MEMBER ELIGIBILITY

Persons who are non-US citizens, fourteen (14) days of age and older who are traveling to the United States for business, pleasure, or to study, who have arrived in the United States within one hundred and eighty (180) days preceding the proposed Effective Date of the program, who have paid premium as outlined in the enrollment application, and who have completed the enrollment form in complete detail are eligible for Inbound Guest. The Company maintains its right to investigate to verify that the eligibility requirements have been met. If and whenever the Company discovers that the eligibility requirements have not been met, its only obligation is refund of premium.

For the purposes of this program, persons fourteen (14) days of age through sixty-nine (69) years are considered one class of Insured Person, and persons age seventy (70) and over are considered another class of Insured Person.

The eligibility date for Dependent Child(ren) of a Named Insured (as defined) shall be determined in accordance with the following: (1) If a Named Insured has Dependent Child(ren) on the date he or she is eligible for insurance; or (2) If a Named Insured acquires Dependent Child(ren) after the Effective date, such Dependent Child(ren) becomes eligible on the date the Insured acquires a Dependent Child who is within the limits of a dependent, unmarried child set forth in the “Definition” section of the Certificate. Dependent Child(ren) eligibility expires concurrently with that of the Named Insured.

EFFECTIVE DATE

Effective Date under the program shall become effective at 12:01 AM North Amer ican Eastern Time on the latest of the following dates:

  • The day after the Company receives your application and correct premium if application and payment is made online or by f ax; or
  • The day after the postmark date of your application and correct
  • premium if application and payment is made by mail; or
  • The moment you depart your Home Country; or
  • The date you request on your application.

Dependent Child(ren) coverage will not be effective prior to that of the Named Insured.

EXPIRATION DATE

The coverage provided with respect to the Named Insured shall terminate at 12:01 AM North American Eastern Time on the earliest of the following dates:

  • The date shown on the insurance confirmation card, for which the premium is paid; or
  • The date the Insured Person returns to his Home Country;
  • One hundred and eighty (180) days after the Insured Person’s original effective date; or
  • The date the Insured Person becomes a United States citizen; or
  • The date of entry into active duty military service.
  • The date the Master Policy terminates (unless the Company agrees, in writing, to permit coverage to continue to the end of the period for which premiums have been paid in lieu of a return of unearned premiums);
  • In addition, for Dependent Child(ren), coverage expires the date the Named Insured(s) coverage expires or the date they cease to be considered a Dependent Child.

INSURANCE COMPANY

This Insurance, under Certificate LON16-160810-02TM, is underwritten by Certain Underwriters at Lloyds, London, rated A "Excellent" by AM Best.

Entire Contract; Changes: The Certificate, including the Application, Schedule of Benefits, endorsements and the attached papers, if any, constitutes the entire contract of Insurance. No change in the Certificate shall be valid until approved by an executive officer of the Company and unless such approval is endorsed hereon. No agent has authority to change this Certificate or to waive any of its provisions;

Physical Examination and Autopsy: The Company at its own expenses shall have the right and opportunity to examine the person of any individual whose Injury or Illness is the basis of claim when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death, where it is not forbidden by law.

Grace Period: There is no Grace Period associated with this program.

Not in Lieu of Worker's Compensation: This Insurance is not in lieu of and does not affect any requirements for coverage by Worker's Compensation Insurance.

Certificate of Insurance: The Company shall issue to each Insured Person an individual Program Summary (Certificate of Insurance), which shall state the essential features of Insurance to which such person is entitled and to whom benefits are payable, if required to do so by the laws of the locality in which the Insured Person resides when his Insurance becomes effective.

Data Furnished by Insured Person(s): Insured Person shall furnish all information requested on the Application and any additional information requested by the Company.

The refusal of the Insured Person, the Insured Person's Physician, Hospital or Service Provider to make all medical reports and records available to the Company could cause an otherwise valid claim or Application to be denied or the file to be closed due to lack of or limited reply from the Insured Person’s medical providers.

Failure on the part of the Insured Person to maintain adequate documentation regarding travel history could cause an otherwise valid claim (where travel history is material to the benefit and claim) to be denied or the file to be closed.

The Company has the option whether or not to consider medical information provided by friends / relatives of the Insured Person as valid for underwriting or claim administration.

Assignment: The Insurance provided hereunder is not assignable, but benefits may be assigned in accordance with #5, Payment of Claims.

Excess Benefits: All coverages shall be in excess of all other valid and collectible insurance and shall apply only when such benefits are exhausted.

Other valid and collectible insurance for which benefits may be payable are insurance programs provided by:

1. Individual, group or blanket insurance or coverage;

2. Other prepayment coverage provided on a group or individual basis;

3. Any coverage under labor management trusteed plans, union welfare plans, employer organizational plans, employee benefit organization plans, or other arrangement of benefits for individuals of a group;

4. Any coverage required or provided by any statute, socialized insurance program; or

5. Any no-fault automobile insurance;

6. Any third party liability insurance.

Monetary Limits: The monetary limits stated in this Certificate and the premium shall be in United States dollars. For services outside of the territorial limits of the United States, the exchange rate used to determine the amount of United States dollars to be paid is the exchange rate effective for the date the claims expense was incurred.

Subrogation: The Certificate has the right to full subrogation and reimbursement of any and all amounts paid by the Certificate to or on behalf of, an Insured Person, if the Insured person receives any sum of money from any person, plan or legal entity which is legally obligated to make payments arising out of any act or omission of any person whether a third party or another covered person under the Certificate, which directly or indirectly caused a physical or mental condition, in connection with which payment of any benefits under the Certificate to, or on behalf of, such Insured Person was made. The Certificate shall have a lien against such sum of money received from third parties or other personsdescribed above or their insurers, or the insurer of the Insured Person, and shall be reimbursed therefrom. The Insured Person further agrees to notify other persons described above in writing, of the Certificate's subrogation and lien rights before the receipt of any payment from said parties or other persons.

The Insured Person shall be responsible for all expenses of recovery from such parties or other persons, including but not limited to, all attorneys' fees incurred in collection of such payments or payments by other persons, which fees and expenses shall not reduce the amount of reimbursement to the Certificate required of the Insured Person. The Insured Person agrees to reimburse the Certificate for any benefit paid hereunder, out of any monies recovered from such party or other persons as a result of judgment, settlement or otherwise, even though such monies are not characterized as amounts paid for medical expenses or claims. The Insured Person agrees to furnish such information and assistance, and to execute and deliver all necessary instruments, as the Company or its designee may request to facilitate the enforcement of these subrogation rights, including but not limited to the execution of a subrogation agreement prior to payments of benefits under the Certificate to, or on behalf of the Insured Person.

The Insured Person shall not release or discharge any party from his or her obligation to the Insured Person or the Certificate or take any other action which could impair the Certificate's subrogation rights. The Certificate's exercise of its rights to take whatever action it sees fit against any third party or other persons shall not affect the Insured Person's right to pursue other forms of recovery.

The Certificate's right to reimbursement as set forth herein shall be payable first from sums received from the parties or other persons and such reimbursement shall continue until the Insured Person's obligations hereunder to the Certificate are fully discharges, even though the Insured Person does not receive full compensation or recovery for his/her injuries, damages loss or debt. This right to subrogation pro tanto shall exist in all cases.

If an Insured Person fails to comply with these requirements, the Insured Person shall not be eligible to receive any benefits, services or payments under the Certificate until there is compliance regardless of whether such benefits are related to the act or omission of such party or other persons. Fraud and Misrepresentation: Any misstatement, concealment or fraud in the Applicant’s (or Applicant’s authorized representative) statements, either on the Application or on subsequent contact (including any claim submissions), whether in writing or otherwise, to the Company or its representatives, shall render this insurance null and void and all claims hereunder shall be forfeited. In addition, if any fraudulent means or devices are used by any Insured Person (or Applicant) or anyone acting on their behalf, this insurance shall be null and void and all claims hereunder shall be forfeited.

Patient Protection and Affordable Care Act: THIS IS NOT QUALIFYING HEALTH COVERAGE ("MINIMUM ESSENTIAL COVERAGE") THAT SATISFIES THE HEALTH CARE COVERAGE REQUIREMENT OF THE AFFORDABLE CARE ACT. IF YOU DON’T HAVE MINIMUM ESSENTIAL COVERAGE, YOU MAY OWE AN ADDITIONAL PAYMENT WITH YOUR TAXES.

Maximum Benefit Limit Per Sickness or Injury:
Ages 14 days through 69: Option $25,000 (Plan A), $45,000 (Plan B), Option $65,000 (Plan C), $85,000 (Plan D), or $120,000 (Plan E)
Age 70 and over: Option $40,000 (Plan J), Option $60,000 (Plan K), or Option $100,000 (Plan L)
Deductible Per Person Per Sickness or Injury:
Ages 14 days through 69:Option $0, $50 or $100
Age 70 and over:$200.00

Age 14 Days through 69 Plan A Plan B Plan C Plan D Plan E
INPATIENT $25,000 Max per Injury/Sickness $25,000 Max per Injury/Sickness $65,000 Max per Injury/Sickness $85,000 Max per Injury/Sickness $120,000 Max per Injury/Sickness
Hospital Room & Board Including Laboratory Tests, X-Rays, Prescription Medical, Extended Care Facility and other miscellaneous Up to $910/day, 30 day max Up to $1260/day, 30 day max Up to $1565/day, 30 day max Up to $1725/day, 30 day max Up to $2340/day, 30 day max
Hospital Intensive Care Unit Additional $430/day, 8 day max Additional $595/day, 8 day max Additional $720/day, 8 day max Additional $790/day, 8 day max Additional $1020/day, 8 day max
Surgical Treatment Up to $2150 Up to $2970 Up to $3960 Up to $4840 Up to $6600
Anesthetist Up to $500 Up to $740 Up to $990 Up to $1210 Up to $1650
Assistant Surgeon Up to $500 Up to $740 Up to $990 Up to $1210 Up to $1650
Physician’s Non-Surgical Visits Up to $40/visit, 1/day, 30 visits max Up to $60/visit, 1/day, 30 visits max Up to $65/visit, 1/day, 30 visits max Up to $75/visit, 1/day, 30 visits max Up to $100/visit, 1/day, 30 visits max
A Consulting Physician, when requested by attending Physician Up to $350 Up to $405 Up to $465 Up to $485 Up to $600
Private Duty Nurse Up to $400 Up to $495 Up to $550 Up to $550 Up to $660
Pre-Admission Tests w/in 7 days before Hospital admission Up to $750 Up to $990 Up to $1100 Up to $1100 Up to $1100
OUTPATIENT          
Surgical Treatment Up to $2150 Up to $2970 Up to $3960 Up to $4840 Up to $6600
Anesthetist Up to $500 Up to $740 Up to $990 Up to $1210 Up to $1650
Assistant Surgeon Up to $500 Up to $740 Up to $990 Up to $1210 Up to $1650
Physician’s Non-Surgical/ Urgent Care Visits Up to $50/visit, 1/day, 10 visits max Up to $60/visit, 1/day, 10 visits max Up to $65/visit, 1/day, 10 visits max Up to $75/visit, 1/day, 10 visits max Up to $100/visit, 1/day, 10 visits max
Diagnostic X-rays & Lab Services Up to $295 - Additional $250- One CAT scan, PET scan or MRI Up to $405 - Additional $250 - One CAT scan, PET scan or MRI Up to $465 - Additional $375 – One CAT scan PET or MRI Up to $485 -Additional $450 - One CAT scan, PET scan or MRI Up to $600 - Additional $500- One CAT scan, PET scan or MRI
Hospital Emergency Room (all expenses incurred therein) Up to $215 Up to $295 Up to $395 Up to $465 Up to $660
Prescription Drugs Up to $150 Per Period of Coverage Up to $250 Per Period of Coverage Up to $125 Per Period of Coverage Up to $135 Per Period of Coverage Up to $180 Per Period of Coverage
Outpatient Surgical Facility Up to $750 Up to $900 Up to $1030 Up to $1070 Up to $1320
OTHER TREATMENT AND SERVICES          
Ambulance Services Up to $295 Up to $450 Up to $450 Up to $475 Up to $475
Initial Orthopedic Prosthesis/brace Up to $715 Up to $990 Up to $1160 Up to $1240 Up to $1560
Durable Medical Equipment Up to $1,100 Up to $1,200 Up to $1,300 Up to $1,700 Up to $1,700
Chemotherapy and/or radiation therapy Up to $715 Up to $990 Up to $1175 Up to $1275 Up to $1620
Dental Treatment for Injury to Sound, Natural Teeth Up to $360 Up to $550 Up to $550 Up to $550 Up to $550
Mental & Nervous Disorder & Substance Abuse Same as any Sickness Same as any Sickness Same as any Sickness Same as any Sickness Same as any Sickness
Physiotherapy Up to $30/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max
Extended Care Facility Covered under the Hospital Room & Board benefit Covered under the Hospital Room & Board benefit Covered under the Hospital Room & Board benefit Covered under the Hospital Room & Board benefit Covered under the Hospital Room & Board benefit
Emergency Evacuation $50,000 $50,000 $50,000 $50,000 $50,000
Return of Remains/Local Cremation/Burial $25,000$5,000 $25,000$5,000 $25,000$5,000 $25,000$5,000 $25,000$5,000
Common Carrier AD&D Principal Sum $25,000 $25,000 $25,000 $25,000 $25,000
Acute Onset of Pre-existing Condition(s) $25,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. $45,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. $65,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. $85,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. $120,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation.
If an insured person turn 70 years old during the purchased coverage period, the 70 and over benefit schedule becomes effective upon the day the insured turns 70. Individuals with the $20,000 and $45,000 per Injury or Sickness Certificate maximum will receive the $40,000 per Injury or Sickness schedule for age 70 and older. Individuals with the $65,000 and $85,000 per Injury or Sickness Certificate maximum will receive the $60,000 per Injury or Sickness schedule for age 70 and older. Individuals with the $120,000 per Injury or Sickness Certificate maximum will receive the $100,000 per Injury or Sickness schedule for age 70 and older.
Age 70-99 Plan J Plan K Plan L
INPATIENT $40,000 Max per Injury/Sickness $60,000 Max per Injury/Sickness $100,000 Max per Injury/Sickness
Hospital Room & Board including miscellaneous Up to $870/day, 30 day max Up to $1,260/day, 30 day max Up to $2,050/day, 30 day max
Hospital Intensive Care Unit Additional $380/day, 8 day max Additional $380/day, 8 day max Additional $900/day, 8 day max
Surgical Treatment Up to $2,285 Up to $3,300 Up to $5,365
Anesthetist Up to $570 Up to $825 Up to $1,340
Assistant Surgeon Up to $570 Up to $825 Up to $1,340
Physician’s Non-Surgical Visits Up to $45/visit, 1/day, 30 visits Up to $45/visit, 1/day, 30 visits Up to $100/visit, 1/day, 30 visits max
A Consulting Physician, when requested by attending Physician Up to $330 Up to $480 Up to $780
Private Duty Nurse Up to $375 Up to $450 Up to $450
Pre-Admission Tests w/in 7 days before Hospital admission Up to $775 Up to $775 Up to $775
OUTPATIENT      
Surgical Treatment Up to $2,285 Up to $3300 Up to $5,365
Anesthetist Up to $570 Up to $825 Up to $1,340
Assistant Surgeon Up to $570 Up to $825 Up to $1,340
Physician’s Non-Surgical / Urgent Care Visits Up to $45/visit, 1/day, 10 visits Up to $65/visit, 1/day, 10 visits max Up to $100/visit, 1/day, 30 visits max
Physician’s Non-Surgical / Urgent Care Visits Up to $45/visit, 1/day, 10 visits Up to $65/visit, 1/day, 10 visits max Up to $100/visit, 1/day, 30 visits max
Diagnostic X-rays & Lab Services Up to $330 - Additional $250 - One CAT scan, PET scan or MRI Up to $480 – additional $300 – One CAT scan PET or MRI Up to $780 – additional $300 - One CAT scan, PET scan or MRI
Hospital Emergency Room (all expenses incurred therein) Up to $208 Up to $300 Up to $480
Prescription Drugs Up to $250 Per Period of Coverage Up to $250 Per Period of Coverage Up to $480
Outpatient Surgical Facility Up to $705 Up to $1020 Up to $1,660
OTHER TREATMENT AND SERVICES
Ambulance Services Up to $450 Up to $450 Up to $880
Initial Orthopedic Prosthesis/brace Up to $705 Up to $1020 Up to $1,660
Durable Medical Equipment Up to $1,100 Up to $1,200 Up to $1,300
Chemotherapy and/or radiation therapy Up to $705 Up to $1020 Up to $1,660
Dental Treatment for Injury to Sound, Natural Teeth Up to $550 Up to $550 Up to $1,075
Mental & Nervous Disorder & Substance Abuse Same as any Sickness Same as any Sickness Same as any Sickness
Physiotherapy Up to $40/visit, 1/day, 12 visits Up to $40/visit, 1/day, 12 visits max Up to $80/visit, 1/day, 12 visits max
Extended Care Facility Covered under the Hospital Room & Board benefit Covered under the Hospital Room & Board benefit Covered under the Hospital Room & Board benefit
Emergency Evacuation $50,000 $50,000 $50,000
Return of Remains $25,000 $25,000 $25,000
Return of Remains/Local Cremation/Burial $25,0005,000 $25,0005,000 $25,0005,000
AD&D Principal Sum $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier

EMERGENCY EVACUATION AND RETURN OF REMAINS (PART B)

BENEFIT MAXIMUM AMOUNT
Emergency Evacuation $50,000 maximum benefit per Injury or Sickness
Return of Remains $25,000 maximum benefit

PRE-EXISTING MEDICAL CONDITIONS

"Pre-Existing Condition" shall mean any medical condition, Sickness, Injury, illness, disease, Mental Illness or Mental Nervous Disorder,regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or within the one hundred and eighty (180) days (three hundred and sixty five (365) days for Insured Persons 70 and older) immediately prior to the Insured Person’s Effective Date under the Certificate, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, Sickness, Injury, illness, disease, Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the one hundred and eighty (180) days (three hundred and sixty five (365) days for Insured Persons 70 and older) immediately preceding the effective date of coverage under this Certificate.

MEDICAL EXPENSE BENEFITS – INJURY AND SICKNESS

When a covered Injury or Sickness requires treatment by a Physician, this program will provide benefits for the Usual and Customary Charges for Medically Necessary Covered Medical Expenses which exceed the deductible per person for each Injury or Sickness, and which are incurred within one hundred and eighty-two (182) days following the Injury or Sickness. Payment for any Covered Medical Expense will be no more than the Benefit Limit shown for it in the Schedule of Benefits. The total payable for all Covered Medical Expenses will be no more than the Maximum Benefit Limit per Sickness or Injury. Benefits are subject to the Excess Benefits Provision.

If a benefit is designated in the Schedule of Benefits, Covered Medical Expenses include:

1. Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional services and (with the exception of personal services of a non-medical nature; charges made for an operating room.

2. Charges made for Intensive Care of Coronary Care charges and nursing services.

3. Hospital Miscellaneous Expenses: 1) while Hospital Confined; or 2) for pre-admission expenses for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.

4. Charges for physiotherapy, if recommended by a Physician for the treatment of a specific Injury and administered by a licensed physiotherapist(inpatient).

5. Charges made for diagnosis, treatment and Surgery by a Physician for inpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this inpatient surgery benefit; or under the outpatient surgery benefit, but not for both.

6. Charges made for the cost and administration of anesthetics: in connection with inpatient surgery.

7. Private Duty Nurse’s Services: 1) private duty nursing care only; 2) while Hospital Confined; 3) ordered by a licensed Physician; and 4) a Medical Necessity. General nursing care provided by the Hospital is not covered under this benefit.

8. Physician’s Visits: when Hospital Confined. Benefits are limited to one Physician’s visit per day. Benefits do not apply when related to surgery.Covered medical expenses will be paid under the inpatient benefit or under the outpatient benefit for Physician’s Visits but not both.

9. Pre-admission Testing: limited to routine tests such as: complete blood count; urinalysis; and chest x-ray. If otherwise payable under the Certificate, major diagnostic procedures such as: CAT scans; NMR’s; and blood chemistries will be paid under the “Hospital Miscellaneous" benefit.

10. Mental and Nervous Disorder (inpatient): the benefits and the maximum amounts are specified in the Schedule of Benefits. Benefits are limited to one Physician’s visit per day.

11. Charges made for diagnosis, treatment and Surgery by a Physician for outpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this outpatient surgery benefit; or under the inpatient surgery benefit, but not both.

12. Day Surgery Miscellaneous (Outpatient Surgical Facility): in connection with outpatient day surgery; excluding non-scheduled surgery, and surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and x-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies.

13. Anesthetist (Outpatient): in connection with outpatient surgery.

14. Physician’s Visits (Outpatient): Includes injections administered during visit. Benefits do not apply when related to surgery or Physiotherapy. Covered medical expenses will be paid under the outpatient benefit or under the inpatient benefit for Physician’s visits but not both.

15. Medical Emergency Expenses (Outpatient): only in connection with a Medical Emergency as defined. Benefits will be paid for the use of the emergency room and supplies.

16. Radiation Therapy (Outpatient)

17. Chemotherapy (Outpatient)

18. Prescription Drugs (Outpatient)

19. Mental and Nervous Disorder (Outpatient): the benefits and the maximum amounts are specified in the Schedule of Benefits. Benefits are limited to one Physician’s visit per day.

20. Ground ambulance (within the metropolitan area) to and from the nearest Hospital with facilities for required treatment. If the Insured Person is in a rural area, then licensed group ambulance transportation to the nearest metropolitan area shall be considered.

21. Braces and Appliances: 1) when prescribed by a Physician; and 2) a written prescription accompanies the claim when submitted. Replacement braces and appliances are not covered. Braces and appliances include Durable Medical Equipment (consisting of a standard basic hospital bed and/or a standard basic wheelchair). No benefits will be paid for rental charges in excess of purchase price.

22. Consultant Physician Fees: when requested and approved by the attending Physician.

23. Dental Treatment: 1) performed by a Physician; and 2) made necessary by Injury to Sound, Natural Teeth. Routine dental care and treatment to the gums are not covered.

24. Alcoholism/Drug Abuse Treatment: the benefits and the maximum amounts are specified in the Schedule of Benefits.

25. Care in an Extended Care Facility following direct transfer from an acute care Hospital, provided such care is recommended by the Physician for convalescence related to the Illness or Injury for which the Member was hospitalized as Inpatient. Extended Care Facility benefits accrue toward the limits for Hospital Room and Board.

EMERGENCY EVACUATION

The Company shall pay benefits for Covered Expenses incurred up to $50,000, if any covered Injury or Illness commencing during the Period of Coverage results in the Medically Necessary Emergency Medical Evacuation or Return of the Insured Person. The Emergency Medical Evacuation or Return must be ordered by the Assistance Company in consultation with the Insured Person’s local attending Physician.

Emergency Medical Evacuation or Return means: a) the Insured Person's medical condition warrants immediate transportation from the place where the Insured Person is located to the nearest adequate medical facility where medical treatment can be obtained; or b) after being treated at a local medical facility as a result of a Emergency Medical Evacuation, the Insured Person's medical condition warrants transportation with a qualified medical attendant to his/her Home Country to obtain further medical treatment or to recover; or c) both a) and b) above. All transportation arrangements must be by the most direct and economical route and be performed by the Administrator.

RETURN OF REMAINS / LOCAL CREMATION OR BURIAL

The Company will pay the reasonable Covered Expenses incurred up to $25,000 to return the Insured Person's remains to his/her Home Country, if he or she dies. Covered Expenses include, but are not limited to, expenses for embalming, [a minimally necessary container appropriate for transportation, shipping costs, and the necessary government authorizations. All transportation arrangements must be performed by the Administrator.

The Company will pay the reasonable Eligible Expenses incurred up to the maximum stated in the SCHEDULE OF BENEFITS for preparation, local burial or cremation of the Insured Person’s mortal remains at the place of death in accordance with the commonly accepted cultural and religious beliefs practiced by the Insured Person. Coverage is not provided for burial and cremation costs incurred for religious practitioner, flowers, music, food or beverages.

If the Local Cremation or Burial is chosen, the Return of Mortal Remains benefit will not apply.

COMMON CARRIER ACCIDENTAL DEATH AND DISMEMBERMENT INDEMNITY

Accidental Death & Dismemberment Coverage shall apply only to covered accidents sustained by an Insured Person:

1. while riding as a passenger (but not as a pilot, operator or member of the crew) in or on (including getting in or out of, or on or off of): A) any land, water or air conveyance operated under a license for the transportation of passengers for hire; or

B) any Military Air Transport Aircraft; or

2. by being struck down by any aircraft.

The Company shall pay an indemnity determined from the Table of Losses below if an Insured Person sustains a loss stated therein resulting from Injury, provided that:

(a) such loss occurs within 365 days after the date of accident causing such loss; or

(b) the indemnity payable for any such loss shall be the amount stated opposite such loss in said

Table and the Principal Sum stated therein shall be the amount stated in the Schedule of Benefits, as applicable to such person and this Coverage; and

(c) if more than one loss stated in said Table is sustained as the result of one accident, only one of the amounts so stated in said Table, the largest, shall be payable.

For Loss of: Indemnity
Life Principal Sum
Both Hands or Both Feet or Sight of Both Eyes Principal Sum
One Hand and One Foot Principal Sum
Either Hand or Foot and Sight of One Eye Principal Sum
Either Hand or Foot One-Half the Principal Sum
Sight of One Eye One-Half the Principal Sum

AGGREGATE LIMIT OF INDEMNITY

The Aggregate Limit of Indemnity of $125,000 shall be the total limit of the Company’s liability for all indemnities payable under Accidental Death and Dismemberment Indemnity with respect to all classes of Insured Persons arising out of Injury sustained by two or more Insured Persons as the result of any one accident.

If the total of such indemnity exceeds said Aggregate Limit of Indemnity, the Company shall not be liable to any one such Insured Person for a greater proportion of such Insured Person’s Indemnity afforded by the Accidental Death and Dismemberment Indemnity than said Aggregate Limit of Indemnity bears to the total Indemnities afforded by this Accident Death and Dismemberment Indemnity to all such Insured Persons.

INTERNATIONAL TRAVEL COVERAGE

An insured person may travel to additional countries, other than the United States, up to a maximum of 30 days. You must purchase a minimum of 30 days of coverage. International travel coverage does not include travel back to the insured person’s home country, and it does not extend after your current expiration date. International travel must be utilized during your current Period of Coverage.

DEFINITIONS

"Accident" or “Accidental” shall mean an event, independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.

"Benefit Period" shall mean the duration of time following a covered Injury or Sickness in which to receive Medically Necessary Covered Expenses.

Treatment must be performed within one hundred and eighty-two (182) days following the Injury or Sickness.

"Certificate" shall mean the summary of the terms of Coverage, which includes this document, the Insured Person's Application and any endorsements or amendments that will attach during the Insured Person’s Period of Coverage.

"Company" shall mean Certain Underwriters at Lloyd's, London

"Coverage Period" or "Period of Coverage" shall mean the period between the Individual Effective Date of Coverage and the IndividualTermination Date of Coverage for this Certificate, which is stated on the Insured Person’s ID Card.

"Covered Event" shall mean the Covered Expenses for an Illness or an Accidental bodily Injury necessitating medical Treatment by a Service Provider as defined in this Certificate.

"Covered Expenses" or "Covered Medical Expenses" shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment; due to Illness or Injury, as described in the Certificate; prescribed, performed or ordered by a licensed Physician and/or Service Provider; Reasonable and Customary charges; incurred by the Insured Person during their Period of Coverage; and which are (1.) listed in the Schedule of Benefits, (2.) not excluded in the Exclusions and (3.) do not exceed the maximum limits stated in the Schedule of Benefits "Deductible" means the amount stated in the Schedule of Benefits or any endorsement to the Certificate as a deductible. Such amount will be subtracted from the amount or amounts charged and otherwise payable as Covered Medical Expenses.

The deductible will apply per occurrence (for each Injury or Sickness) as specified in the Schedule of Benefits.

“Dependent Child(ren)" means a Named Insured's dependent, unmarried children living with the Named Insured. This includes stepchildren, legally adopted children and children of adopting parents pending adoption procedures. Children shall cease to be dependent on the first to occur of: (1) the end of the month in which they marry; or (2) the end of the month in which they attain the age of nineteen (19) years. The attainment of the limiting age will not operate to terminate the coverage of such child while the child is and continues to be both: (1) incapable of self-sustaining employment by reason of mental retardation or physical handicap; and (2) chiefly dependent upon the Insured Person for support and maintenance. Proof of such incapacity and dependency shall be furnished to the Company: 1) by the Named Insured; and 2) within 31 days of the child’s attainment of the limiting age. Subsequently, such proof must be given to the Company upon request following the child’s attainment of the limiting age. If a claim is denied under the Certificate because the child has attained the limiting age for dependent children, the burden is on the Insured

Person to establish that the child is and continues to be handicapped as defined by subsection (1) and (2). "Disablement" as used with respect to medical expenses shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician as defined in this Certificate. "Durable Medical Equipment” shall mean a standard basic hospital bed and/or a standard basic wheelchair. "Eligible Benefits" shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment; due to Illness or Injury; prescribed, performed or ordered by a licensed Physician and/or Service Provider; Reasonable and Customary charges; incurred by the Insured Person during their Period of Coverage; and which are (1.) listed in the Schedule of Benefits, (2.) not excluded in the Exclusions and (3.) do not exceed the maximum limits stated in the Schedule of Benefits. “Emergency” shall mean a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s life or limb in danger, if medical attention is not provided within 24 hours.

"Extended Care Facility" means an institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a Physician; and 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 treatment, Custodial Care, nursing care or for care of Mental Health Disorders, or the mentally incompetent.

"Home Country" shall mean the country where the insured person(s) has his or her true, fixed and permanent residence. For United States Citizens, the Home Country is always the United States. "Hospital" shall mean a place that 1.) is legally operated for the purpose of providing medical care and Treatment to Sick or Injured persons for which a charge is made that the Insured Person is legally obligated to pay in the absence of insurance 2.) provides such care and Treatment in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) operates under the supervision of a staff of one or more Physicians. Hospital also means a place that is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Heath Care Organizations (JCAHO). Hospital does not mean: -a Convalescent, nursing, or rest home or facility, or a home for the aged; -a place mainly providing Custodial, Educational, or Rehabilitative Care; or -a facility mainly used for the Treatment of drug addicts or alcoholics.

"Hospital Confined" or "Hospital Confinement" means confined in a Hospital for at least 18 hours by reason of an Injury or Sickness for which benefits are payable.

"Injury" shall mean bodily Injury listed in the most recent edition of the International Classification of Diseases and caused solely and directly by Accidental, external, and visible means occurring while this Certificate is in force and resulting directly and independently of all other causes resulting in a Covered Event under this Program. "Inpatient" shall mean a person who is confined in an institution for a period of 24 hours or more and is charged for room and board.

"Insured Person(s)" shall mean a person eligible for Coverage under the Certificate as stated on the ID Card, who has applied for Coverage and is named on the Application and for whom the Company has Approved for Coverage and accepted the corresponding Premium. This may be the Primary Insured Person or Dependent(s).

"Intensive Care or Coronary Unit" shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.

"Master Policy" means that certain group insurance policy, No. NA16SC01 issued to World Commercial Trust by Certain Underwriters at Lloyd’s, London, which is available upon request from Seven Corners. “Medical Emergency” means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of immediate medical attention, a reasonable person could believe this condition would result in: (1) Death; (2) Permanent placement of the Insured’s health in jeopardy; (3) Serious impairment of bodily functions; or (4) Serious and permanent dysfunction of any body organ or part. Expenses incurred for “Medical Emergency” will be paid only for Sickness or Injury which fulfills the above conditions. These expenses will not be paid for minor injuries or minor Sicknesses.

"Medically Necessary or Medical Necessity" shall mean services, Treatment or supplies received by the Insured Person that are determined by the Company to be: 1.) appropriate and necessary for the symptoms, diagnos is, or direct care and Treatment of the Insured Person's medical conditions; 2.) within the standards the organized medical community deems good medical practice for the Insured Person's condition; 3.) not provided solely for educational purposes or primarily for the convenience of the Insured Person, the Insured Person's Physician or another Service Provider or person; 4.) not Experimental / Investigational and/or for Research; and 5.) not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate Treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person is receiving or the severity of the Insured Person's condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe, order, recommend, or approve a service, Treatment, supply or level of care, does not of itself, make such Treatment Medically Necessary or make the charge a Covered Expense under this Certificate.

"Mental Illness" or “Mental and Nervous Disorder” shall mean Mental, emotional, and psychiatric disorders, Illnesses or conditions (whether organic or non-organic, whether biological, non-biological, genetic, chemical or non-chemical in origin). Mental and nervous disorders include, but are not limited to psychoses; neurotic disorders; bipolar disorders; affective disorders; personality disorders; psychological or behavioral abnormalities, associated with transient or permanent dysfunction of the brain or related neurohomonal systems; and disorders, conditions, and Illnesses listed in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders IV-R or the most recent edition of the International Classification of Diseases ICD-9-CM, which is the required reporting tool for all diagnoses and diseases to all U.S. Public Health Service and Health Care Financing Administration programs on the date the medical care or Treatment is rendered to an Insured Person.

"Named Insured" shall mean a person eligible for Coverage under the Certificate as stated on the ID Card, who has applied for Coverage and is named on the Application and for whom the Company has Approved for Coverage and accepted the corresponding Premium. This may be the Primary Insured Person or Dependent(s).

"Outpatient" shall mean a person who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician's office, for an Illness or Injury, but who is not confined and is not charged for room and board.

"Physician" or "Surgeon" shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed.

"Physiotherapy" shall mean physical therapy, recommended by a Physician for the treatment of a specific Covered Event and administered by a licensed physical therapist.

"Policyholder" means Global International Trust, Washington DC

"Prescription Drugs" means: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a Physician; and 4) injectable insulin "Reasonable and Customary" shall mean the maximum amount that the Company determines is Reasonable and Customary for Eligible Benefits the Insured Person receives, up to but not to exceed charges actually billed. The Company's determination considers: 1.) amounts charged by other Service Providers for the same or similar service in the medical community where the services were received; 2.) any unusual medical circumstances requiring additional time, skill or experience; 3.) the cost to the Service Provider of providing the services or supplies or performing the procedure; and 4.) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale. For a Service Provider who has a reimbursement agreement with the Company, the Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company.

If a Service Provider accepts as full payment an amount less than the negotiated rate under a reimbursement agreement, the lesser amount will be the maximum Reasonable and Customary charge. The Reasonable and Customary charge is reduced by any penalties for which a Service Provider is responsible as a result of that Service Provider’s agreement with the Company.

"Service Provider" shall mean a Hospital, Hospice, Convalescent/skilled nursing facility, ambulatory surgical center, psychiatric Hospital, community mental health center, residential treatment facility, psychiatric treatment facility, alcohol or drug dependency treatment center, birthing center, Physician, Dentist, chiropractor, licensed medical practitioner, nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves to provide services under the Certificate.

"Sickness" shall mean Illness or Disease of any kind listed in the most recent edition of the International Classification of Diseases. All related conditions and recurrent symptoms of the same or a similar condition will be considered one Sickness.

"Sound, Natural Teeth" means natural teeth, the major portion of the individual tooth is present, regardless of fillings or caps; and is not carious, abscessed or defective.

"Treatment" shall mean medical or surgical management of a patient designed to resolve the Illness or Injury based on standard and accepted medical practice. For purposes of this Certificate, the course of action will only include those scheduled and approved benefits, for which the Insured Person is eligible.

"Usual and Customary Charges", see "Reasonable and Customary".

GENERAL EXCLUSIONS AND LIMITATIONS

No benefits will be paid for loss or expense caused by, contributed to, or resulting from:

  • Pre-existing Conditions as defined herein. If you are a non-U.S. citizen under age 70, this exclusion is waived for eligible medical expenses for an Acute Onset of a Pre-existing Condition(s) (as defined herein) as shown in the Schedule of Benefits for your chosen plan (Plan A, B, C, D, or E). Benefits will be administered as stated in section G, Acute Onset of a Pre-Existing Condition(s), for eligible medical expenses incurred in the United States, minus your Deductible and subject to the scheduled limits for benefits as stated in the Schedule of Benefits. For persons age 70 and over, there is no benefit. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program. Any exclusion specifically listed in General Exclusions and Limitations, numbers 2 through 35, as well as the section entitled Additional Limitations and Exclusions for Elective Surgery and Elective Treatment, will not receive benefits from this waiver;
  • Any expenses incurred when travel was undertaken solely for the purpose obtaining medical treatment or while traveling against the advise of a Physician;
  • Expense incurred within the Insured Person’s Home Country or country of regular domicile;
  • Routine physicals, inoculations, or other examinations where there are no objective indications of impairment of normal health, or well baby care, new-born baby care; well-baby nursery and related Physician charges;
  • Prescriptions or fitting of eyeglasses and contact lenses; eye examinations; or other treatment for visual defects and problems. “Visual defects: means any physical defect of the eye which does or can impair normal vision;
  • Hearing examinations or hearing aids; or other treatment for hearing defects and problems. “Hearing defects: means any physical defect of the ear which does or can impair normal hearing:
  • Dental treatment, except as the result of injury to sound, natural teeth;
  • Services or supplies performed or provided by a Member of the Insured Person’s family, or anyone who lives with the Insured Person;
  • Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
  • Weak, strained or flat feet, corns, calluses, or toenails;
  • Cosmetic surgery, or treatment for congenital anomalies (except as specifically provided), except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or covered Sickness;
  • Elective Surgery and Elective Treatment;
  • Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth;
  • Injury sustained while participating in professional, sponsored and/or organized Amateur or Interscholastic Athletics; including but not limited to the event, games, practice, conditioning and any other activity related to professional sponsored and/or organized Amateur of Interscholastic Athletics;
  • Organ transplants;
  • War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the insured person or the country in, or over, which the act occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the insured person whether war be declared with that state or not, Terrorist activity. For the purpose of this Exclusion; i) Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s). ii) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals. iii) Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals. iv) Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals. Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;
  • Participation in a riot or civil disorder, commission of or attempt to commit a felony in the country in which it was attempted or committed;
  • Suicide or attempted suicide (including drug overdose), while sane or insane (while sane in Missouri), or intentionally self-inflected Injury;
  • Expenses of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;
  • Treatment of nervous or mental disorders, except as stated in the Schedule of Benefits, or treatment of alcoholism or drug abuse, except as provided for treatment of mental or nervous disorders, according to the Schedule of Benefits;
  • Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;
  • Treatment services, supplies or facilities in a hospital owned or operated by: a) The Veteran’s Administration; or b) A national government or any of its agencies. (This exclusion does not apply to treatment when a charge is made which the Insured is required by law to pay);
  • Duplicate services actually provided by both a certified nurse-midwife and Physician;
  • Expenses incurred during a hospital emergency room visit which is not of an emergency nature;
  • Expenses incurred for outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or sublimation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
  • Injury sustained while taking part in mountaineering where ropes or guides are normally used, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snow boarding;
  • Treatment paid for or furnished under any other individual, government, or group plan; previous plan; payable under any Worker’s Compensation or Occupational Disease Law or Act; or charges provided at no cost to the Insured Person;
  • Occupational Diseases, including but not limited to Disease(s) related to asbestos exposure, and the complications thereof, including asbestosis and mesothelioma related to asbestos exposure;
  • Expense incurred after the Expiration Date for an Insured Person except as may be specifically provided;
  • Expenses for treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent or for Injury or Sickness due to wholly or partly to the effects of intoxicating liquor or drugs, unless prescribed by a Physician
  • Sexually transmitted diseases;
  • Pregnancy expenses or Sickness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from Injury; or voluntary or elective abortion;
  • Treatment while confined primarily to receive custodial care, educational or rehabilitative care and nursing services in a long term facility, spa, hydroclinic, weight loss clinic, sanatorium, nursing home or similar facilities;
  • Expenses for Speech therapy, Occupational therapy or Vocational Rehabilitation.
  • Treatment(s) which is incurred by an Insured Person(s) who is HIV Positive (i.e., infected with the human immunodeficiency virus, the cause of acquired immunodeficiency syndrome) at the time of Application for this Insurance, whether or not the Insured Person(s) was asymptomatic or symptomatic or had knowledge of his/her HIV status on the initial Effective Date of Coverage, or any associated diagnostic tests or charges for HIV infection, seropositivity to the AIDS virus, AIDS related Illness(es), ARC Syndrome, AIDS, and all diseases caused by and/or related to HIV;
  • Treatment(s) for HIV, the AIDS virus, AIDS related Illness(es), ARC Syndrome, AIDS, and all diseases and illnesses caused by and/or related to HIV or arising as complications from these conditions including but not limited to the cost of testing for these conditions and/or charges for drug treatment(s) or surgeries;

ADDITIONAL LIMITATIONS AND EXCLUSIONS FOR ELECTIVE SURGERY AND ELECTIVE TREATMENT:

There are no benefits provided for the following: Elective surgery and elective treatment including but not limited to surgery and/or treatment for acne; acupuncture; allergy; includingallergy testing; alopecia; biofeedback-type services; birth control; breast implants; breast reduction; circumcision; corns, calluses and bunions; cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under the Certificate; family planning; fertility tests; gynecomatia; hirsutism; impotence, organic or otherwise; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; learning disabilities; nasal and sinus surgery; nicotine addiction; nonmalignant warts, moles and lesions; obesity and any condition resulting therefrom (including hernia of any kind); patient controlled anesthesia treatment of a covered Injury; sexual reassignment surgery; skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; sleep disorders, including testing thereof; temporomandibular joint dysfunction, tubal ligation; vasectomy; and weight reduction. Elective surgery and elective treatment includes any service, treatment; or supplies that: 1) are deemed by the company to be researched or experimental; or 2) are not recognized and generally accepted medical practices in the United States.

  Age 14 Days To Age 69
Plan A - $25,000
Age 14 Days To Age 69
Plan B -$45,000
Age 14 Days To Age 69
Plan C - $65,000
Age 14 Days To Age 69
Plan D – 85,000
Age 14 Days To Age 69
Plan E - $120,000
Age 70 to Age 99
Plan J - $40,000
Age 70 to Age 99
Plan K - $60,000
Age 70 to Age 99
Plan L - $100,000
Acute Onset of Pre-existing Condition(s) $25,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. $45,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. $65,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. $85,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. $120,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. N/A N/A N/A

ACUTE ONSET OF PRE-EXISTING CONDITION

If you are a non-U.S.citizen under age 70, you are covered for an Acute Onset of a Pre-existing Condition(s) as defined in the Definitions section. This benefit does not apply to insureds age 70 and older. Coverage is provided per Period of Coverage, to the limit shown in the Schedule of Benefits for your chosen plan (Plan A, B, C, D, or E). Your deductible applies to this coverage, and it is paid according to the sublimits for benefits listed in the Schedule of Benefits above.

An Acute Onset of a Pre-existing Condition(s) is defined as a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms and is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the Certificate. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.

EXCLUSION

Pre-existing Conditions as defined herein. If you are a non-U.S. citizen under age 70, this exclusion is waived for eligible medical expenses for an Acute Onset of a Pre-existing Condition(s) (as defined herein) as shown in the Schedule of Benefits for your chosen plan (Plan A, B, C, D, or E). Benefits will be administered as stated in section G, Acute Onset of a Pre-Existing Condition(s), for eligible medical expenses incurred in the United States, minus your Deductible and subject to the scheduled limits for benefits as stated in the Schedule of Benefits. For persons age 70 and over, there is no benefit. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, ortreatments existent or necessary prior to the effective date of this program. Any exclusion specifically listed in General Exclusions and Limitations, numbers 2 through 35, as well as the section entitled Additional Limitations and Exclusions for Elective Surgery and Elective Treatment, will not receive benefits from this waiver;

Your coverage length may vary from 5 days to 180 days. You have the option to renew coverage in any increment of 5 days or more (there is a $5 fee each time you renew). You may apply for a new period of coverage after 180 days if you return to your home country before doing so.

CANCEL

REFUND PROCEDURE :Seven Corners realizes that there is uncertainty in international travel. Refund of total plan cost will only be considered if written request is received by Seven Corners prior to the Effective Date of Coverage. If written request is received after the Effective Date of coverage, the unused portion of the plan cost may be refunded minus a cancellation fee, provided no claim has been submitted to Seven Corners for reimbursement.

If this Certificate provides for cancellation and this Certificate is cancelled after the inception date, earned premium must be paid for the time the insurance has been in force. The Certificate is renewable for up to a total period of one hundred and eighty (180) days. The Company may cancel an entire class of Insured Persons based upon claims experience in a certain region or within a gender / age category.

Cancellation Fee: 25$

Claim

Proof of Loss

Written Proof of Loss, which will include, but not limited to: original signed and dated claim form, original receipts and bills, copies of medical records; must be furnished to Seven Corners, at its said office, within ninety (90) days after the date of such Disablement. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible. In any case, the proof required must be given no later than one (1) year from the time specified except in the absence of legal capacity. The Company at its option may pend resolution and adjudication of submitted claims and/or deny coverage for Proof of Loss submitted thereafter, or for incomplete Proof of Loss and/or failure to submit Proof of Loss.

Claims Submission

  • All claims must be submitted to Seven Corners within 90 days of the date of service.
  • Claims may be mailed, faxed, or scanned. Contact details provided above.
  • A Proof of Loss form must be completed and provided for each medical condition.
  • A copy of your passport with entry/exit/visa stamps is required.
  • Detailed bills for services received and detailed receipts for payments made.
  • A signed authorization from the Insured is necessary to reimburse any person other than the Insured.

Claims Services

Important Note: Claim forms and receipts for medical expenses must be sent to Seven Corners quickly. Claim submissions must be made within ninety (90) after the Date of Service. Should they be received after ninety (90) days, they may be considered ineligible.

To report claims or verify eligibility, send the original bills and claim forms to Seven Corners, Inc., or call or fax to the numbers below. Be certain to include Your ID# shown on the ID Card with all correspondences:

Seven Corners, Inc.

303 Congressional Blvd; Carmel, IN 46032

800-335-0477 or 317-575-2652 FAX 317-575-2256 email: claims@sevencorners.com www.SevenCorners.com

Claim Forms

The Company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing Proofs of Loss. If such forms are not furnished within fifteen (15) days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of the Certificate as to Proof of Loss upon submitting, within the time fixed in the Certificate for filing Proofs of Loss, written proof covering the occurrence, the character and the extent of the Disablement for which claim is made.

Payment of Claims

Subject to any written direction of the Insured Person all or a portion of any indemnities provided by this Certificate on account of Hospital, nursing, medical or Surgical service may, at the Company's option and unless the Insured Person requests otherwise in writing not later than the time for filing proof of such loss, be paid directly to the Hospital or person rendering such services.

Notice of Claim

Written notice of claim must be given to the Company within ninety (90) days after the occurrence or commencement of any Disablement covered by the Certificate, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the claimant to Seven Corners, or to any authorized agent of the Company, with information sufficient to identify the Insured Person shall be deemed notice to the Company.

Legal Actions

Any disputes arising from this Certificate or its alleged breach may, if not resolved by the parties, be referred to arbitration by either party pursuant to the commercial arbitration rules of the American Arbitration Association (“AAA”). Either party may make a demand for arbitration and such arbitration shall be conducted in Carmel, Indiana, and judgment on any award rendered in such arbitration may be entered in any state or federal court in Indiana. Notices in connection with such arbitration and process in any judicial proceeding in connection wherewith may be served by personal delivery or registered mail on the Company at 303 Congressional Boulevard, Carmel, Indiana 46032 and on the Insured Person(s) at the most current address appearing in the records of the Company, with the same effect as if personally served in Carmel, Indiana. Arbitration shall be before a single arbitrator jointly selected by the parties hereto. If the parties are unable to agree on an arbitrator within thirty (30) days after the arbitration demand is filed, the AAA shall select the arbitrator. The arbitration filing fee, if any, and fees of the arbitrator shall initially be shared equally between the parties, provided however, that the prevailing party shall be reimbursed for these costs by the non- prevailing party at the conclusion of the arbitration proceeding. Each side shall bear their own legal fees and costs and any other fees associated with participating in the arbitration process. All fees and expenses of the arbitration shall be borne by the parties equally. The arbitrators are precluded from awarding punitive, treble or exemplary damages, however so denominated. If more than one insured is involved in the same dispute arising out of the same Certificate and relating to the same Loss or claim, all such Insured(s) will constitute and act as one party for the purposes of the arbitration. Nothing in this clause will be construed to impair the rights of the Insured(s) to assert several, rather than joint, claims or defenses No actions at law or in equity shall be brought to recover on the Certificate prior to the expiration of sixty (60) days after written Proof of Loss has been furnished in accordance with the requirements of this Certificate. No such action shall be brought after expiration of three (3) years after the time that written Proof of Loss is required to be furnished.

Service of Suit

It is agreed that in the event of the failure of Underwriters to pay any amount claimed to be due hereunder, Underwriters, at the request of the Assured, will submit to the jurisdiction of a Court of competent jurisdiction within the United States. Nothing in this Clause constitutes or should be understood to constitute a waiver of Underwriters’ rights to commence an action in any Court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another Court as permitted by the laws of the United States or of any State in the United States. It is further agreed that service of process in such suit may be made upon Mendes and Mount; 750 Seventh Avenue; New York, NY 10019-6829 USA (For California residents, contact Eileen Ridley, FLWA Service Corp., c/o Foley & Lardner LLP, 555 California Street, Suite 1700, San Francisco, CA 94104-1520 USA.), and that in any suit instituted against any one of them upon this contract, Underwriters will abide by the final decision of such Court or of any Appellate Court in the event of an appeal.The above-named are authorized and directed to accept service of process on behalf of Underwriters in any such suit and/or upon request of the Assured to give a written undertaking to the Assured that they will enter a general appearance upon Underwriters’ behalf in the event such a suit shall be instituted. Further, pursuant to any statute of any state, territory or district of the United States which makes provision therefor, Underwriters hereby designate the Superintendent, Commissioner or Director of Insurance or other officer specified for that purpose in the statute, or his successors in office, as their true and lawful attorney upon whom may be served any lawful process in any action, suit or proceeding instituted by or on behalf of the Assured or any beneficiary hereunder arising out of this contract of insurance, and hereby designate the above-mentioned as the person to whom the said officer is authorized to mail such process or a true copy thereof.