All Coverage and Benefits are in U.S. Dollar Amounts:
|Accidental Death & Dismemberment||$25,000|
Accident and Sickness
Medical policy maximum
Amount chosen - maximum
Amount chosen - $100 or
80% to $5,000, then 100%
to policy maximum
Only 60% will be paid if not
Incidental trips to your Home
60 days per 12 months of
coverage up to $25,000
|Extension of benefits||30 days up to $5,000|
$200 per tooth, maximum
|Return of Minor Children||$5,000|
Repatriation of Mortal
|Emergency Medical Reunion||$10,000|
Baggage and Personal
|Optional Sports Rider||
Available up to Plan
[NOTICE TO ALL RESIDENTS:]
You may cancel insurance under the Policy by giving the Company or the agent written notice within the first to occur of the following: (a) 14 days after the Effective Date of Your insurance; or (b) Your Scheduled Departure Date. If You do this, the Company will refund Your premium paid provided no Insured has filed a claim under the policy.
"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.
"Airworthiness Certificate" as used in this Hazard shall mean the "Standard" Airworthiness Certificate issued by the Federal Aviation Agency of the United States or its foreign equivalent issued by the government authority having jurisdiction over civil aviation in the country of its registry.
"Amateur or Interscholastic Athletics" shall mean a sponsored and/or organized league.
"Assistance Company" means the service provider with which the Company has contracted to coordinate and deliver Emergency travel assistance, medical evacuation, and repatriation.
"Benefit Period" means the allowable time period the Insured Person has from the date of Injury or onset of Illness to receive Treatment for a covered Injury or Illness.
"Child" shall mean the Insured Person's step-child or a Child under the Insured Person's legal guardianship, but only if such Child depends on the Insured Person's support and maintenance and lives with the Insured Person in a parent-Child relationship. The term Child does not include a foster Child who is eligible for benefits provided by a governmental program or law, unless required by the law of the State.
"Coinsurance" shall mean the percentage amount of eligible Covered Expenses, after the Deductible, which are the responsibilities of the Insured Person and must be paid by the Insured Person. The Coinsurance amount is stated in Your Schedule of Coverage and Service, under each stated benefit.
"Common Carrier" shall mean any land, sea, and/or air conveyance operating under a valid license for the transportation of passenger for hire.
"Covered Expenses" shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment; due to Illness or Injury; prescribed, performed or ordered by a Physician; Reasonable and Customary charges; incurred while insured under the policy; and which do not exceed the maximum limits shown in Your Schedule of Coverage and Service, under each stated benefit.
"Deductible" shall mean the amount of eligible Covered Expenses which are the responsibility of each Insured Person and must be paid by each Insured Person before benefits under the Policy are payable by the Company. The Deductible amount is stated in Your Schedule of Coverage and Service, under each stated benefit.
"Dentist" shall mean a legally licensed doctor of dental Surgery; dental medicine or dental science. A dental hygienist who works within the scope of his/her license, under the supervision of a Dentist, is a covered practitioner.
"Dependent" shall mean the spouse who is legally married to the Insured Person; the Insured Person's unmarried Child from 30 days until his/her 19th birthday; or the Insured Person's unmarried Child who is over 18 years old but not older than 25 years old and is enrolled as a full-time student at an accredited school or college and is not employed on a full-time basis and is dependent on the Insured Person for his/her support and maintenance. The age limits that apply to Dependent Child(ren) will not apply to any insured Child of the Insured Person who remains dependent on the Insured Person for support and maintenance because he or she becomes incapable of working due to a physical handicap or retardation which occurs: before reaching the age limit; and while insured under the policy or any prior plan, provided such Child was insured on the date of termination of the prior plan.
"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 the policy.
"Effective Date" shall mean the date the Insured Person's coverage under the policy begins. The Effective Date is the later of the following:
"Elective Surgery" means Surgery or medical Treatment which is not necessitated by a pathological or traumatic change in the function or structure in any part of the body first occurring after the Insured's effective date of coverage. Elective Surgery includes, but is not limited to, circumcision, tubal ligation, vasectomy, breast reduction, sexual reassignment Surgery, and submucous resection and/or other surgical correction for deviated nasal septum, other than for necessary Treatment of covered acute purulent sinusitis. Elective Surgery does not apply to cosmetic surgery required to correct a covered Accident.
"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.
"Experimental/Investigational" means all services or supplies associated with: 1) Treatment or diagnostic evaluation which is not generally and widely accepted in the practice of medicine in the United States of America or which does not have evidence of effectiveness documented in peer reviewed articles in medical journals published in the United States. For the Treatment or diagnostic evaluation to be considered effective such articles should indicate that it is more effective than others available: or if less effective than other available Treatments or diagnostic evaluations, is safer or less costly; 2) A drug which does not have FDA marketing approval; 3) A medical device which does not have FDA marketing approval; or has FDA approval under 21 CFR 807.81, but does not have evidence of effectiveness for the proposed use documented in peer reviewed articles in medical journals published in the United States. For the devise to be considered effective, such articles should indicate that it is more effective than other available devices for the proposed use; or if less effective than other available devices, or is safer or less costly. The company will make the final determination as to whether a service or supply is Experimental/Investigational.
"Family Member" shall mean a spouse, parent, sibling or Child of the Insured Person.
"Home Country" shall mean the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.
"Hospital" as used in the policy shall mean except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and Treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision and means 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 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 Doctors. 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.
"Host Country" shall mean any country other than the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.
"Illness" wherever used in the policy shall mean Sickness or disease of any kind contracted and commencing after the Effective Date of the insurance and Disablement covered by the policy.
"Incident" or "Occurrence" shall mean all Illnesses that exist simultaneously and which are due to the same or related causes are considered to be one Incident. Further, if an Illness is due to causes which are the same as or related to the causes of a prior Illness, the Illness will be deemed to be a continuation of the prior Illness and not a separate Incident. All Injuries due to the same Accident shall be deemed to be one Incident.
"Individual Coverage Term" means the period of time beginning when the Insured Person has been enrolled for coverage under the Policy and for whom the required premium has been paid and ending on the termination date as described in the Schedule of Coverage and Service.
"Injury" wherever used in the policy shall mean bodily Injury caused solely and directly by violent, Accidental, external, and visible means occurring while the policy is in force and resulting directly and independently of all other causes in Disablement covered by the policy. Any loss due to Injury must begin after the Effective Date of the policy.
"Inpatient" shall mean an Insured Person who is confined in an institution and is charged for room and board.
"Insured Person(s)" shall mean a person who has applied for coverage and is named on the enrollment form and for whom the company has accepted premium. This may be the Insured Person or Dependent(s) as shown in the Schedule of Coverage and Service. Insured Persons are also referred to as You and Your.
"Loss" in reference to quadriplegia, paraplegia, hemiplegia, and uniplegia, shall mean the complete and irreversible paralysis of such limbs and with regard to hands and feet, actual severance through and above the wrist or ankle joints, and with regard to eyes, entire irrecoverable Loss of sight and with regard to thumb and index finger, actual severance through or above the joint that meets the finger at the palm. Loss in reference to other coverages shall mean injury or damage sustained by the Insured in consequence of happening of one or more of the accidents against which the Company has undertaken to indemnify the Insured.
"Medically Necessary" or "Medical Necessity" shall mean services and supplies received by the Insured Person that are determined by the Company to be: 1) appropriate and necessary for the symptoms, diagnosis, 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 or unproven, as recognized by the organized medical community, or which are used for any type of research program or protocol; 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, supply, or level of care does not, of itself, make such Treatment Medically Necessary or make the charge a Covered Expense under the policy.
"Medicine" or "Medications" shall mean the drugs
prescribed or dispensed to the Insured Person, by a licensed
Physician, as a result of a Covered Expense. Medicine or Medication
shall mean the generic equivalent of a drug, or if the generic
equivalent is not available, the brand name drug.
Mental and Nervous Disorder" shall mean any condition or disease listed in the most recent edition of the International Classification of Diseases as a mental disorder, which exhibits clinically significant behavioral or psychological disorder marked by a pronounced deviation from a normal healthy state and associated with a present painful symptom or impairment in one or more important areas of functioning. This disease must not be merely an expectable response to a particular stimulus. Mental Illness does not mean learning disabilities, attitudinal disorders or disciplinary problems.
"Outpatient" shall mean an Insured 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 confined and is not charged for room and board.
"Participating Provider Network" shall mean the Hospitals, Physicians, or other Service Providers who have entered into a contractual agreement with the Company to provide Hospital and medical services to Insured Persons at negotiated fee.
"Physician" as used in the policy 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, however, such definition will exclude chiropractors and physiotherapists.
"Pre-Certification" and "Pre-Certify" shall mean the Company, following advance notification for all Hospital admissions worldwide, or for any Outpatient Surgery or Covered Expenses will provide the Insured Person with the names and addresses of United States Hospitals that are members of the Participating Provider Network, to which the Insured Person may have access, and confirm that such confinement is Medically Necessary.
"Pre-existing Condition" for the purposes of the policy shall mean 1) a condition that would have caused a person to seek medical advice, diagnosis, care or Treatment during the 36 months prior to the Effective Date of coverage under the policy; 2) a condition for which medical advice, diagnosis, care or Treatment was recommended or received during the 36 months prior to the Effective Date of coverage under the policy.
"Reasonable and Customary" shall mean the maximum amount that the Company determines is Reasonable and Customary for Covered Expenses 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 locality where received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; 2) any usual medical circumstances requiring additional time, skill or experience; and 3) 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, 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 its agreement with the Company.
"Registered Nurse" shall mean a graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other jurisdictional authority, and who is legally entitled to place the letters "R.N." after his or her name.
"Relative" shall mean spouse, parent, sibling, Child, grandparent, grandchild, step-parent, step-child, step-sibling, in-laws (parent, son, daughter, brother and sister), aunt, uncle, niece, nephew, legal guardian, ward, or cousin of the Insured Person.
"Scheduled Departure Date" means the date on which the Insured Person is originally scheduled to leave on the Trip.
"Scheduled Return Date" means the date on which the Insured Person is originally scheduled to return to the point of origin or to a different final destination.
"Service Provider" shall mean a Hospital, 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, Registered Nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves.
"Sickness" means illness or disease contracted and causing loss commencing while coverage under the Policy is in force as to the Insured Person whose Sickness is the basis of claim. Any complication or any condition arising out of a Sickness for which the Covered Person is being treated or has received Treatment will be considered as part of the original Sickness.
"Surgery" shall mean an invasive diagnostic 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.
"Treatment" means a specific in-office or Hospital physical examination of, care rendered to, the Insured Person."
"Unexpected" means not anticipated or expected and occurring after the effective date of the Policy.
SCOPE OF COVERAGE
Benefits are payable for the items stated in Your Schedule of Coverage and Service. Benefits shall be payable to either the Insured Person or the Service Provider for Covered Expenses incurred outside the Insured Person's Home Country except for Home Country coverage as stated in Your Schedule of Coverage and Service, Home Country Coverage. The Insured Person must utilize the Company's Pre-Certification Program. Failure to utilize the Pre-Certification Program will result in a 40% reduction of Covered Expenses.
The charges enumerated herein shall in no event include any amount of such charges which are in excess of Reasonable and Customary charges. If the charge incurred is in excess of such average charge such excess amount shall not be recognized as a Covered Expense. All charges shall be deemed to be incurred on the date such services or supplies, which give rise to the expense or charge, are rendered or obtained.
Accidental Death and Dismemberment Insurance is afforded to an Insured Person which shall apply only to Injury, as defined in Section I, Definitions, sustained by such Insured Person during the course of coverage. Such Insurance includes such Injury which occurs during the course of time the Insured Person is covered under the Policy;
The Company shall pay an indemnity determined from Your Schedule of Coverage and Service Accidental Death and Dismemberment, Table of Losses, if an Insured Person sustains a Loss stated therein resulting from Injury, provided that:
Exposure: If by reason of an Accident covered by the Policy an Insured Person is unavoidably exposed to the elements and as a result of such exposure suffers a Loss for which the Principal Sum is otherwise payable hereunder such Loss will be covered under the terms of the policy.
Disappearance: If the body of an Insured Person has not been found within one year of the disappearance, forced landing, stranding, sinking, or wrecking of a conveyance in which such Insured Person was an occupant, then it shall be deemed, subject to all other terms and provisions of the Policy, that such Insured Person shall have suffered Loss of life within the meaning of the Policy.
Beneficiary Designation and Change: The beneficiary or beneficiaries of an Insured Person shall be that person or those persons designated by the Insured Person and filed with the Company. Any Insured Person who has not made an irrevocable designation of beneficiary may designate a new beneficiary at any time, without the consent of the beneficiary, by filing with the Company a written request for such change but such change shall become effective only upon receipt of such request at the office of the Company. When such request is received by the Company, whether the Insured Person be then living or not, the change of beneficiary shall relate back to and take effect as of the date of execution of the written request, but without prejudice to the Company on account of any payment theretofore made by it.
The Company will pay Covered Expenses due to Accident and Sickness as per the limits stated in Your Schedule of Coverage and Service, Accident and Sickness Medical. Coverage is limited to Covered Expenses incurred subject to Section III, Exclusions. All bodily Injuries sustained in any one Accident or Sickness shall be considered one Disablement; all bodily disorders existing simultaneously which are due to the same or related causes shall be considered one Disablement. If a Disablement is due to causes which are the same or related to the cause of a prior Disablement (including complications arising there from), the Disablement shall be considered a continuation of the prior Disablement and not a separate Disablement. When a covered Injury is incurred by the Insured Person the Company will pay Reasonable and Customary medical expenses of the Deductible and Coinsurance as stated in Your Schedule of Coverage and Service, Accident and Sickness Medical. In no event shall the Company's maximum liability exceed the maximum stated in Your Schedule of Coverage and Service for Accident and Sickness Medical, as to Covered Expenses during any one period of individual coverage.
The Deductible and Coinsurance amount consists of Covered Expenses which would otherwise be payable under the policy. These expenses must be borne by the Insured Person.
Covered Accident and Sickness Medical Expenses: For the purpose of this section, only such expenses, incurred as the result of a Disablement, which are specifically enumerated in the following list of charges, and which are not excluded in Section III, Exclusions, shall be considered as Covered Expenses:
Accident and Sickness Medical Incidental Home Country Benefit Period. As an accommodation and supplemental benefit, the Insured Person will be covered under this insurance during incidental return trips to his/her Home Country ("Incidental Trips") up to a cumulative total of sixty (60) days during the Period of Coverage, provided that:
Extension of Benefits: Those Covered Expenses that are incurred inside the Insured Person's Home Country related to an Illness or Injury which occurred outside the Insured Person's Home Country and during the period of coverage shall be paid. Covered Expenses described in (1 through 10) above which are incurred in the Insured Person's Home Country are limited to 30 days, and the maximum stated in Your Schedule of Coverage and Service, Accident and Sickness Medical, Extension of Benefits.
When covered Dental expenses are incurred by the Insured Person the Company will pay Reasonable and Customary expenses in excess of the Deductible and Coinsurance as stated in Your Schedule of Coverage and Service, Dental. In no event shall the Company's maximum liability exceed the maximum stated in Your Schedule of Coverage and Service, Dental, as to Covered Expenses during any one period of individual coverage.
For the purpose of this section, only such expenses, incurred as the result of an eligible Dental condition, in which services or Medications are prescribed, performed, or ordered by a Dentist and enumerated below, and which are not excluded in Section III, Exclusions, shall be considered as Covered Expenses. With respect to Accidental Dental, an eligible Dental condition shall mean emergency dental repair or replacement to sound, natural teeth damaged as a result of a covered Accident.
EMERGENCY MEDICAL EVACUATION/REPATRIATION
The Company will pay, subject to the limitations set out herein, for Covered Emergency Evacuation Expenses reasonably incurred if the Insured suffers an Injury or Emergency Sickness that warrants his or her Emergency Evacuation while covered under the policy. Benefits payable are subject to the Maximum Amount per Insured shown in Your Schedule of Coverage and Service for all Emergency Evacuations due to all Injuries from the same Accident or all Emergency Sicknesses from the same or related causes.
A legally licensed Physician, in coordination with the Assistance Company, must order the Emergency Evacuation and must certify that the severity of the Insured's Injury or Emergency Sickness warrants his or her Emergency Evacuation to the closest adequate medical facility. It must be determined that such Emergency Evacuation is required due to the inadequacy of local facilities.
The certification and approval for Emergency Evacuation must be coordinated through the most direct and economical conveyance and route possible, such as air or land ambulance, or commercial airline carrier.
Covered Emergency Evacuation Expenses are those for Medically Necessary Transportation, including Reasonable and Customary medical services and supplies incurred in connection with the Emergency Evacuation of the Insured. Expenses for Transportation must be: (a) recommended by the attending Physician; and (b) required by the standard regulations of the conveyance transporting the Insured. and(c) reviewed and pre-approved by the Assistance Company;
The Company will also pay reasonable and customary charges, up to the maximum escort limit shown on the Policy, for escort expenses required by the Insured, if the Insured is disabled and an escort is recommended in writing, by the Company's attending Physician and must be pre-approved by the Assistance Company.
Emergency Evacuation - means the Insured Person's medical condition warrants immediate transportation from the place where the Insured is injured or sick to the nearest Hospital where appropriate medical treatment can be obtained;
Emergency Sickness - means an Illness or disease, diagnosed by a legally licensed Physician, which meets all of the following criteria: (1) there is a present severe or acute symptom requiring immediate care and the failure to obtain such care could reasonably result in serious deterioration of the Insured's condition or place his or her life in jeopardy; (2) the severe or acute symptom occurs suddenly and unexpectedly; and (3) the severe or acute symptom occurs while coverage is in force while the Insured suffers the symptom.
Transportation - means any land, sea or air conveyance required to transport the Insured Person during an Emergency Evacuation. Transportation includes, but is not limited to, Common Carrier, air ambulances, land ambulances and private motor vehicles.
RETURN OF MINOR CHILDREN
If the Insured Person is hospitalized following a Covered Emergency Evacuation Expense, the Company will pay subject to the limitations set out herein, for expenses to return to where they reside with an attendant if necessary, any of the Insured Person's Dependent Children who were accompanying the Insured when the Injury or Emergency Sickness occurred; but not to exceed the cost of a single one-way economy airfare ticket less the value of applied credit from any unused return travel tickets per person.
RETURN OF MORTAL REMAINS
The Company will pay the reasonable Covered Expenses incurred to return the Insured Person's body to their primary residence if he/she dies while covered under the policy. This will not exceed the maximum stated in Your Schedule of Coverage and Service, Return of Mortal Remains.
Covered Expenses include, but are not limited to, expenses for embalming, cremation, casket for transport and transportation.
All Covered Expenses in connection with a return of mortal remains must be pre-approved and arranged by the Assistance Company.
EMERGENCY MEDICAL REUNION
When an Insured Person is traveling alone and is going to be hospitalized, the Company will arrange and pay for round-trip economy-class transportation for one individual selected by the Insured Person from the Insured Person's Home Country to the location where the Insured Person is hospitalized and return to the current Home Country. The benefits payable will include:
All transportation in connection with an Emergency Medical Reunion must be pre-approved and arranged by the Assistance Company.
BAGGAGE AND PERSONAL EFFECTS
The Company will reimburse the Insured Person for theft or damage to baggage and personal effects, checked with a Common Carrier provided the Insured Person has taken all reasonable measures to protect, save and/or recover his/her property at all times. The baggage and personal effects must be owned by and accompany the Insured Person at all times.
There will be a per article limit of $50. There will also be a combined maximum limit of $250.
The Company will pay the lesser of the following:
Coverage is provided for losses (after the Effective Date) the Insured Person incurs due to the interruption of the Insured Person's trip if caused by:
OPTIONAL SPORTS RIDER:
If the optional Hazardous Sport Coverage is purchased: benefits will be paid if the Insured Person is injured while participating in any of the following sports: mountaineering where ropes or guides are normally used (4500 meter limit), parachuting, bungee jumping, snowmobiling, scuba diving involving underwater breathing apparatus, snorkeling, water skiing, snow skiing, spelunking, and snow boarding
For benefits listed in Your Schedule of Coverage and Service, Accidental Death and Dismemberment, this Insurance does not cover:
For benefits listed in Your Schedule of Coverage and Service, Accident Medical, Sickness Medical, In-Hospital Indemnity, Unexpected Recurrence, Dental, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Emergency Medical Reunion, Trip Interruption, this Insurance does not cover:
Hazardous Sport Coverage: the following are covered if the required premium has been paid: mountaineering where ropes or guides are normally used (4500 meter limit), parachuting, bungee jumping, snowmobiling, scuba diving involving underwater breathing apparatus, snorkeling, water skiing, snow skiing, spelunking, and snow boarding;
For benefits listed in Your Schedule of Coverage and Service, Baggage Loss, this Insurance does not cover:
To facilitate prompt claims settlement:
TRIP INTERRUPTION: Contact the travel supplier and the administrator as soon as possible after the event causing the need to cancel. Obtain medical statements from the doctors in attendance in the country where Sickness or Accident occurred. These statements should give complete diagnosis, stating that the Sickness or Accident prevented traveling on dates contracted. Provide all unused transportation tickets, official receipts, etc.
MEDICAL EXPENSES: Obtain receipts from the providers of service, etc., stating the amount paid and listing the diagnosis and treatment.
BAGGAGE: Obtain a statement from the Common Carrier that the Insured Person's baggage was delayed or a police report showing baggage was stolen along with copies of receipts for the Insured Person's purchases.
FOR PLAN INQUIRIES OR INFORMATION ON FILING A CLAIM PLEASE CONTACT:
MEDEX Insurance Services at 1-800-739-5309 or 1-410-453-6380.
Conformity With State Statutes: Any provision of the Policy which, on its effective date, is in conflict with the statutes of the state in which the Policy was delivered or issued for delivery is hereby amended to conform to the minimum requirements of such statues.
Individual Period of Coverage: An Insured Person's Coverage is in effect for a stated term as shown on the Schedule of Coverage and Service. The insurance is not renewable.
When An Insured Person's Coverage Begins: All coverage will take effect at 12:01 A.M. local time, at the location of the Insured Person, on the latest of the following: 1.) The Date the Company receives a completed enrollment form and premium for the Individual Period of Coverage, or 2.) The Effective Date requested on the enrollment form, or 3.) The moment the Insured Person departs their Home Country provided 1.) coverage has been elected, and 2) the required premium has been paid.
When an Insured Person's Coverage Ends: Individual coverage will terminate upon the earlier of the following: 1.) The moment the Insured Person returns to their Home Country, unless otherwise covered under the Insured Person's Policy; or 2.) The expiration of twelve months from the Effective Date of Coverage; or 3.) The date shown on the Schedule issued by the Company; or 4.) The end of the period for which premium has been paid; or 5.) The Date the Insured Person fails to be considered an Eligible Person; or 6.) The insurance does not renew.
Assignment: The Insurance provided hereunder is not assignable, but benefits may be assigned in accordance the Payment of Claims provision.
Renewal of Individual Insurance: The initial Period of Coverage cannot exceed twelve (12) months.
Not in Lieu of Worker's Compensation: The Policy is not in lieu of and does not affect any requirements for coverage by Worker's Compensation Insurance.
Aggregate Limit of Indemnity: The Aggregate Limit of Indemnity stated in Your Schedule of Coverage and Service Accidental Death and Dismemberment, shall be the total limit of the Company's liability for all independents 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.
Excess Benefits: All coverages, except Accidental Death and Dismemberment, shall be in excess of all other valid and collectible Insurance Indemnity and shall apply only when such benefits are exhausted.
Monetary Limits: The monetary limits stated in the policy and the premium shall be in U.S. dollars. For service outside of the territorial limits of the United States, the exchange rate date used to determine the amount of U.S. dollars to be paid is the exchange rate effective for the date the claims expense was incurred.
Subrogation: To the extent the Company pays for a loss suffered by an Insured, the Company will take over the rights and remedies the Insured had relating to the loss. This is known as subrogation. The Insured must help the Company to preserve its rights against those responsible for the loss. This may involve signing any papers and taking any other steps the Company may reasonably require. If the Company takes over an Insured's rights, the Insured must sign an appropriate subrogation form supplied by the Company.
An Insured Person must follow the Pre-Certification Program in order to receive full benefits under the Policy. If the Insured Person does not properly follow the Pre-Certification Program, their benefits under the Policy will be reduced, as described below. The Insured Person is responsible for obtaining any required Pre-Certification for all Hospital admissions or transplants worldwide, or for any Outpatient Surgery or Covered Expenses. The Insured Person or someone on his behalf, must notify the Company prior to Treatment, by telephoning the Company's Assistance Company. The telephone number of the Assistance Company is shown on the Insured Person's Identification Card.
The Pre-Certification Program requires that the Insured Person obtain Pre-Certification (unless otherwise noted herein) for the following: For Scheduled Hospital Admissions, Outpatient Treatments or Covered Expenses, and transplants: The Pre-Certification Program requires that the Insured Person, or someone on their behalf, contact the Assistance Company as soon as possible, but not less than 48 hours, prior to the date of admission for any Scheduled Hospital Confinement or Scheduled Treatment, to obtain the following:
If additional days of Hospital confinement are necessary beyond the initial number of Pre-Certified days, the attending Physician or an official representative of the facility where the Insured Person is confined, must contact the Company (no later than the last day originally Pre-Certified) to obtain Pre-Certification for any additional days of Hospital confinement. The Company will review with the attending Physician the request for the additional days of Hospital confinement.
A list with the name(s) and address(es) of the United States Hospitals that are members of the Participating Provider Network, to which the Insured Person will have access as an Insured Person under the Policy. The Insured Person must use a Hospital which is a member of the Participating Provider Network in order to receive full benefits under the Policy, as described below.
For Emergency Hospital confinements: The Pre-Certification Program requires that the Insured Person, or someone on their behalf, contact the Company as soon as possible, but no later than 48 hours after the date of admission to a Hospital in case of Emergency.
For Transplants Worldwide: The Insured Person, or someone on their behalf, must contact the Company immediately, but not later than 48 hours after the Insured Person is identified by the attending Physician, as a candidate for a bone marrow, cornea, heart, heart and lung, single lung, pancreas and kidney, or liver transplant, and at least 2 days prior to any scheduled admission to a Hospital.
PRE-CERTIFICATION. PROGRAM EFFECT ON BENEFITS: Subject to all provisions of the Policy, when the requirements of the Pre-Certification Program are properly followed and the Hospital admission or transplant Treatment is Pre-Certified, benefits for Covered Expenses will be payable as described in Your Schedule of Coverage and Service and in any amendments of endorsements to the Policy.
If an Insured Person does not properly follow the Pre-Certification Program and if the required Pre-Certification is not obtained, the benefit percentage payable for Covered Expenses incurred for all Treatment, services, and supplies related to the Disablement will be reduced to and payable at 60% (whether or not the Coinsurance has been met), after any Deductible amount which may apply. The reduction in the benefit percentage payable will not apply where there is no Participating Provider Network Hospital in the city or immediate vicinity where the Insured Person is to be Hospitalized, provided the Insured Person complied with the Pre-Certification requirements.
The additional amounts an Insured Person is required to pay as a result of the lower percentage payable due to not following this Pre-Certification Program will not be used to satisfy any Deductible amount or the Coinsurance in the Policy.
PRE-CERTIFICATION DOES NOT GUARANTEE BENEFITS: Benefits payable under the Policy are still subject to eligibility at the time charges are actually incurred, and to all other terms, limitations, and exclusions of the Policy. Pre-Certification does not guarantee or confirm benefits under the Policy.
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