TripMed Multi-Trip
Plan Details
TripMed Multi-Trip Travel Medical Plan
Evidence of Benefits
U.S. citizens with a current passport traveling outside their Home Country. Home Country will mean where you have your true, fixed and permanent home and principal establishment.
Eligible individuals may also purchase coverage for their eligible dependents. An eligible spouse shall be defined as the Primary Insured’s legal spouse. An Eligible Dependent Child shall mean the Primary Insured Person’s unmarried children over thirty (30) days and under nineteen (19) years of age or under twenty-five (25) years of age if they are attending an accredited institution of higher learning on a regular full-time basis and/or wholly dependent upon the Insured Person for maintenance and support.
Destination Restrictions: OFAC restricted countries
Effective Date of Coverage begins on the latest of the following:
1. The Date the Company receives a completed application and premium for the Policy Period; or
2. The Effective Date requested on the application; or
3. The moment the Insured Person departs their Home Country airspace.
Expiration Date of Coverage terminates on the earlier of the following:
1. The expiration of twelve (12) months from the Effective Date of Coverage; or
2. The date shown on the certificate issued by the Company; or
3. The end of the period for which premium has been paid; or
4. The Date the Insured Person fails to be considered an Eligible Person; or
5. The maximum benefit amount has been paid.
SCHEDULE OF BENEFITS:
| All Coverages and Benefits are in U.S. Dollar Amounts | |
|
Medical Maximums Accident Medical; Sickness Medical |
Per Injury or Illness $500,000 Age 70 – 79: $100,000 Age 80 and Over: $10,000 |
|
Deductible – Per Injury or Illness (Your Deductible option as selected during enrollment as shown on Your Confirmation of Benefits) |
$0 or $100 or $250 |
| Coinsurance | Payable at 100% to Medical Maximum |
| Benefit Period | Period of Coverage |
| Dental (Emergency) | $100 per tooth to a maximum of $500 |
| Dental (Palliative) | To a maximum of $100 |
| Emergency Medical Evacuation | Up to $500,000 per Period of Coverage |
| Return of Mortal Remains/Cremation | Up to $25,000 per Period of Coverage |
| Emergency Reunion | Up to $25,000 per Period of Coverage |
| Return of Minor Children | Up to $10,000 per Period of Coverage |
| In-Hospital Indemnity | Up to $100 a day, up to a maximum of 30 days |
| Unexpected Recurrence of a Pre-existing Condition | Up to $10,000, Benefit Period 30 days |
| Interruption of Trip | Up to $5,000 per Period of Coverage |
| Loss of Baggage | Up to $250 per Period of Coverage |
|
Accidental Death & Dismemberment (“AD&D”) For Any Reason: Result of a Common Carrier: Aggregate Limit of Indemnity per Accident: |
Principal Sum: $10,000 per Insured; $5,000 per Spouse/Dependent Child $25,000 per Insured/Spouse; $10,000 per Dependent Child Five times the Principal Sum |
| Assistance | 24 hours – Worldwide |
DESCRIPTION OF BENEFITS:
Medical Expenses:
This Plan shall pay Reasonable and Customary charges for Covered Expenses, excess of the Deductible and Coinsurance up to the Medical Maximum, incurred by you, due to an accidental Injury or Illness which occurred during the Period of Coverage outside your Home Country. 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, the Disablement shall be considered a continuation of the prior Disablement and not a separate Disablement. The initial Treatment of an Injury or Illness must occur within thirty (30) days of the date of Injury or onset of Illness.
Only such expenses which are specifically enumerated in the following list of charges are incurred within the Benefit Period, and which are not excluded, shall be considered Covered Expenses:
1) Charges made by a Hospital for semi-private room and board, floor nursing and other services inclusive of charges for professional service and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the Hospital’s average charge for semiprivate room and board accommodation.
2) Charges made for Intensive Care or Coronary Care charges and nursing services.
3) Charges made for diagnosis, Treatment and Surgery by a Physician.
4) Charges made for an operating room.
5) Charges made for Outpatient Treatment, same as any other Treatment covered, on an Inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion consultations.
6) Charges made for the cost and administration of anesthetics.
7) Charges for Medication, X-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood, transfusions, iron lungs, and medical Treatment.
8) Charges for physiotherapy, to a maximum of $500, if recommended by a Physician for the Treatment of a specific Disablement and administered by a licensed physiotherapist.
9) Dressings, drugs, and Medicines that can only be obtained upon a written prescription of a Physician or Surgeon.
10) Local transportation to or from the nearest Hospital, or to and from the nearest Hospital with facilities for required Treatment. Such transportation shall be by licensed ground ambulance only to a limit of $350, within the metropolitan area in which you are located at that time the service is used. If you are in a rural area, then licensed air ambulance transportation to the nearest metropolitan area shall be considered a Covered Expense.
Extension of Benefits:
Your coverage will be extended if you are Hospital confined for a Covered Injury or Illness and under the care of a Physician on the termination date of your Period of Coverage. Coverage will terminate on the earlier of the following:
1) 30 days from the end of you Period of Coverage; or
2) The maximum benefit has been paid; or
3) Your release from the hospital or Physician care.
Benefits are paid for Reasonable and Customary expenses in excess of the Deductible and Coinsurance of $100 per tooth up to a maximum of $500, for the emergency repair or replacement to sound, natural teeth damaged as the result of a Covered Accident.
Dental – Relief of Pain (Palliative): This plan shall pay in excess of the Deductible and Coinsurance up to a maximum of $100, for emergency treatment for the relief of pain to natural teeth.
Benefits are paid for Covered Expenses incurred up to the maximum as stated in the Schedule of Benefits, for any covered Injury or Sickness commencing during the Period of Coverage that result in a Medically Necessary Emergency Medical Evacuation or Repatriation. The decision for an Emergency Medical Evacuation or Repatriation must be pre-approved and arranged by the Assistance Company in consultation with your local attending Physician.
Emergency Medical Evacuation or Repatriation means: a) your medical condition warrants immediate transportation from the place where you are located (due to inadequate medical facilities) to the nearest adequate medical facility where medical Treatment can be obtained; or b) after being treated at a local medical facility, your medical condition warrants transportation with a qualified medical attendant to your Home Country to obtain further medical Treatment or to recover; or c) both a) and
b) above.
Covered Expenses are expenses for transportation, medical services and medical supplies necessarily incurred in connection with Emergency Medical Evacuation or Repatriation. All transportation arrangements must be by the most direct and economical route. Expenses for special transportation and medical supplies and services must be: a) pre-approved and ordered by the Assistance Company and b) required by the standard regulations of the conveyance transportation. Transportation means any land, water or air conveyance required to transport you. Special transportation includes, but is not limited to, licensed ground and air ambulances, commercial airlines, and private motor vehicles.
Return of Mortal Remains/Cremation:
Benefits will be paid for Reasonable and Customary Covered Expenses incurred up to the maximum as stated in the Schedule of Benefits, to return your remains to your Home Country, if you should die. Covered Expenses include, but are not limited to, expenses for embalming or Cremation, a minimally necessary container appropriate for transportation, shipping costs, and the necessary government authorizations. All Covered Expenses in connection with a Return of Mortal Remains or Cremation must be pre-approved and arranged by the Assistance Company.
Emergency Medical Reunion:
When the Assistance Company and your attending Physician determine that it is necessary and prudent for you to have an Emergency Medical Evacuation or Repatriation, this Plan will arrange to bring an individual of your choice, from your current Home Country, to be at your side while you are hospitalized and then accompany you during your return to your current Home Country. Benefits will be paid up to the maximum as stated in the Schedule of Benefits for a round-trip economy airfare ticket as well as for reasonable travel and accommodation expenses up to a maximum of ten (10) days, as pre-approved and arranged by the Assistance Company.
Return of Minor Child(ren):
Should you be traveling alone and are hospitalized because of a covered Injury or Sickness and your Minor Child(ren) is left unattended, this Plan will arrange for a one way economy fare(s) to your current Home Country. If an attendant/escort is necessary to ensure the safety and welfare of your Minor Child(ren), this Plan will also arrange these services. The Plan will
pay for these services up to the maximum as stated in the Schedule of Benefits, provided all transportation and services are pre-approved and arranged by the Assistance Company. Meals and lodging are your responsibility.
In Hospital Indemnity:
If you are confined to a Hospital as a registered inpatient as the result of an Injury or Sickness which first occurs during your Period of Coverage and that Injury or Sickness is not covered under this Plan, this Plan will pay benefits up to $100 per day of confinement up to a maximum of thirty (30) days.
Benefits shall be paid up to the maximum as stated in the Schedule of Benefits, subject to the Deductible and Coinsurance, for Covered Expenses resulting from a sudden and unforeseen recurrence of a Pre-Existing Condition, as defined hereunder, while traveling outside the United States. Only such expenses which are incurred within thirty (30) days from the date of recurrence of Sickness, and which are not excluded, shall be considered Covered Expenses.
If your trip is interrupted due to one of the following reasons:
1. Death of a Family Member
2. Serious damage to your principal residence from fire, flood or similar natural disaster (tornado, earthquake, hurricane, etc.)
Benefits will be paid up to the maximum as stated in the Schedule of Benefits for the cost of economy travel less the value of applied credit from an unused return travel ticket to return you home to your area of principal residence.
This Plan will reimburse you for loss, theft or damage to your baggage or personal effects, checked with a Common Carrier provided you have taken all reasonable measures to protect, save and/or recover your property at all times. This Plan is secondary to any coverage provided by a Common Carrier and all other valid and collective insurance. This Plan will pay the lesser of: 1) The actual cash value (cost less proper deduction for depreciation at the time of loss, theft or damage); 2) The cost to repair or replace the article with material of a like kind and quality; or 3) $50 per article, to a maximum of $250.
Accidental Death & Dismemberment:
Benefits shall be paid to you if you sustain an accidental Injury. The Injury must occur during the Period of Coverage and death or dismemberment as a result of that accident must occur within 365 days from the date of Accident. Benefits payable for any such loss shall be in accordance with the following table: If you incur more than one Loss stated in the following Table as the result of one Accident, only the largest amount shall be payable.
| Description of Loss | Percent of Principal Sum |
| Life | 100% |
| Both Hands or Both Feet or Sight of Both Eyes | 100% |
| One Hand and One Foot | 100% |
| Either Hand or Foot and Sight of One Eye |
100% |
| Either Hand or Foot |
50% |
| Sight of One Eye |
50% |
| Quadriplegia | 100% |
| Paraplegia (total paralysis of both lower limbs) | 75% |
| Hemiplegia (total paralysis of upper and lower limbs of one side of the body) | 50% |
| Uniplegia (total paralysis of one limb) | 20% |
PLAN DEFINITIONS
Benefit Period shall mean the allowable time period you have from the date of Injury or onset of Illness to receive Treatment for a Covered Injury or Illness.
Coinsurance shall mean the percentage amount of Covered Expenses, after the Deductible, which is your responsibility to pay.
Home Country shall mean the country where you have your true, fixed and permanent home and principal establishment.
Illness shall mean Sickness or disease of any kind contracted and commencing after the Effective Date of this Plan.
Injury shall mean accidental bodily Injury or injuries caused by an Accident. The Injury must be the direct cause of the loss, independent of disease, bodily infirmity or other causes. Any loss due to Injury must begin after the Effective Date of this Plan.
Inpatient shall mean if you are confined in an institution and are charged for room and board.
Outpatient shall mean if you receive 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.
Reasonable and Customary shall mean the maximum amount that the Plan determines is Reasonable and Customary for Covered Expenses you receive, up to, but not to exceed, charges actually billed. The 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 included but not limited to, a resource based relative value scale.
Treatment shall mean a specific in-office or Hospital physical examination of, or care rendered to you; consultation; diagnostic procedures and services; Surgery; medical services and supplies, including Medication prescribed or provided by a Service Provider.
You, Your or Insured shall mean Insured Person.
No Benefit shall be payable for Accident Medical, Sickness Medical, Dental, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Emergency Medical Reunion, Return of Minor Child(ren), In-hospital Indemnity and Unexpected Recurrence of a Pre-existing Condition, as the result of:
1. Any Pre-existing Condition as defined hereunder. This exclusion does not apply to Emergency Evacuation/Repatriation or Return of Mortal Remains; This exclusion does not apply to the first $10,000 of an Unexpected Recurrence of a Pre-existing Condition;
2. Injury or Sickness which is not presented to the Company for payment within three (3) months of receiving Treatment;
3. Charges for Treatment which is not Medically Necessary;
4. Charges provided at no cost to you;
5. Charges for Treatment which exceed Reasonable and Customary charges;
6. Charges incurred for Surgery or Treatments which are Experimental/Investigational, or for research purposes;
7. Services, supplies or Treatment, including any period of hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
8. Suicide or any attempts thereof, while sane; or self destruction or any attempt thereof, while insane;
9. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with:
a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war
b) mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power
c) acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence
d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the “Occurrences”)
Any consequence happening or arising during the existence of these conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, arising in connection with, any of the said Occurrences shall be deemed to be consequences for which the Plan shall not be liable for, except to the extent that you prove that such consequence happened independently of the existence of such conditions;
10. Injury sustained while participating in professional athletics;
11. Injury sustained while participating in Amateur or Interscholastic Athletics. This exclusion does not apply to non-competitive, recreational or intramural activities.
12. Routine physicals, immunizations or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or X-ray examinations, except in the course of a Disablement established by a prior call or attendance of a Physician;
13. Vocational, speech, recreational or music therapy;
14. Services or supplies performed or provided by a Relative of yours, or anyone who lives with you;
15. Cosmetic or plastic Surgery, except as the result of a covered Accident; for the purposes of this Plan, Treatment of a deviated nasal septum shall be considered a cosmetic condition;
16. Elective Surgery which can be postponed until you return to your Home Country, where the objective of the trip is to seek medical advice, Treatment or Surgery;
17. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids;
18. Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eyeglasses or for the fitting thereof, unless caused by Accidental bodily Injury incurred while covered hereunder;
19. Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent, unless otherwise covered under this policy;
20. Injury sustained while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician for a condition which is covered hereunder, but not for the Treatment of drug addiction;
21. Any Mental and Nervous disorders or rest cures;
22. Congenital abnormalities and conditions arising out of or resulting there from;
23. Expenses which are non-medical in nature;
24. Expenses as a result of, or in connection with, intentionally self-inflicted Injury or Sickness;
25. Expenses as a result of, or in connection with, the commission of a felony offense;
26. Injury sustained while taking part in mountaineering; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; snowmobiling; scuba diving involving underwater breathing apparatus, unless PADI or NAUI certified; water skiing; snow skiing; snowboarding; spelunking; and parasailing;
27. Treatment paid for or furnished under any other individual or group policy or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for Treatment without any cost to you;
28. Dental care, except as the result of Injury to natural teeth caused by Accident, unless otherwise covered under this Plan;
29. Routine Dental Treatment;
30. For Pregnancy or Sickness resulting from Pregnancy, childbirth or miscarriage unless hospitalized;
31. For miscarriage resulting from Accident;
32. Drug, Treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, Treatment for infertility or impotency, sterilization or reversal thereof;
33. Treatment for human organ tissue transplants and their related Treatment;
34. Expenses incurred while in your Home Country;
35. Covered Expenses incurred once a trip exceeds ninety (90) days in duration;
36. Injury sustained as the result of the Insured Person operating a motor vehicle while not properly licensed to do so in the jurisdiction in which the motor vehicle accident takes place;
37. Covered Expenses incurred for which the Trip to the Host Country was undertaken to seek medical Treatment for a condition;
38. Covered Expenses incurred during a Trip after your Physician has limited or restricted travel;
39. Sex change operations, or for Treatment of sexual dysfunction or sexual inadequacy;
40. Weight reduction programs or the surgical Treatment of obesity;
41. Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), Aids-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV).
No Benefit shall be payable for Accidental Death and Dismemberment as the result of:
1. Suicide, or attempt thereof, while sane; or self destruction, or any attempt thereof, while insane;
2. Disease of any kind; Bacterial infections, except pyogenic infection, which shall occur through an accidental cut or wound;
3. Hernia of any kind;
4. Injury sustained while you are riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting from, any type of aircraft;
5. Injury sustained while you are riding as a passenger in any aircraft (a) not having a current and valid Airworthy Certificate and (b) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft;
6. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with:
a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war
b) mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power
c) acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence
d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the “Occurrences”)
Any consequence happening or arising during the existence of these conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed to be consequences for which the Plan shall not be liable, except to the extent that you can prove that such consequence happened independently of the existence of such conditions;
7. Service in the military, naval or air service of any country;
8. Flying in any aircraft being used for, or in connection with, acrobatic or stunt flying, racing or endurance tests;
9. Flying in any rocket-propelled aircraft;
10. Flying in any aircraft being used for, or in connection with, crop dusting or seeding or spraying, fire fighting, exploration, pipe or power line inspection, any form of hunting or herding, aerial photography, banner towing or any experimental purpose;
11. Flying in any aircraft which is engaged in any flight which requires a special permit or waiver from the authority having jurisdiction over civil aviation, even though granted;
12. Sickness of any kind;
13. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified Physician or surgeon;
14. Injury occasioned or occurring while you are committing or attempting to commit a felony or to which a contributing cause was your being engaged in an illegal occupation;
15. While riding or driving in any kind of competition;
16. This plan does not insure against loss or damage (including death or Injury) and any associated cost or expense resulting directly or indirectly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or radioactive force, or chemical, biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act, regardless of any other cause or event contributing concurrently or in any other sequence thereto.
1. You, Your Traveling Companion or Your Traveling Companion’s family has made changes to personal plans; having business or contractual obligations; being unable to obtain necessary travel documents (passports, visas, etc.); being detained or having property confiscated by customs authorities; carrier caused delays (including bad weather);
2. Prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which You have purchase Your trip arrangements.
1. Aircraft, automobiles, automobile equipment, motors, motorcycles, bicycles (except bicycles when checked as baggage with a common carrier,) boats or other conveyances or their accessories;
2. Animals;
3. Artificial teeth or limbs, hearing aids;
4. Sunglasses, contact lenses or eyeglasses;
5. Documents of any kind, including but not limited to documents, bills, currency, deeds, evidences of debt, letters of credit, stamps, credit cards, money, notes, securities, transportation or other tickets;
6. Household furniture or furnishings.
FOR RESIDENTS IN THE STATE OF DELAWARE:
• Exclusions & Limitations section, Exclusion 6 under the Accidental Death and Dismemberment section is deleted in its entirety and replaced as follows:
6. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with the following, which shall hereinafter for the purposes of this Exclusion be called the “Incidents”:
a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war.
b) mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power.
c) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government du jure or de facto.
d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of marital law or state of siege.
Any consequence happening or arising during the existence of these conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Incidents shall be deemed to be consequences for which the Company shall not be liable under this Policy except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such conditions.
• Exclusions & Limitations section, Exclusion 9 under the Accident Medical, Illness Medical section is deleted in its entirety and replaced as follows:
9. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with the following, which shall hereinafter for the purposes of this Exclusion be called the “Incidents”:
a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war.
b) mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power.
c) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government du jure or de facto.
d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of marital law or state of siege.
Any consequence happening or arising during the existence of these conditions (whether physical or otherwise), whether proximately or remotely occasioned by, traceable to, arising in connection with, any of the said Incidents shall be deemed to be consequences for which the Company shall not be liable under this Policy except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such conditions.
FOR RESIDENTS IN THE STATE OF KENTUCKY:
• Exclusions & Limitations section, Exclusion 6 under the Accidental Death and Dismemberment section is deleted in its entirety and replaced as follows:
6. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to, or arising in connection with the following, which shall hereinafter for the purposes of this Exclusion be called the “Incidents”:
a) war, invasion, act or foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war.
b) Mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power.
c) Any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government du jure or de facto or to the influencing of it by violence.
d) Martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege.
Any consequence happening or arising during the existence of these conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Incidents shall be deemed to be consequences for which the Company shall not be liable under this Policy except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such conditions.
• Exclusions & Limitations section, Exclusion 9 under the Accident Medical, Illness Medical section is deleted in its entirety and replaced as follows:
9. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with the following, which shall hereinafter for the purposes of this Exclusion be called the “Incidents”;
a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not); or civil war.
b) mutiny, riot, strike, military of popular uprising insurrection, rebellion, revolution, military or usurped power.
c) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government du jure or de facto or to the influencing of it by violence.
d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege.
Any consequence happening or arising during the existence of these conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, arising in connection with, any of the said incidents shall be deemed to be consequences for which the Company shall not be liable under this Policy except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such conditions.
• Exclusions & Limitations section, Exclusion 32 under the Accident Medical, Illness Medical section, is deleted in its entirety and replaced as follows:
32. Drug, Treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, Treatment for infertility or impotency, sterilization or reversal thereof, or abortion;
• Exclusions & Limitations section, Exclusion 41 under the Accident Medical, Illness Medical section, regarding Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV) is deleted in its entirety.
FOR RESIDENTS IN THE STATE OF MISSOURI:
• Definitions, the definition of Eligible Dependent Child is deleted in its entirety and replaced as follows:
“Eligible Dependent Child” shall mean the Primary Insured Person’s unmarried children over 30 days and under 19 years of age or under 25 years of age if they are attending an accredited institution of higher learning on a regular full-time basis and/or wholly dependent upon the Insured Person for maintenance and support. An Eligible Dependent Child includes a natural child, a legally adopted child, a step-child or a child under the Insured Person’s legal guardianship.
The age limits that apply to Eligible Dependent Child(ren) will not apply to any Insured Dependent Child of the Primary Insured Person who remains dependent on the Primary Insured Person for support and maintenance because he or she becomes incapable of working due to a mental or physical handicap which occurs: before reaching the age limit[; and while insured under this Policy or any Prior Plan, provided such Insured Dependent Child was insured on the date of termination of the prior plan.
• Exclusions & Limitations section, Exclusion 24 under the Accident Medical, Illness Medical section, is deleted in its entirety and replaced as follows:
24. Expenses as a result or in connection with intentionally self-inflicted Injury or Illness while insane;
FOR RESIDENTS IN THE STATE OF MISSISSIPPI:
• Definitions, the definition of Pre-existing Condition is deleted in its entirety and replaced as follows:
Pre-existing Condition shall mean 1) a condition that would have caused a person to seek medical advice, diagnosis, care or treatment during the 180 days prior to the Effective Date of coverage under this Policy; 2) a condition for which medical advice, diagnosis, care or treatment was recommended or received during the 180 days prior to the Effective Date of coverage under this Policy.
• Description of Benefits, Medical Expenses section, the following benefits are added:
11.) Charges made for Spinal Manipulation which is prescribed, performed, or ordered by a licensed chiropractor for the relief of pain.
12.) Charges made for diagnosis and Surgery of temporomandibular joint disorder and craniomandibular disorder by either a Physician or a Dentist. The lifetime maximum for the treatment of temporomandibular joint disorder and craniomandibular disorder is $5,000.
• Exclusions & Limitations section, Exclusion 6 under the Accidental Death and Dismemberment section is deleted in its entirety and replaced as follows:
6. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to, or arising in connection with the following, which shall hereinafter for the purposes of this Exclusion be called the “Incidents”:
a) War, invasion, act or foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war.
b) Mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power.
c) Any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government du jure or de facto or to the influencing of it by violence.
d) Martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege.
Any consequence happening or arising during the existence of these conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Incidents shall be deemed to be consequences for which the Company shall not be liable under this Policy except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such conditions.
• Exclusions & Limitations section, Exclusion 9 under the Accident Medical, Illness Medical section is deleted in its entirety and replaced as follows:
9. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with the following, which shall hereinafter for the purposes of this Exclusion be called the “Incidents”;
a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not); or civil war.
b) mutiny, riot, strike, military of popular uprising insurrection, rebellion, revolution, military or usurped power.
c) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government du jure or de facto or to the influencing of it by violence.
d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege.
Any consequence happening or arising during the existence of these conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, arising in connection with, any of the said incidents shall be deemed to be consequences for which the Company shall not be liable under this Policy except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such conditions.
• Policy Provisions, the Payment of Claims provision is deleted in its entirety and replaced with:
Time of Payment of Claims: Indemnities payable under the Policy for any loss other than loss for which the Policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss.
Subject to due written Proof of Loss, all accrued indemnities for loss for which the Policy provides periodic payment will be paid monthly during the continuance of the period for which the Company is liable, and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof of loss.
If a claim is not paid within 35 days of receipt of written proof of loss in the form of a clean claim (25 days if proof of loss is submitted to the Company electronically in the form of a clean claim), interest will be paid on the overdue amount at a monthly rate of 1½ % per month or as required by law until the claim is finally settled or adjudicated. If the Company fails to pay benefits when due, the person entitled to such benefits may bring action to recover such benefits, any interest which may accrue, and any other damages permissible by law. A "clean claim" means a claim which requires no further information, adjustment or alteration by the provider of the services or the Insured Person in order to be processed and paid by the Insurance Company. A claim is clean if it has no defect or impropriety, including any lack of substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this provision. A clean claim includes resubmitted claims with previously identified deficiencies corrected.
Refund of Plan Cost:
Unearned premiums will be refunded for the number of full days only. Premium refunds will be considered only for school withdrawal or entry into the armed forces. The refund request must be in writing, and your ID card must be returned with your request. Premium refunds will not be considered if a claim has been filed during the Period of Coverage. All refunds are subject to the approval of the Plan Administrator.
Important Information:
In the event of Injury or Sickness, you should:
If an emergency:
• Go directly to the hospital
• Call the 24-hour assistance service center at the number listed on your ID card to alert the center of your situation
If not an emergency:
• Call the 24-hour assistance services provider for assistance in locating English speaking or appropriate providers, facilities, medical or medical transport advice and they will be happy to assist you.
Notice of Claim:
Written notice of claim(s) must be given to the Claims Administrator, Co-ordinated Benefit Plans, LLC (CBP), within thirty (30) days after the occurrence or commencement of any Disablement, or as soon thereafter as is reasonably possible. Notice given by someone on your behalf to CBP, with information sufficient to identify you shall be deemed sufficient notice to CBP.
Payment of Claims:
Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to your estate. If any indemnity of the Plan shall be payable to a minor, or one otherwise not competent to give a valid release, the Plan shall pay such indemnity, up to an amount not exceeding $1,000, to any Relative by blood or connection by marriage to you who is deemed to be equitably entitled thereto. Any payment made by the Plan in good faith pursuant to this provision shall fully discharge the Plan to the extent of such payment. Subject to any written direction by you, all or a portion of any indemnities provided by this Plan on account of hospital, nursing, medical or Surgical service may, at the Plan’s option and unless you request 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, but is not required the service be rendered by a particular hospital or person.
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. Other valid and collectable Insurance Indemnity, for which benefits may be payable, are Insurance programs provided by:
(a) Individual, group or blanket Insurance or coverage
(b) Other pre-payment coverage provided on a group or individual basis
(c) Any coverage under labor management trusted plans, union welfare plans, employer organization plans, employee benefit organization plans, or other arrangement of benefits for individuals of a group
(d) Any coverage required or provided by any state or socialized Insurance program
(e) Any no-fault automobile Insurance
(f) Any third party liability Insurance
Monetary Limits:
The monetary limits stated in this Plan and the Plan Cost 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 claim expense was incurred.
Subrogation:
To the extent the Plan pays for a loss suffered by you, the Plan will take over the rights and remedies you had relating to the loss. This is known as subrogation. You must help the Plan to preserve its rights against those responsible for the loss. This may involve signing any papers and taking any other steps the Plan may reasonably require. If this Plan takes over your rights, you must sign an appropriate subrogation form supplied to you.
Renewal:
Coverage under this Plan is not renewable. If additional coverage time is needed, a new application must be completed and correct Premium submitted to Plan Administrator. A new Deductible, Coinsurance, and Pre-existing Condition Exclusion will apply at each succeeding or subsequent Period of Coverage.
Products underwritten by: Nationwide Life Insurance Company. Notice for Florida Residents: Products underwritten by Allied Property and Casualty Insurance Company.
Important Notice:
Please keep this document as a general summary of the Insurance. This Evidence of Benefits is a brief summary of filed form number NHPINTRVL which contains complete details of the coverage. A copy of the Travel Protection Policy is available for inspection at the Plan Administrator's office. The Evidence of Benefits shall control in the event of any conflict between this Evidence of Benefits and the Travel Protection Policy.
TRAVEL ASSISTANCE SERVICES:
TripMed Multi-Trip includes the following Services which are available to You for and during Your Covered Trip:
• Medical evacuation
• Rebooking Services
• Medically necessary repatriation
• Repatriation of remains
• Medical or legal referral
• Hospital admission assistance
• Translation service
• Lost Baggage retrieval
• Lost Document Assistance
• Worldwide Medical information
• Passport / Visa information
• Emergency cash advance
• Prescription drug / eyeglass replacement
• Legal Referral/Bail bond
• Embassy & Consular Services
NOTE: Any expenses incurred for services rendered while not on a TripMed Multi-Trip Covered Trip will be Your responsibility.
TripMed Multi-Trip Services are provided by an independent organization and not by Nationwide Life Insurance Company or it’s affiliated companies. There may be times when circumstances beyond the assistance company’s control hinder their endeavors to provide travel assistance services. They will, however, make all reasonable efforts to provide travel assistance services and help You resolve Your emergency situation.
For Emergency 24 Hour Medical & Travel Assistance:
MedjetAssist
P.O. Box 43099 Birmingham, AL 35243
1-888-847-7866 (toll-free)
1-609-986-1206 (collect)
7 days a week / 24 hours a day
CLAIMS:
Co-ordinated Benefit Plans, LLC
On Behalf of Nationwide Life Insurance Company and Affiliated Companies
P.O. Box 26222
Tampa, FL 33623
Email to: team1@cbpinsure.com
Phone: 1-866-224-5772 / Fax: 1-800-560-6340
Hours of operation:
Monday, Tuesday, Wednesday, Friday 8:30am-5:00pm (eastern)
Thursday 9:30am-5:00pm (eastern)
Nationwide® Privacy Statement
Thank you for choosing Nationwide
Our privacy statement explains how we collect, use, share, and protect your personal information. So just how do we protect your privacy? In a nutshell, we respect your right to privacy and promise to treat your personal information responsibly. It’s as simple as that. Here’s how.
Confidentiality and security
We follow all data security laws. We protect your information by using physical, technical, and procedural safeguards. We limit access to your information to those who need it to do their jobs. Our business partners are legally bound to use your information for permissible purposes.
Collecting and using your personal information
We collect personal information about you when you ask about or buy one of our products or services. The information comes from your application, business transactions with us, consumer reports, medical providers, and publicly available sources. Please know that we only use that information to sell, service, or market products to you.
We may collect and use the following types of information:
• Name, address, and Social Security number
• Assets and income
• Account and policy information
• Credit reports and other consumer report information
• Family member and beneficiary information
• Public information
Sharing your information for business purposes
We share your information with other Nationwide companies and business partners. When you buy a product, we share your personal information for everyday purposes. Some examples include mailing your statements or processing transactions that you request. You cannot opt out of these. We also share your information where federal and state law requires.
Sharing your information for marketing purposes
We don’t sell your information for marketing purposes. We have chosen not to share your personal information with anyone except to service your product. So there’s no reason for you to opt out. If we change our policy, we’ll tell you and give you the opportunity to opt out before we send your information.
Using your medical information
We sometimes collect medical information. We may use this medical information for a product or service you’re interested in, to pay a claim, or to provide a service. We may share this medical information for these business purposes if required or permitted by law. But we won’t use it for marketing purposes unless you give us permission.
Accessing your information
You can ask us for a copy of your personal information. Please call the number on your insurance ID card if applicable, contact your customer service representative, or send a letter to the address below and have your signature notarized. This is for your protection so we may prove your identity. We don’t charge a fee for giving you a copy of your information now, but we may charge a small fee in the future.
We can’t update information that other companies, like credit agencies and third parties, provide to us. So you’ll need to contact these other companies to change and correct your information.
Send your privacy inquiries to the address below. Please include your name, address, and policy number. If you know it, include your agent’s name and number.
Co-ordinated Benefit Plans, LLC
On Behalf of Nationwide Life Insurance Company and Affiliated Companies
P.O. Box 26222
Tampa, FL 33623
A parting word …
These are our privacy practices. They apply to all current and former clients of Nationwide health plans. They also apply to joint policy or contract holders. This includes the following companies:
Nationwide Better Health, Inc.
Nationwide Life Insurance Company
Nationwide Mutual Insurance Company
National Casualty Company
Allied Property and Casualty Insurance Company