as the case may be.
Routine Physical Exam: Examination of the physical body by a Physician for preventative or informative purposes only, and not for the Treatment of any Illness or Injury.
Scheme Administrator: The Scheme Administrator, as referred to herein; Azimuth Risk Solutions, acts solely as the disclosed and authorized agent and representative for and on behalf of the Master Policyholder and Underwriters, and has and shall have no direct, indirect, joint, several, separate, individual, or independent liability or obligation of any kind under the Master Policy or the Evidence of Insurance to the Participating Member or to any other person or entity. Azimuth Risk Solutions is located at 8520 Allison Pointe Blvd, Suite #220, Indianapolis, Indiana 46250, USA. Telephone Number: 317-644-6291 or 888-201- 8050, Fax Number:317-423-9620 or 888-201-8851, Website:www.azimuthrisk.com, Email:
Sports Diving: Recreational underwater diving activities requiring the use of underwater or artificial breathing apparatus, and carried out in strict accordance with the guidelines, codes of good practice and recommendations for safe diving practices as laid out by an Authoritative Diving Body.
Spouse: Wife/husband or domestic partner living at the same address and sharing financial responsibilities but not including business partners or associates.
Sub-Limits: Extra limitations in an insurance policy's coverage of certain losses. They are part of the Maximum Limit (see Maximum Limit definition). That is, they do not provide extra coverage, but set a maximum to cover a specific loss. Sub-Limits may be expressed as a dollar amount or a percentage of the coverage available.
Substance Abuse: Alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency. Surgery/Surgical Procedure: An invasive diagnostic or surgical procedure; or the Treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
Terms: Terms, provisions, conditions, definitions, limits, Sub-Limits, limitations, wordings, restrictions, qualifications and/or exclusions.
Third-party Liability: Third-party liability insurance coverage is the portion of an insurance policy that covers loss to others caused by the Participating Member during the Coverage Period, whether it is personal Injury or property damage. Subject to the Terms, Conditions and Limits set for in Section 34.
Trampolining: The act of jumping, bouncing or tumbling on a trampoline for recreational, exercise or competitive purpose.
Treatment: Any and all services and procedures rendered in the management and/or care of a patient for the purpose of identifying, diagnosing, treating, curing, preventing, controlling and/or combating any Illness or Injury, which would include, without limitation, verbal or written advice, consultation, examination, discussion, diagnostic testing or evaluation of any kind, pharmacotherapy or other medication, and/or Surgery.
Unexpected: Sudden, unintentional, not expected and unforeseen.
US: The United States of America and or any of its territories.
Usual, Reasonable and Customary: The most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. The Scheme Administrator reserves the right to determine, in the reasonable exercise of its discretion, whether charges are Usual, Reasonable and Customary. In determining whether a charge is Usual, Reasonable and Customary, the Scheme Administrator may consider one or more of the following factors, without limitation: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or service as compared to the length of time required to perform other similar services; the severity or nature of the Illness or Injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; and such other factors as the Scheme Administrator, in the reasonable exercise of its discretion, determines are appropriate.
THIRD-PARTY LIABILITY ENDORSEMENT — The Scheme Administrator will pay, on behalf of the Participating Member, all sums that the Participating Member shall become legally obligated to pay as Damages for claims first made against the Participating Member and reported to Azimuth Risk Solutions during the Period of Insurance that the Third-Party Liability Insurance Coverage is in force.
Arising Out Of Any Incident Covered Under This Endorsement, Provided Always That Such Incident Occurs:
On or after the Effective Date of Coverage; and
Outside the Home Country; and
Outside the United States of America or any of its territories. The Scheme Administrator shall have the right and duty to defend any suit against the Participating Member, seeking Damages to which this insurance applies even if any of the allegations of the suit are groundless, false or fraudulent. The Scheme Administrator may make such investigation and settlement of any claim, or suit as it deems expedient. In no event shall the Scheme Administrator be obligated to pay Damages or Claim Expenses, or to defend, or continue to defend, any suit after the applicable limit of the Scheme Administrator’s liability has been exhausted by payment of Damages.
Host Family and/or Homeowner Coverage — only applies while the Participating Member is residing with a Host Family; and If an Incident results in an eligible claim under a valid and collectible homeowner’s insurance policy of the Host Family or similar insurance policy covering Property Damage to the Participating Member’s Location, the Scheme Administrator will pay the loss Incurred up to the amount of the Deductible under the Host Family’s homeowner’s insurance policy (or similar insurance policy), not to exceed $1,000 per Participating Member’s Period of Insurance. In case that the Host Family has no Homeowner insurance the Maximum benefits will be paid. The Scheme Administrator will pay the benefit pursuant to this provision only after the Participating Member has submitted to the Scheme Administrator due proof of the Property Damage amount that was incurred.
Other Insurance — If any Other Insurance is available to the Participating Member, Host Family or third-party for a covered loss under Third-Party Liability Insurance Coverage, the Scheme Administrator's obligations under this Endorsement are excess of such Insurance. In no event shall this Endorsement, apply until all Other Insurance has paid its applicable limit of insurance.
EXCLUSIONS TO THIRD PARTY LIABILITY INSURANCE — The following exclusions apply to Third-Party
Personal Injury or Property Damage Arising Out of the Ownership, Operation or Use of:
Any automobile; and
Any type of land vehicle, which would include off-road vehicles, snowmobiles, mopeds, motorbikes;
Any watercraft; and
Any aircraft or anything that flies; and
Any motorized equipment. This exclusion does not apply if Participating Member are a passenger on any of the above items; and
For Personal Injury or Property Damage Arising Out of Participating In High-Risk Sports, Which Would Include:
Hunting activities; and
Boxing or combat sports; and
Mountaineering, rock climbing or caving; and
Aerial sports, heli-skiing, or bungee jumping; and
Scuba diving, wild water rafting, jet-skiing; and
Motorized racing or speed trials; and
Professional sports; and
Contact sports which would include Field Hockey, Flag football, Football, Rugby, Soccer, Water Polo; and
Competitive sporting events of any kind.
Based on or Arising Out of Liability — by the Participating Member under any contract or agreement which would include interest penalties or debts; and arising from the transmission of Illness or communicable disease by the Participating Member or transmission of or infection by, or the testing or the failure to test for the presence of Acquired Immune Deficiency Syndrome (AIDS); any AIDS related virus or any other disease transmitted through sexual contact or another person's body fluids; and based on or arising out of an actual or attempted dishonest, fraudulent, criminal act, or malicious act or omission or deliberate misrepresentation committed by, at the direction of, or with the knowledge of any Participating Member which would include brawling or acts of violence or the initiation of confrontation; and
Related to Discrimination — by the Participating Member against others because of their race, creed, age, sex, color, sexual preference, or national origin; arising from acts by any Participating Member expected or intended to cause Personal Injury or Property Damage sustained (This exclusion does not apply to Personal Injury resulting from the use of reasonable force to protect person or Property; and
Property Damage To:
Property owned by or in the custody of the Participating Member, or
Property rented to, occupied by or on loan to the Participating Member or in the Participating Member’s care to the extent that the Participating Member is obligated by contract to provide insurance for such property;
Property of the Host Family except as provided under the Host Family Homeowner coverage; or
Property obtained through unlawful interference; or
Rented furniture, furnishings, or damage to buildings or installations of Youth centers; or
Hostels of any kind, however, liability arising from damage to rented holiday accommodation and hotel rooms shall be included; and
Sexual Abuse — Brought against any Participating Member alleging, in whole or part, sexual assault, abuse, corporal punishment, molestation, physical or mental abuse, or similar criminal behavior that was threatened, committed, or alleged to have been committed by any Participating Member; and
Alcohol or Drug Abuse — For Personal Injury or Property Damage arising from the consumption of alcohol or the misuse of intoxicants, narcotics, or addictive drugs or their derivatives as well as impairments due to such means, irrespective of whether they were directly or indirectly responsible for the damages incurred; misuse of medical preparations; mental illness, mental or emotional disorders or reactions, which would include stress, anxiety, panic attacks, depression, eating disorders, or weight problems; and
War or Acts of War — For Personal Injury or Property Damage due to war or acts of war, whether or not declared, rebellion, revolution, Act of Terrorism, hijacking of aircraft, insurrection, civil commotion, strikes, armed force of any kind, enforcement of law and Emergency services, and acts by public authorities; and
Professional Activates — For Personal Injury or Personal Injury to the Participating Member;
Brought against any Participating Member arising out of the Participating Member’s professional activities; or
Any other physical work undertaken for wage or profit; or
The Participating Member’s rendering of services when such services are for persons other than the Host Family; and
Radiation — For injuries caused directly or indirectly by nuclear reaction, radiation, contamination whether radioactive or not, regardless of how it was caused; and
For Personal Injury or Property Damage among or between Participating Member’s traveling together; and
For Personal Injury to any member of the Participating Member’s Family.
GENERAL OBLIGATIONS AND PROVISIONS FOR THE THIRD-PARTY LIABILITY BENEFIT — These provisions are in addition to the General Provisions noted above for all benefits.
Action Against The Scheme Administrator — No action shall lie against the Scheme Administrator unless, as a condition precedent thereto, there shall have been full compliance with all of the Terms of this policy, but not until the amount of the Participating Member 's obligation to pay shall have been finally determined either by judgment against the Participating Member after actual trial or by written agreement of the Participating Member , the claimant and the Scheme Administrator .
Assignment — The interest of any Participating Member is not assignable. If any Participating Member shall die or be judged incompetent, this insurance shall thereupon terminate for such person, but shall cover the Participating Member’s legal representative as the Participating Member with respect to liability previously incurred and covered by this insurance.
DEFINITIONS FOR THIRD-PARTY LIABILITY INSURANCE: A claim is a demand for money or the service of a suit naming a Participating Member and alleging an Incident. A claim does not include proceedings seeking injunctive or other non-pecuniary relief. Punitive damages will not be covered.
Claim Expenses: Fees charged by an attorney or attorneys designated by the Scheme Administrator and all other fees, costs and expenses resulting from the investigation, adjustment, defense settlement and appeal of a claim, suit or proceeding arising in connection therewith, if incurred by the Scheme Administrator , or incurred by the Participating Member with written consent of the Scheme Administrator , but does not include salary changes or expenses of regular employees or officials of the Scheme Administrator , or fees and expenses of independent adjusters; All costs against the Participating Member in such suits and all interest on the entire amount of any judgment therein which accrues after entry of the judgment and before the Scheme Administrator has paid, tendered or deposited, whether in court or otherwise, that part of the judgment that does not exceed the limit of the Scheme Administrator's liability thereon; and Premiums on appeal bonds and Premiums on bonds to release attachments in such suits, but not for bond amounts in excess of the applicable limit of liability of this Endorsement. The Scheme Administrator shall have no obligation to pay for or furnish any bond.
Damages: Compensatory judgments, settlements or awards, but does not include punitive or exemplary damages, fines or penalties, the return of fees or other consideration paid to the Participating Member, or that portion of any award or judgment caused by the trebling or multiplication of actual damages under federal or state law.
Host Family: A family consisting of at least one parent and one child under the age of eighteen (18) that invites an au pair from a foreign country for a specified period of time. The au pair lives “on equal terms” with the other members of the family and in return for food, board, and a salary, cares for children and does simple domestic work. Hosting an au pair is considered a program of cultural exchange, by no means an employment contract. Placement of the au pair shall initially be for a period not exceeding one year but may be extended to permit a maximum stay of two years.
Incident: Any act or omission committed by the Participating Member during the Period of Insurance which results in Personal Injury or Property Damage.
Participating Member Location: The residence, premises and the part of any other premises; structures and grounds used by the Participating Member other than any property owned by the Host Family.
Personal Injury: Personal Injury, Sickness (but not any communicable disease) or disease sustained by any person, which would include Death.
Property Damage: physical Injury to or destruction of tangible property, which would include the loss of use thereof at any time resulting there from
Benefit
Beacon Series Travel Medical Plan Schedule of Benefits |
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Maximum Limits |
$60,000; $110,000; $550,000; $1,100,000 or $2,000,000 (Ages 70-79 limited to $50,000; Ages 80+ limited to $12,000) |
Deductibles |
$0; $50; $100; $250; $500; $1,000; $2,500 per Participating Member, per Coverage Period |
Pre-existing Condition Look-Back |
730 days from Effective Date of Coverage |
Coinsurance - Claim incurred outside the US |
After the Deductible the Plan will pay 100% of Eligible Medical Expenses to the Maximum Limit |
Pre-notification Penalty |
50% of Eligible Medical Expenses |
Hospital Services |
|
Hospital Indemnity |
$150 Sub-Limit per night, maximum for 7 nights for Inpatient Hospitalization. Outside the US only |
Hospital Room and Board |
Average semi-private room rate, which would include nursing services |
Intensive Care Unit |
Usual, Reasonable, and Customary charges to the Maximum Limit |
Emergency Room Illness or Injury |
Usual, Reasonable, and Customary charge. Subject to additional $350 Deductible if Illness or Injury does not result in Hospitalization |
Outpatient Services |
|
Physician Visit |
Usual, Reasonable and Customary charges |
Physical Therapy |
$60 Sub-Limit per visit, 1 visit per day, Maximum of 15 visits per Coverage Period |
Prescription Drugs |
Reimbursement Only, Usual, Reasonable and Customary charges, Subject to 20% Coinsurance inside the US |
Urgent Care Services Claims in US |
$35.00 Co-pay per visit, Subject to Co-insurance. (Not subject to the Deductible) |
Other Services |
|
Acute Onset of Pre-existing Conditions |
$150,000 Sub-Limit for Maximum Limits purchased for $550,000, $1,100,000 or $2,000,000; All other Maximum Limits purchased will have a $50,000 Sub-Limit, Emergency Medical Evacuation $25,000 Sub-Limit, only available to Participating Members under the age of 70 |
Emergency Quarantine Indemnity- COVID- 19 |
Up to $50 Sub-Limit per day (maximum of 10 days). Must submit proof of quarantine mandated by a physician or governmental authority. Quarantine must be due to the Participating Member testing positive for COVID-19/Coronavirus/SARS-CoV2 or being symptomatic and waiting on a diagnostic test result. Quarantine is not available in your home country. (Not subject to Deductible or Coinsurance) |
COVID-19 / Coronavirus |
$100,000 Maximum Sub-Limit |
Ambulance – Local Land |
Usual, Reasonable and Customary charges, when covered Illness or Injury results in Hospitalization |
Complications of Pregnancy |
Up to $1,500 Maximum Sub-Limit. Up to 26 weeks of gestation. As defined in the policy |
Durable Medical Equipment |
Usual, Reasonable and Customary charges, limited to a standard Hospital bed and/or a standard basic wheelchair |
Dental - Injury as Result of Accident |
$1,000 Sub-Limit per Coverage Period, available for Policies purchased for 180 days or more |
Dental - Acute Onset of Pain |
$500 Sub-Limit per Coverage Period, available for Policies purchased for 90 days or more |
Emergency Vision Exam |
Up to $100 for an emergency eye examination for the replacement of contact lenses or eyeglasses as a result of an accident |
Emergency Medical Evacuation |
Up to Policy Maximum; benefit reduced when related to Acute Onset of Pre-existing Conditions |
Emergency Reunion |
Up to $100,000 Maximum Sub-Limit (Not subject to Deductible or Coinsurance) |
Local Burial or Cremation |
Up to $5,000 Maximum Sub-Limit (Not subject to Deductible or Coinsurance) |
Return of Mortal Remains |
$50,000 Maximum Sub-Limit (Not subject to Deductible or Coinsurance) |
Return of Minor Dependent Child(ren) |
$50,000 Maximum Sub-Limit (Not subject to Deductible or Coinsurance) |
Quick Trip Home Country Coverage |
14 days cumulative Home Country Coverage, subject to 90-day minimum purchase, As defined in the policy |
End of Trip Home Country Coverage |
15 days free with a 180-day purchase, or 30 days free with a 364-day purchase, As defined in the policy |
Lost Checked Luggage |
$500 Sub-Limit per Coverage Period, As defined in the policy (Not subject to Deductible or Coinsurance) |
Border Protection |
Up to $500 for the reimbursement of travel expenses on a valid B-2 visa with travel to the US if denied entry at the US Border (Not subject to Deductible or Coinsurance) |
Accidental Death & Dismemberment (AD&D) Participating Members age 18 and older |
Up to $30,000 Maximum Principal Sum; Death of Primary Participating Member-$30,000; Death of Spouse-$20,000; Death of Dependent Child(ren)-$6,000; Loss of 2 or more Limbs or Sight in both eyes-$30,000 ; Loss of 1 Limb or Sight in 1 eye-$15,000; Age 70-74 benefits are reduced by 50%; Age 75+ benefits are reduced by an additional 50%; $250,000 Maximum Principal Sum for any one Family (Not subject to the Deductible or Coinsurance) |
Accidental Death & Dismemberment Participating Members under the age 18 |
Up to $6,000 Principal Sum; Death of Participating Member-$6,000; Loss of 2 or more Limbs or Sight in both eyes-$6,000; Loss of 1 Limb or Sight in 1 eye-$3,000; $250,000 Maximum Principal Sum for any one Family (Not subject to the Deductible or Coinsurance) |
Common Carrier Accidental Death |
$50,000 Principal Sum for the Death of a Participating Member age 18 and older; $30,000 Principal Sum for the Death of a Participating Member under age 18. $250,000 Maximum Principal Sum for any one Family (Not subject to Deductible or Coinsurance) |
Natural Disaster- Relocation Accommodations |
Up to $500 Sub-Limit per day (maximum of 5 days) per Coverage Period (Not subject to Deductible or Coinsurance) |
Political Evacuation |
$100,000 Sub-Limit (Not subject to Deductible or Coinsurance) |
Act of Terrorism |
$50,000 Sub-Limit, Eligible Medical Expenses only |
Third-Party Liability |
$500 Sub-Limit, As defined in the policy (Not subject to Deductible or Coinsurance) |
Bedside Visit |
$1,000 Sub-Limit, Participating Member must be Hospitalized for at least 5 days, Reimbursement only, Outside the US only |
Trip Delay/Missed Connection |
$100 Sub-Limit per day (maximum 2 days), After a 12-hour delay period, As defined in the policy (Not subject to Deductible or Coinsurance) |
Trip Interruption Benefit |
Up to $10,000 Sub-Limit per Coverage Period (Not subject to Deductible or Coinsurance) |
Rental Car Deductible Reimbursement Benefit |
Up to $500 Sub-Limit, As defined in the policy (Not subject to Deductible or Coinsurance) |
Emergency Pet Return Home |
Up to $500 Sub-Limit per Coverage Period for an economy return ticket for a cat or dog in the event you are Hospitalized for 36 hours or more (Not subject to Deductible or Coinsurance) |
Exclusion
EXCLUSIONS — All charges, costs Expenses Incurred by the Participating Member and directly or relating to or arising from or in connection with any of the following acts, omissions, events, conditions, charges, consequences, claims, treatment (which would include diagnoses, consultations, tests, examinations and
evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Scheme Administrator shall provide no benefits and shall have no liability therefor:
War; Military Action — The Scheme Administrator shall not be liable for and will not provide coverage or benefits for any claim or Charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with any of the following acts or events (collectively, "Occurrences"):
War, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not) or civil war; or
Mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power; or
Any act of any person acting on behalf of or in connection with any organization with activities directed toward the overthrow by force of the government de jure or de facto or to the influencing of it by violence of any type; martial law or state of siege, or any events or causes that determine the proclamation or maintenance of martial law or state of siege; or
Pre-Existing Conditions — Any Illness, Injury, Mental or Nervous Disorder, sickness, disease, physical, or any other condition or ailment for which medical advice , diagnosis, care, or treatment (would include but not limited to receiving services and supplies, consultations, diagnostic tests, or prescription medications) was recommended or received during the seven-hundred thirty (730) days immediately preceding the Effective Date of Coverage, Effective Date of the Evidence of Insurance, or Effective Date of the insurance; any condition that manifested itself (whether known or unknown) in such a manner that would cause a reasonably prudent person to seek medical attention, treatment, advice, diagnosis, or care that with reasonable medical certainty, existed at the time of application or within the seven-hundred thirty (730) days immediately preceding the Effective Date of Coverage or Effective Date of Insurance. For the purposes of the Complications of Pregnancy coverage offered herein, Pregnancy will not be included within the definition of a Pre-existing Condition; and
Maternity- Charges related to or incurred for Pregnancy; and
Pregnancy Test(s), Routine pre-natal care, childbirth, and post-natal care; and
False labor, edema, prolonged labor, prescribed rest during the period of Pregnancy, which would include Newborn Care; and
Charges Incurred For Surgery, Treatment Or Supplies That Are:
Investigational, Experimental, or for Medical Research purposes; and
Charges for any Participating Member under the age of fourteen (14) days; and
Any treatment for or related to any Congenital condition; and
Any charges that are not incurred by a Participating Member during his/her Coverage Period; and
Charges that are not submitted within the timely filing limits; and
Treatment, services or supplies that are related to genetic medicine or genetic testing, which would include, without limitation, amniocentesis, genetic screening, risk assessment, prevention and/or to determine pre-disposition, genetic counseling, and/or gene therapy; and
Any immunizations/vaccinations, Routine Physical or gynecology exams; and
Charges Incurred While Confined Primarily To Custodial Care, Educational, Or Rehabilitation Care; and
Charges Incurred For Any Surgery, Treatment, Or Supplies Relating To, Arising From Or In Connection With, For, Or As A Result Of:
Weight modification or any Inpatient, Outpatient, Surgical or other treatment of obesity (which would include, without limitation, morbid obesity), which would include, without limitation, wiring of the teeth and all forms of bariatric Surgery by whatever name called, or reversal thereof, which would include, without limitation, intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling; and/or
Modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Participating Member (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof); and/or
Cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery that was covered under this insurance; and/or
Medical Expenses Incurred for Injury or Illness resulting from Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, and club sports or athletic activities and Professional Sports which would include practice; mountaineering at elevations of 14,763 Feet/4,500 meters or higher, avalanche training, rock climbing, and caving; aviation (except when traveling solely as a passenger in a commercial aircraft), and hot air ballooning as a pilot; base-jumping, hang-gliding, parachuting, paragliding, parasailing, kite-surfing, sky surfing, bungee jumping, abseiling, and zip lining; heli-skiing, snow skiing, or snowboarding, recreational downhill and/or cross country snow skiing or snowboarding, bobsleigh, skeleton or luge, and ice climbing;sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, or accompanied by a certified instructor at depths of less than 10 meters; white water rafting, spelunking or cave diving, surfing, body boarding, waterskiing, wakeboarding, windsurfing, knee boarding, kayaking, and jet skiing; off-road motorized vehicles which would include all- terrain vehicles, snowmobiles, motorized dirt bikes, and tractors; racing by any animal, skateboarding, BMX biking, mountain biking, and speed trials and speedway; any type of boxing or martial arts, powerlifting, and wrestling; big game hunting, wild safaris, running with the bulls, and horseback riding; Aussie rules football, jousting, modern pentathlon, and quad biking outdoor endurance events.
Any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where such activity is undertaken against the advice or direction of any local authority or any qualified instructor, or contrary to the rules, recommendations and procedures of a recognized governing body for the sport or activity; and/or
Any Illness or Injury sustained while participating in any activity where such activity is undertaken against medical advice; and/or
Any Injury or Illness sustained while or after the consumption of intoxicating liquor, alcohol, narcotics or drugs other than Prescription Drugs taken in accordance with Treatment prescribed and directed by a Physician; and/or
Any willfully self-inflicted Injury or Illness; and/or
Any sexually transmitted disease or infections; and/or
Treatment by a chiropractor; and/or
Any Mental Health Disorder; and/or
Treatment for acne, other acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, and hypertrophic and atrophic conditions of skin; and/or
Telephone consultations or failure to keep a scheduled appointment; and/or
Any testing for: HIV, seropositivity to the AIDS virus, AIDS-related Illnesses, ARC Syndrome and AIDS; and/or
Any Illness or Injury resulting from or occurring during the commission of a violation of law by the Participating Member, which would include, without limitation, the engaging in an illegal occupation or act; and/or
Any Substance Abuse; and/or
Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy; and/or
Orthoptics, visual therapy or visual eye training; and
Psychometric, behavioral and Educational testing; and
The Zika Virus or complications there of; and
The Coronavirus/COVID-19- Testing for the purposes of travel of any kind; and
Pandemic, Epidemic, Public Health Emergencies- Any Illness or Injury incurred in the Destination Country as a result of epidemic, pandemic, public health emergencies, Natural Disasters, or other disease outbreak conditions that may affect a person’s health when, prior to the Participating Member’s entry into the Destination Country any of the following were issued regarding the Destination Country:
The United States Centers for Disease Control & Prevention issued a Warning Level 3 (avoid nonessential travel); or
The World Health Organization issued an Emergency Travel Advisory; or
A similar governmental agency of the Participating Member’s Country of Residence had published, communicated or issued a Travel Warning or Emergency Travel Advisory restriction or official declaration informing the public about such health issued before the Participating Member traveled to the Destination Country. This exclusion does not apply to charges resulting from Coronavirus/COVID-19, Coronavirus disease (COVID- 19); and Illness or Injuries sustained while operating a moving vehicle after the consumption of intoxicating liquor, alcohol, narcotics or drugs, other than Prescription drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, "vehicle" shall include both motorized devices for which a driver or operator license is required which would include watercraft, aircraft and non-motorized bicycles and scooters for which no permit or license is required; and/or
Any injury and/or illness resulting from Trampolining
The Feet, Which Would Include, Without Limitation:
Orthopedic shoes, prescribed orthopedic devices to be attached to or placed in shoes; and/or
Treatment of weak, strained, flat, unstable or unbalanced feet; and/or
Metatarsalgia, bone spurs, hammertoes or bunions; and
Any treatment or supplies for corns, calluses or toenails provided, however, that claims for treatment or supplies for the feet may be eligible for coverage under this insurance at the sole option of the company and subject to all other Terms of this insurance when related to
An Injury to the foot arising from an Accident covered hereunder; or
An Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of treatment; and
Hair Loss, Which Would Include, Without Limitation:
Which would include without limitation, wigs; and/or
Hair transplants; and/or
Any drug that promises to promote hair growth, whether prescribed by a Physician or not; and
Any Sleep Disorders, which would include, without limitation, sleep apnea; and
Any Exercise Programs — Whether or not prescribed or recommended by a Physician; and
Nuclear or Atomic Radiation — Any exposure to any medical or non-medical radioactive material(s); and
Any Artificial or Mechanical Devices — designed to replace human organs temporarily or permanently; and
Fertility/Infertility — Charges incurred for any treatment or supply that either promotes, prevents or attempts to promote or prevent conception; which would include, but not limited, to;
Artificial insemination; and
Oral contraceptives; and
Treatment for infertility or impotency; and
Vasectomy or reversal of vasectomy; and
Sterilization or reversal of sterilization; and
Sexual Dysfunction — Charges incurred for any treatment or supply that either promotes, enhances or corrects, or attempts to promote, enhance or correct impotency or sexual dysfunction; and
Dental Treatment — Except for Emergency Dental Treatment necessary to repair or replace sound natural teeth lost or damaged in an Accident covered hereunder or as necessary treatment of sudden, Unexpected pain to sound natural teeth, and subject to the limits set forth in the Schedule of Benefits/Limits;
Routine or general dental care; and
Charges incurred for treatment of the temporomandibular joint; and
Vision — Charges incurred but not limited to;
For eyeglasses or contact lenses; and/or
Charges for any treatment, supply, examination or fitting related to these devices; and
Eye refraction for any reason; and
Eye Surgery, included, but not limited to, radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness or astigmatism; and
Charges for Treatment of cataracts or glaucoma
Hearing — Hearing test, Hearing aids, Hearing implants and charges for any Treatment, supply, examination or fitting related to these devices; and
Newborn Care — Charges incurred by the Participating Member for the treatment of his/her Newborn(s) (or for supplies related thereto); and
Accommodations — Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and
Taxes and Other Miscellaneous Fees — Any taxes, assessments, charges, fees or surcharges imposed by any governmental agency or authority:
Arising out of or as a result of any treatment or supplies received by the Participating Member; or
Based upon the Company's election hereunder, if any, to pay benefits directly to providers; or
For any other reason; and
Non-Prescription/Over-The-Counter Medication — Charges or Expenses Incurred for non- prescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the US Food and Drug Administration or which are considered " off-label" drug use and for drugs or medicines not prescribed by a Physician; and
Transplants:
Any organ, tissue or other transplant or related services, treatment or supplies, except for Covered Transplants as defined herein and covered pursuant to the Terms of this insurance; and/or
Any artificial, non-human organs, or mechanical devices designed to replace human organs temporarily or permanently; and/or
Any efforts to keep a donor alive for a transplant procedure, whether the transplant procedure is a Covered Transplant or not; and
Disease Outbreak “Infectious or Contagious” — This Insurance/Plan does not cover claims in any way caused by or resulting from an infectious or contagious disease, an outbreak of which has been declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) and or the United States Center for Disease Control and Prevention (CDC). Diagnosis, testing or treatment of Injury or Illness resulting from a disease outbreak in a country or location for which the “WHO” and or “CDC” has declared a Public Health Emergency of International Concern; and
This exclusion shall apply to claims made after the date of any such declaration(s), other than where a relevant diagnosis has been made by a qualified medical practitioner before the date of any such declaration(s); and or
A Warning Level 3 has been issued by the “WHO” or “CDC” has been in effect within one- hundred and eighty (180) days immediately prior to the Participating Member(s) date of arrival; and
Within ten (10) days following the date the warning is issued the Participating Member(s) has failed to depart the country or location; and
Against Medical Advice — Any Charges and/or services related to Inpatient, Outpatient or Emergency room services in which the Participating Member chooses not to comply with recommended treatment and/or where the Participating Member terminates such services or leaves the facility against medical advice (AMA).
Rare Condition/Defect — Any claim, Charges, Illness, Injury or other consequence happening or arising during the existence of Rare Conditions/Defects (whether physical or otherwise), whether or not directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed and considered to be consequences for which the Scheme Administrator shall not be liable under the Evidence of Insurance , except to the extent that the Participating Member shall prove that such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such Rare Conditions/Defects.
Motorized Vehicle — Charges incurred for Injuries/Illness sustained while operating or riding on a two, three- or four-wheel cycle, bike, scooter, moped or Segway will be excluded when the following terms are not met:
Participating Members age sixteen (16) or older must have a valid driver’s license; and
Participating Member must be wearing a safety helmet; and
The motorized vehicle must have active auto insurance.
Acute Pre-Ex Coverage
Other Services |
|
Acute Onset of Pre-existing Conditions |
$150,000 Sub-Limit for Maximum Limits purchased for $550,000, $1,100,000 or $2,000,000; All other Maximum Limits purchased will have a $50,000 Sub-Limit, Emergency Medical Evacuation $25,000 Sub-Limit, only available to Participating Members under the age of 70 |
Acute Onset Of A Pre-Existing Condition — The sudden and Unexpected outbreak or reoccurrence of a Pre-existing Condition(s), which occurs Unexpectedly and without advance warning either in the form of Physician recommendation or symptoms (which would have caused a prudent person to seek medical advice, attention or treatment), is short in duration, is rapidly progressive and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the Effective Date of Coverage or Effective Date of insurance. Treatment for the Acute Onset of a Pre-existing Condition must be obtained within twenty-four (24) hours of the sudden and Unexpected outbreak or reoccurrence. A Pre-existing Condition that is a Chronic or Congenital condition or that gradually gets worse over time will not be considered an “Acute Onset of a Pre-existing Condition”. The Acute Onset of a Pre-existing Condition does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatment existent or necessary prior to the Effective Date of Coverage or Effective Date of Insurance. The Acute Onset of a Pre-existing Condition does not include treatment after the initial stabilization of a covered or eligible benefit for “Acute Onset of a Pre-existing Condition”.
Acute Onset of a Pre-existing Condition: An Unexpected outbreak or recurrence of a Pre-existing Condition, that occurs Unexpectedly and without advance warning, either in the form of Physician recommendation or symptoms that have caused a prudent person to seek medical attention prior to the outbreak or recurrence. Treatment must be obtained within twenty-four (24) hours of the sudden and Unexpected occurrence of pain.
The Scheme Administrator will provide Emergency Medical Evacuation benefits only when the Illness or Injury giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance, except when provided under the Acute Onset of Pre-existing Condition.
PPO Network
UNITED STATES PREFERRED PROVIDER ORGANIZATION (PPO)— If treatment or supplies eligible for coverage under this insurance are received directly from the Scheme Administrator's approved list of independent PPO providers while the Participating Member is in the United States, the Scheme Administrator will waive any and all Coinsurance applicable to such claims. However, all treatment or supplies received in the United States from a non-PPO provider will remain subject to the applicable Deductible and Coinsurance, whether the Participating Member may be eligible for the foregoing special benefits relating to treatment or supplies received from PPO providers.
PPO Information —The Scheme Administrator endeavors to maintain a contractual arrangement with an independent Preferred Provider Organization (PPO) that has established and maintains a network of US -based Physicians, Hospitals and other healthcare and health service providers who are contracted separately and directly with the PPO and who may provide repricing, discounts or reduced charges for treatment or supplies provided to the Participating Member. The Scheme Administrator has no authority or control over the operations or business of the PPO, or over the operations or business of any provider within the independent PPO network. Neither the PPO, nor any provider within the PPO network, nor any of their respective agents, employees or representatives has or shall have any power or authority whatsoever to act for or on behalf of the Scheme Administrator in any respect, which would include, without limitation, no power or authority to: (i) approve Applications or enrollments for initial insurance coverage, extended coverage under this insurance plan or to accept Premium payments, (ii) accept risks for or on behalf of the Scheme Administrator, (iii) act for, speak for, or bind the Scheme Administrator in any way, (iv) waive, alter or amend any of the Terms of the Master Policy or the Evidence of Insurance or waive, release, compromise or settle any of the Scheme Administrator's rights, remedies, or interests thereunder or hereunder, or (v) determine Pre-notification, eligibility for coverage, verification of benefits, or make any coverage, benefit or claim adjudications or decisions of any kind. It is not a requirement of this insurance that the Participating Member seek treatment or supplies exclusively from a provider within the independent PPO network. However, the Participating Member's use or non-use of the PPO network may affect the scope and extent of benefits available under this insurance, which would include without limitation the applicable Deductible, Coinsurance and any Additional Deductible, as set forth above in the Schedule of Benefits. A Participating Member may contact the Scheme Administrator and request a PPO Directory for the area where the Participating Member will be receiving treatment (therein listing the Physicians, Hospitals and other healthcare providers within the PPO network by location and specialty) or may visit the Scheme Administrator's website at www.azimuthrisk.com to obtain such information.
Renew
EXTENSION(S) and AMENDMENT(S):
- EXTENSION(S) — The Beacon Series Policy may extend multiple times, up to the maximum Coverage Period of three hundred and sixty-four (364) to seven hundred and twenty-eight (728) days depending upon your citizenship. A Participating Member may extend his/her policy by logging onto the ARS Client Center at www.azimuthrisk.com after your initial purchase of Insurance. The Beacon Series Extension(s) are subject to the original Policy ID #, Sub-Limits and Maximum Limits up to the Maximum Policy Limit or Coverage Period, unless the Participating Member reaches seventy (70) or eighty (80) years of age prior to his/her date of Extension, in which, the Maximum Limit of the policy will change to the reduced Maximum Limit for that specified age group. Terms of this plan then in effect (which would include the Terms of the then applicable Master Policy) and so long as Extension fees and Premium is paid when due and the Participating Member otherwise continues to meet the applicable eligibility requirements of the plan. The Scheme Administrator's commitment and the Participating Member's ability to extend is also subject to termination upon thirty (30) days written notice to the other party prior to the expiration date of the then existing Period of Insurance.
- AMENDMENT(S) — The Scheme Administrator reserves the right in its sole discretion to make changes, additions to and/or deletions from to the Terms of the Master Policy, the Evidence of Insurance, Extensions or replacements of either, and/or to the Beacon/Axis Group Insurance plan (which would include the issuance of Riders to effectuate same) at any time or from time to time after the Effective Date of Coverage of the Master Policy, upon no less than ninety (90) days prior written notice to Underwriters and the Participating Member ("Notice of Amendment"). The Notice of Amendment shall include a complete description of the changes, additions and/or deletions to be made, the effective date thereof (the "Change Date"), and notice of the Participating Member's cancellation rights as set forth above, and shall be sent first class mail, postage pre-paid, to the last known place of residence or mail- forwarding address of the Participating Member. Upon issuance of the Notice of Amendment, Underwriters and/or the Participating Member shall have the right to request cancellation of the Evidence of Insurance pursuant to the provisions set forth in the Master Policy, at any time prior to the Change Date; provided, however that cancellation shall be at the option of the Participating Member, and coverage under this insurance shall terminate with effect from the cancellation date specified by the Participating Member is subject to the provisions of Section 15, above. If the Participating Member does not elect to cancel the Evidence of Insurance in accordance with the foregoing, the changes, additions and/or deletions as made by the Scheme Administrator and specified in said Notice of Amendment shall take effect as of the Change Date specified in the Scheme Administrator's Notice, and this insurance shall thereafter continue in effect in accordance with its Terms, as so amended and modified.
Cancel
CANCELLATION PROCEDURES IN RESPECT OF THE EVIDENCE(S) OF INSURANCE
Cancellation by Participating Member — All cancellation requests must be submitted in writing to Azimuth Risk Solutions. To be eligible for a full refund, the request must be received before the Participating Members Effective Date of Coverage. Cancellation requests received after the Effective Date of Coverage will be subject to the following:
- A $25.00 cancellation fee; and
- Only the unused portion of the Premium cost will be refunded; and
- No claims will be eligible for Premium refund.
Claim
CLAIM(S) PROCEDURES:
Proof of Claim — When the Scheme Administrator receives notice of a claim for benefits under this insurance, it will provide the Participating Member with form(s) (“Claim Form”) for filing a Proof of Claim. The Claim Form is provided with all fulfillment documents issued by the Scheme Administrator. The Claim Form is always available via the Scheme Administrator’s website at www.azimuthrisk.com. The following items must be submitted to be considered a complete Proof of Claim eligible for consideration of coverage (“Proof of Claim”):
- A duly completed and signed Claim Form; and
- Itemized bills from all Physicians, Hospitals and other healthcare or medical service providers involved with respect to the claim; and
- Receipts for any Expenses Incurred or paid by or on behalf of the Participating Member(s) with respect to the claim; and
- The Participating Member(s) shall have ninety (90) days from the date a claim is incurred to submit a complete Proof of Claim, and the Scheme Administrator may deny coverage for any Proof of Claim submitted thereafter or for an incomplete Proof of Claims. All claim decisions made by or on behalf of the Scheme Administrator are with the express consent of Underwriters. All Complete Proof of Claim(s) can be submitted as follows:
1.1 Mail- Azimuth Risk Solutions - PO Box 627, Indianapolis, IN 46206
1.2 Email - service@azimuthrisk.com
1.3 Fax - 1 (317) 423-9620 or 1 (888) 201- 8851 (outside of the US)
Claim Settlement — Eligible and covered claims under this insurance, which have previously been paid by or on behalf of the Participating Member at the time of the Scheme Administrator's adjudication thereof will be reimbursed directly to the Participating Member, by check in USD, at his/her last known place of residence or mail-forwarding address. While the Evidence of Insurance is in effect, the Participating Member shall undertake to promptly notify the Scheme Administrator of any change in such addresses subsequent to the Effective Date of Coverage. Eligible and covered claims that have not yet been paid by or on behalf of the Participating Member at the time of adjudication will be paid by check to the Participating Member at his/her last known place of residence or mail-forwarding address, or at the sole option and discretion of the Scheme Administrator, and as an accommodation to the Participating Member, directly to the provider(s). All claim settlements are subject to the applicable Deductible and Coinsurance, and to the benefit limits and Sub-Limits and all other Terms of this insurance. No provider or other third-party shall have any direct or indirect claim or right of action against the Scheme Administrator under the Master Policy or any Evidence(s) of Insurance issued by the Master Policy, whether by purported assignment of benefits, subrogation of interests or otherwise, unless first expressly agreed and consented to in writing by the Scheme Administrator, and notwithstanding the Scheme Administrator's exercise or failure to exercise any option or discretion under this section regarding the method of claim payment. No provider or other third-party is intended to have or shall have any rights as a third-party Beneficiary under the Master Policy or Evidence of Insurance issued by the Master Policy.
Appealing a Claim — In the event the Scheme Administrator denies all or part of a claim, the Participating Member shall have ninety (90) days from the date that the Notice of Denial was mailed or mailed to the Participating Member’s last known place of residence or mail-forwarding address to file a written appeal with the Scheme Administrator. Upon receipt of a written appeal, the Scheme Administrator will respond in writing as soon as reasonably practicable and in any event within ninety (90) days from receipt thereof.
Fraudulent Claims — If any claim or request for benefits under this insurance shall be in any respect fraudulent or deceitful, or if the Participating Member or anyone acting for or on their behalf under this insurance uses any fraudulent or deceitful means or devices, all benefits and claims under this insurance shall be forfeited and waived, and the Scheme Administrator, Underwriters and/or Master Policyholder shall have no liability for such benefits or claims.
OTHER INSURANCE — The Scheme Administrator shall not be obligated to provide any benefits or to pay any claim under this insurance if there is any Other Insurance, membership benefit, government program, reimbursement or indemnification coverage, right of contribution, recoupment or recovery, contract, or other third-party obligation or provision of benefits ("Other Coverage") that would, or that would but for the existence of this insurance, be available or obligated to provide such benefit or to pay such claim, except in respect of any excess beyond the amount payable or provided under such Other Coverage had this insurance not been effected. The Scheme Administrator shall not be obligated to provide any benefit or to pay any claim in respect to treatment or supplies furnished by any program or agency funded by any government.
PRE-NOTIFICATION PROVISIONS AND REQUIREMENTS — Pre-notification is a general determination of Medical Eligibility only, and all such determinations are made by the Scheme Administrator (acting through its authorized agents and representatives) in reliance and based upon the completeness and accuracy of the information provided by the Participating Member and/or his/her Relatives, guardians and/or healthcare providers at the time of Pre-notification. The Scheme Administrator reserves the right to challenge, dispute and/or revoke a prior determination of Medical Necessity based upon subsequent information obtained. Pre-notification is not an assurance, authorization, or verification of coverage, a verification of benefits, or a guarantee of payment. The fact that treatment or supplies are Pre-notified by the Scheme Administrator does not guarantee the payment of benefits or the amount or eligibility of benefits. The Scheme Administrator's consideration and determination of a Pre-notification request, as well as any subsequent review or adjudication of all medical claims submitted in connection therewith, shall remain subject to all Terms and Conditions of the Master Policy, which would include exclusions for Pre- existing Conditions and other designated exclusions, benefit limitations, and the requirement that claims be Usual, Reasonable and Customary. In addition, any consideration or determination of a Pre-notification request shall not be deemed or considered as the Scheme Administrator's approval, authorization or ratification of, recommendation for, or consent to any diagnosis or proposed course of treatment. Neither the Scheme Administrator (nor anyone acting on their behalf) has any authority or obligation to select Physicians, Hospitals or other healthcare providers for the Participating Member, or to make any diagnosis or medical treatment decisions on behalf of the Participating Member, and all such decisions must be made solely and exclusively by the Participating Member and/or his/her Family members or guardians, treating Physicians and other healthcare providers. If the Participating Member and his/her healthcare providers comply with the Pre-notification requirements of the Master Policy, and the treatment or supplies are Pre- notified as Medically Necessary, the Scheme Administrator will reimburse the Participating Member for Eligible Medical Expenses Incurred in relation thereto, subject to all Terms of this insurance, which would include the Deductible and Coinsurance. Eligibility for and payment of benefits are subject to all the Terms of this insurance.
Specific Requirements — The following treatment and/or supplies must always be Pre-notified for Medical Necessity by the Scheme Administrator, which would include:
1. Inpatient treatment of any kind; and
2. Any Surgery or Surgical procedure; and
3. Care in an Extended Care Facility; and
4. Home Nursing Care; and
5. Durable Medical Equipment; and
6. Artificial limbs; and
7. Diagnostic testing such as MRI, CT scan and PET scan; and
8. Chemo/Radiation Therapy; and
9. Emergency Medical Evacuation; and
10. Labor and Delivery.
General Requirements — To comply with the Pre-notification requirements of this insurance for the Treatment and services listed in Section 24, healthcare providers must comply with the requirements below. If the Participating Member and/or his/her healthcare provider does not comply with the Pre-notification requirements below, a fifty (50%) percent reduction will be applied to all Eligible Medical Expenses incurred for that Treatment, procedure(s) or supplies.
1. Contact the Scheme Administrator at the telephone numbers printed on the ID card, as follows:
Inside the United States: (Ph.) 1-317-644-6291 (Collect if necessary)
Outside the United States: (Ph.) 1-888-201-8850
E-mail: service@azimuthrisk.com Website: www.azimuthrisk.com; and
2. As soon as possible before the treatment is to be obtained; and
3. Notify all Physicians, Hospitals and other healthcare providers that this insurance contains Pre-notification requirements and ask them to fully cooperate with the Scheme Administrator.
4. Comply with the instructions of the Scheme Administrator and submit any information or documents required by the Scheme Administrator.
LOSS OF COVERAGE/BENEFITS FOR NON-COMPLIANCE WITH PRE-NOTIFICATION REQUIREMENTS —
If the Participating Member or his/her healthcare providers do not comply with the Pre-notification requirements or the treatment or supplies identified in Section 24 through 24.2 above, or if such treatment or supplies are not Pre-notified, Eligible Medical Expenses Incurred with respect to said treatment and/or supplies will be reduced by fifty (50%) percent; and for the treatment or supplies identified in Section 24 through 24.2, or if such treatment and/or supplies are not Pre-notified.
EMERGENCY PRE-NOTIFICATION — In the event of an Emergency Hospital admission, Pre-notification must be completed within forty-eight (48) hours after the admission, or as soon as is reasonably possible.
CONCURRENT REVIEW — For Inpatient treatment of any kind, the Scheme Administrator will Pre-notify a limited number of days of confinement based upon the medical condition. Thereafter, Pre-notification must again be requested and approved if additional days of Inpatient treatment are necessary.
APPEAL PROCESS — If the Participating Member disagrees with a Pre-notification decision of the Scheme Administrator, the Participating Member may ask the Scheme Administrator to reconsider the decision and may supply additional documentation to support the appeal. The Scheme Administrator may reconsider its decision based on review of the additional documentation and facts, if any. The Scheme Administrator will advise the Participating Member of its decision.