Safe Travels USA
Safe Travels USA Summary of Coverage ITA270206
Starr Indemnity & Liability Company
A member of Starr Companies
Administrative Office: 90 Park Avenue, 7th Floor, New York, NY 10016
|MEDICAL EXPENSE BENFITS||LIMITS|
|Maximum for all Medical Expenses:
||$50,000; $100,000, $250,000, $500,000 or $1,000,000|
|Deductibles:||$0; $50; $100; $250; $500; $1,000; $2,500; $5,000|
80% of the First $5,000 of Covered Expenses, then 100% up to the Policy Maximum
|Maximum for Emergency Medical Treatment of Pregnancy:||
|Maximum for Room and Board Charges:||the average semi private room rate|
|Maximum for ICU Room and Board Charges:||three times the average semi private room rate|
|Maximum for Mental or Nervous Disorders:||$2,500 per Policy Period|
|Maximum for Physiotherapy Physical Medicine/Chiropractic Care:||$50 per visit per day; up to 10 visits per Policy Period|
|Maximum for Dental Treatment (Injury and emergency alleviation of pain):||$250 per Policy Period|
|Unexpected recurrence of a Pre-existing Condition:||
the Pre-existing Condition exclusion is waived for the first $1,000 of Covered Expenses
Accidental Death & Dismemberment/Disappearance Principal Sum:
Adaptive Home and Vehicle Benefit Maximum:
Seatbelt and Airbag Benefit:
Seatbelt Benefit Maximum:
$25,000 up to $500,000
-$5,000 per Policy Period
-10% of Principal Sum up to a maximum benefit of $50,000
|Emergency Medical Evacuation Benefit Maximum:||100% of Covered Expenses|
|Emergency Reunion Benefit Maximum:||$15,000 per Policy Period|
|Political Evacuation Benefit Maximum:||$25,000 per Policy Period|
|Repatriation of Remains Benefit Maximum:||100% of Covered Expenses|
Hospital Confinement Benefit:
Time Period for Confinement:
$50 per Day
|Return of Minor Child(ren) or Travel Companion Benefit Maximum:||$5,000|
|Trip Interruption Benefit Maximum:||$5,000 per Policy Period|
|Lost Baggage Benefit Maximum:||$300 ($75 per article) per Policy Period|
|Maximum Benefit Period:
||1 year from the date of the Covered Accident or Sickness|
Effective Date- Coverage will begin at 12:01 a.m. CST on the latest of the following dates: 1. your departure from your Home Country; or 2. the date and time your completed enrollment form and correct premium are received; or 3. the effective date requested and shown on this certificate.
Termination Date- Coverage will end at 12:00 a.m. CST on the earliest of the date: 1. Your permanent return to your Home Country; or 2. the termination date shown on this certificate for which premium has been paid; or 3. the maximum benefit has been paid.
OPTIONAL COVERAGE RIDERS - Please see Confirmation to determine applicability
Home Country/Follow Me Home Coverage- In consideration of additional premium paid, under the Exclusions section the following is deleted in its entirety - 35. expenses incurred in your Home Country; and the following is added under the Medical Expense Benefits:
|Home Country Coverage Benefit Maximum:||$50,000|
|Coinsurance:||80% of the first $5,000 of Covered Expenses, then 100% to $50,000 maximum|
|Follow Me Home Coverage Benefit Maximum:||$5,000|
|Coinsurance:||80% of the first $5,000 of Covered Expenses, then 100% to $5,000 maximum|
Accidental Death and Dismemberment Upgrade - In consideration of additional premium paid the accidental death and Dismemberment benefit is increased from $25,000 to $50,000; $100,000; $250,000; or $500,000
Extreme Sports/Hazardous Activity - In consideration of additional premium paid, under the Exclusions section the following are deleted: 11. specific named hazards: Abseiling, Aviation (except when traveling as a passenger in a commercial aircraft), BASE Jumping, Bobsleigh, BMX, Bungee Jumping, Canopying, Canyoning, Caving, Extreme sports, High Diving, Hang Gliding, Heli-skiing, Hot Air Ballooning, Inline Skating, Jet Skiing, Kayaking, Luge, Motocross, Motorcycling, Moto-X, Mountaineering, Mountain biking, Mountain Climbing, Paragliding, Parasailing, Parascending, Piloting any Aircraft, Racing of any kind, Rock Climbing, Rodeo Activities, Rappelling, Scuba Diving, Ski Jumping, Skydiving Snow Skiing, Snowboarding, Snowmobiling, Spelunking, Surfing, Trekking, Water Skiing, Wind Surfing, White Water Rafting, Zip Lining, Zorbing. 18. specific named hazards: Abseiling, Aviation (except when traveling as a passenger in a commercial aircraft), BASE Jumping, Bobsleigh, BMX, Bungee Jumping, Canopying, Canyoning, Caving, Extreme sports, High Diving, Hang Gliding, Heli-skiing, Hot Air Ballooning, Inline Skating, Jet Skiing, Kayaking, Luge, Motocross, Motorcycling, Moto-X, Mountaineering, Mountain biking, Mountain Climbing, Paragliding, Parasailing, Parascending, Piloting any Aircraft, Racing of any kind, Rock Climbing, Rodeo Activities, Rappelling, Scuba Diving, , Ski Jumping, Skydiving Snow Skiing, Snowboarding, Snowmobiling, Spelunking, Surfing, Trekking, Water Skiing, Wind Surfing, White Water Rafting, Zip Lining, Zorbing.
And replaced with: 11. specific named hazards: Abseiling, BASE Jumping, Extreme sports, Luge, Motocross, Moto-X, Mountaineering, Mountain Climbing (exceeding Class V difficulty on the Yosemite Decimal System), Piloting any Aircraft, Racing of any kind, Rock Climbing, Rodeo Activities, Rappelling, Ski Jumping, Sky-diving, and Whitewater Rafting (exceeding Class V). 18. specific named hazards: Abseiling, BASE Jumping, Extreme sports, Luge, Motocross, Moto-X, Mountaineering, Mountain Climbing (exceeding 3500 meters or Class V difficulty on the Yosemite Decimal System), Piloting any Aircraft, Racing of any kind, Rock Climbing, Rodeo Activities, Rappelling, Ski Jumping, Sky-diving, and Whitewater Rafting (exceeding Class V).
War Risk - In consideration of additional premium paid, under the Exclusions section the following is deleted: 4. declared or undeclared war or any act thereof. And replaced with 4. declared or undeclared war or any act thereof (except as provided by the Policy in DESTINATION on the application).
DEFINITIONS Please note, certain words used in this document have specific meanings. These terms will be capitalized throughout the document.
“Accident” means a sudden, unexpected and unintended event.
“Appropriate Authority(ies)” means the government authority(ies) in the Covered Person’s Home Country or country of residence or the government authority(ies) of the Host Country.
"Automobile" means a self-propelled, private passenger motor vehicle with four or more wheels that is a type both designed and required to be licensed for use on the highway of any state or country. Automobile includes, but is not limited to, a sedan, station wagon, sport utility vehicle, or a motor vehicle of the pickup, van, camper, or motor-home type. Automobile does not include a mobile home or any motor vehicle that is used in mass or public transit.
“Covered Accident” means an Accident that occurs while coverage is in force for a Covered Person and results in a loss or Injury covered by the Policy for which benefits are payable.
“Covered Expenses” means expenses actually incurred by or on behalf of a Covered Person for treatment, services and supplies covered by the Policy. Coverage under the Policy must remain continuously in force from the date of the Accident or Sickness until the date treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date such treatment, service or supply, that gave rise to the expense or the charge, was rendered or obtained.
“Covered Loss” or “Covered Losses” means an accidental death, dismemberment or other Injury covered under the Policy.
“Covered Person” means any Insured and Dependent for whom the required premium is paid.
“Deductible” means the dollar amount of Covered Expenses that must be incurred as an out of-pocket expense by each Covered Person on a per Policy Term basis before Medical Expense Benefits and/or other Additional Benefits paid on an expense incurred basis are payable under the Policy.
“Dependent” means an Insured’s lawful spouse or Domestic Partner; or an Insured’s unmarried child, from the moment of birth to age 21, who is chiefly dependent on the Insured for support. A child, for eligibility purposes, includes an Insured’s natural child; adopted child, beginning with any waiting period pending finalization of the child’s adoption; or a stepchild who resides with the Insured or depends chiefly on the Insured for financial support. A Dependent may also include any person related to the Insured by blood or marriage and for whom the Insured is allowed a deduction under the Internal Revenue Code. Insurance will continue for any Dependent child who reaches the age limit and continues to meet the following conditions: 1. the child is handicapped, 2. is not capable of self-support and 3. depends chiefly on the Insured for support and maintenance. The Insured must send Us satisfactory proof that the child meets these conditions, when requested. We will not ask for proof more than once a year.
“Designated Security Consultant” means an employee of a security firm under contract with Us or Our assistance provider who is experienced in security and measures necessary to ensure the safety of the Covered Person(s) in his or her care.
“Doctor” means a licensed health care provider acting within the scope of his or her license and rendering care or treatment to a Covered Person that is appropriate for the conditions and locality. It will not include a Covered Person or a member of the Covered Person’s Immediate Family or household.
“Domestic Partner” means a person of the same or opposite sex of the Insured who: 1. shares the Insured’s primary residence; 2.has resided with the Insured for at least 6 months prior to the date of enrollment and is expected to reside with the Insured indefinitely; 3. is financially interdependent with the Insured 4. has signed a Domestic Partner declaration with the Insured, if recognized by the laws of the state in which he or she resides with the Insured; 5. does not have current Domestic Partner declaration with any other person; 6. is older than 18 years of age; 7. is not currently married to another person; and 8. is not in a position as a blood relative that would prohibit marriage.
“Evacuation Advisory” means a formal recommendation issued by the Appropriate Authorities that the Covered Person or citizens of his or her Home Country or Country of Residence or citizens of the Host Country leave the Host Country.
“Health Care Plan” means a policy or other benefit or service arrangement for medical or dental care or treatment under: 1. group or blanket coverage, whether on an insured or self-funded basis; 2. Hospital or medical service organizations on a group basis; 3. Health Maintenance Organizations on a group basis; 4. group labor-management plans; 5. employee benefit organization plans; 6. association plans on a group or franchise basis; or 7. any other group employee welfare benefit plan as defined in the employee Retirement income Security Act of 1974, as amended.
“Home Country” means a country from which the Covered Person holds a passport. If the Covered Person holds passports from more than one country, his or her Home Country will be that country which the Covered Person has declared to Us in writing as his or her Home Country.
"Hospital” means an institution that: 1. operates as a Hospital pursuant to law for the care, treatment, and providing of in-patient services for sick or injured persons; 2. provides 24-hour nursing service by Registered Nurses on duty or call; 3. has a staff of one or more licensed Doctors available at all times; 4. provides organized facilities for diagnosis, treatment and surgery, either: (i) on its premises; or (ii) in facilities available to it, on a pre-arranged basis; 5. is not primarily a nursing care facility, rest home, convalescent home, or similar establishment, or any separate ward, wing or section of a Hospital used as such; and 6. is not a place solely for drug addicts, alcoholics, or the aged or any separate ward of the Hospital.
“Hospital Confined” means an overnight stay as a registered resident bed-patient in a Hospital.
“Host Country” means any country, other than an OFAC excluded country, in which the Covered Person is traveling while covered under the Policy.
“Immediate Family Member” means a person who is related to the Covered Person in any of following ways: spouse; parent (includes stepparent); child (includes legally adopted and step child); brother or sister (includes stepbrother or stepsister); parent-in-law; son or daughter–in–law; and brother- or sister-in-law.
“Injury” means accidental bodily harm sustained by a Covered Person that results directly and independently from all other causes from a Covered Accident. All injuries sustained by one person in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury.
“Insured” means a person in a Class of Eligible Persons for whom the required premium is paid making insurance in effect for that person. A Dependent covered under the Policy is not an Insured, but rather a Covered Person.
“Medical Emergency” means a condition caused by an Injury or Sickness that manifests itself by symptoms of sufficient severity that a prudent lay person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy.
“Medically Necessary” means a treatment, service or supply that is: 1. required to treat an Injury or Sickness; prescribed or ordered by a Doctor or furnished by a Hospital; 2. performed in the least costly setting required by the Covered Person’s condition; and 3. consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered. Purchasing or renting 1. air conditioners; 2. air purifiers; 3. motorized transportation equipment; 4. escalators or elevators in private homes; 5. eye glass frames or lenses; 6. hearing aids; 7. swimming pools or supplies for them; and 8. general exercise equipment are not considered Medically Necessary. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may, at Our discretion, consider the cost of the alternative to be the Covered Expense.
“Missing Person” means a Covered Person who disappeared for an unknown reason and whose disappearance was reported to the Appropriate Authority(ies).
“Natural Disaster” means storm (wind, rain, snow, sleet, hail, lightning, dust or sand) earthquake, flood, volcanic eruption, wildfire or other similar event that: 1. is due to natural causes; and 2. results in such severe and widespread damage that the area of damage is officially declared a disaster area by the government in which the Covered Person’s Trip occurs and the area is deemed to be uninhabitable or dangerous.
“Nearest Place of Safety” means a location determined by the Designated Security Consultant where: 1. the Covered Person can be resumed safe from the Occurrence that precipitated the Covered Person’s Political Evacuation; and the Covered Person has access to Transportation; and 2. the Covered Person has the availability of temporary lodging, if needed.“Occurrence” means any of the following situations involving a Covered Person: 1. expulsion from a Host Country or being declared persona non-grata on the written authority of the recognized government if a Host Country; 2. political or military events involving a Host Country, if the Appropriate Authorities issue an Advisory stating that citizens of the Covered Person’s Home Country or Country of Residence or citizens of the Host Country should leave the Host Country; 3. deliberate physical harm of the Covered Person confirmed by documentation or physical evidence or a threat against the Covered Person’s health and safety as confirmed by documentation and/or physical evidence; 4. Natural Disaster within seven days of an event; 5. the Covered Person had been deemed kidnapped or a Missing Person by local or international authorities and, when found, his or her safety and/or well-being are in question within seven days of his or her being found.
"Participant” means the organization that signed a Participation Agreement to participate in the Christiana Bank & Trust Company that has been accepted by the Trustee. “Political Evacuation” means the extrication of a Covered Person from the Host Country due to an Occurrence which could result in grave physical harm or death to the Covered Person.
“Related Costs” means food, lodging and, if necessary, physical protection for the Covered Person during the Transport to the Nearest Place of Safety.
“Sickness” means an illness, disease or condition of the Covered Person that causes a loss for which a Covered Person incurs medical expenses while covered under the Policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.
“Transport” or “Transportation” means the most efficient and available method of conveyance. Where practical, economy fare will be utilized. If possible, the Covered Person’s common carrier tickets will be used.
"Supplemental Restraint System" means an airbag that inflates upon impact for added protection to the head and chest areas.
"Traveling Companion” means a person or persons with whom you have coordinated travel arrangements, shares the same accommodations as You and intend to travel with during the Trip.
“Trip” means travel by air, land, or sea from the Covered Person’s Home Country.
“Unexpected Recurrence of a Pre-Existing Condition” means this plan shall pay, up to the maximum shown in the Schedule of Benefits subject to the chosen Deductible and Coinsurance, for Covered Expenses resulting from a sudden, unexpected recurrence of a Pre-existing Condition while traveling outside your Home Country. 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.
“Usual and Customary Charge” means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided.
“We”, “Our”, “Us” means Starr Indemnity & Liability Company or its authorized agent.
DESCRIPTION OF BENEFITS
All benefits are in U.S. Dollar amounts.
Accidental Death & Dismemberment Benefit
Principal Sum Insured $25,000 up to $500,000 Spouse/Domestic Partner/Traveling Companion Principal Sum $25,000 up to $500,000 Dependent Child under age 18 Principal Sum $10,000 or $50,000
If Injury results, within 365 days from date of Accident in any one of the losses shown below, We will pay the Benefit Amount shown below for that loss. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Accident.
|Covered Loss||Benefit Amount|
|Life or Quadriplegia or Two or more Members||100% of the Principal Sum|
|Hemiplegia or Paraplegia||75% of the Principal Sum|
|One Member||50% of the Principal Sum|
|Uniplegia or Thumb and Index Finger of the Same Hand||25% of the Principal Sum|
“Quadriplegia” means total Paralysis of both upper and lower limbs.
“Hemiplegia” means total Paralysis of the upper and lower limbs on one side of the body.
“Uniplegia” means total Paralysis of one lower limb or one upper limb.
“Paraplegia” means total Paralysis of both lower limbs or both upper limbs.
“Paralysis” means total loss of use. A Doctor must determine the loss of use to be complete and not reversible at the time the claim is submitted.
“Member” means Loss of Hand or Foot, Loss of Sight, Loss of Speech, and Loss of Hearing.
“Loss of Hand or Foot” means complete Severance through or above the wrist or ankle joint.
“Loss of Sight” means the total, permanent Loss of Sight of one eye.
“Loss of Speech” means total and permanent loss of audible communication that is irrecoverable by natural, surgical or artificial means.
“Loss of Hearing” means total and permanent Loss of Hearing in both ears that is irrecoverable and cannot be corrected by any means.
“Loss of a Thumb and Index Finger of the Same Hand” or “Loss of Four Fingers of the Same Hand” means complete Severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand).
“Severance” means the complete separation and dismemberment of the part from the body. The amount payable for a Covered Loss will be reduced if you are age 70 or older on the date of the Accident causing the loss. The amount payable for your loss is a percentage of the amount that would otherwise be payable and based on age. Age 70-74 – 65%; Age 75-79-45%; Age 80-84 -30%; Age 85 and older 15%
Exposure and Disappearance Benefit- 100% of the Principal Sum if you are exposed to the elements after the forced landing, stranding, sinking, or wrecking of a vehicle in which you were traveling. You are presumed dead if you are in a vehicle that disappears, sinks or is stranded or wrecked and your body is not found within six months of the Covered Accident.
Hijacking and Air or Water Piracy Benefit- Covers Injury during the: 1. hijacking of an Aircraft; 2. air or water piracy; or 3. unlawful seizure or attempted seizure of an aircraft or watercraft.
Coma Benefit- We will pay this benefit in a lump sum of $10,000 if you become Comatose within 31 days of a Covered Accident or Sickness and remain in a Coma for at least 31 days. We reserve the right, at the end of the first 31 days of Coma, to require additional proof that the Covered Person remains Comatose. This proof may include, but is not limited to, requiring an independent medical examination at Our expense. A person is deemed “Comatose” or in a “Coma” if he or she is in a profound stupor, or state of complete and total unconsciousness, as the result of a Covered Accident or Sickness.
Seatbelt and Airbag Benefit- 10% of the Principal Sum up to a maximum benefit of $50,000 if you die or are dismembered directly and independently from Injuries sustained while wearing a seatbelt and operating or riding as a passenger in an Automobile. An additional benefit is provided if you were also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). Verification of proper use of the seatbelt at the time of the Covered Accident and that the Supplemental Restraint System properly inflated upon impact must be a part of an official police report of the Covered Accident or be certified, in writing, by the investigating officer(s) and submitted with your claim to Us. If such certification or police report is not available or it is unclear whether you were wearing a seatbelt or positioned in a seat protected by a properly functioning and properly deployed Supplemental Restraint System, We will pay a default benefit of $2,000 to you if living, if not, then to your beneficiary. In the case of a child, “seatbelt” means a child restraint, as required by state law and being used as recommended by its manufacturer.
Felonious Assault and Violent Crime Benefit- 100% of the Principal Sum applicable to the Covered Loss to a maximum of $50,000 and subject to the following conditions, when you suffer a Covered Loss resulting directly and independently of all other causes from a Covered Accident that occurs during a violent crime or felonious assault as described below. A police report detailing the felonious assault or violent crime must be provided before this benefit is payable. You must notify the police within 24 hours of the assault. The Covered Accident must occur during any of the following: 1. actual or attempted robbery or holdup; 2. actual or attempted kidnapping; 3. any other type of intentional assault that is a crime classified as a felony by the governing statute or common law in the location where the assault occurred. Benefits will not be paid for treatment of any Injury sustained or Covered Loss incurred during any: 1. violent crime or felonious assault committed by you; or 2. felonious assault or violent crime committed upon you by a Family Member, Fellow Employee, or Member of the Same Household.
Adaptive Home and Vehicle Benefit- up to a $5,000 maximum If you have an Injury which results in a Loss payable under the Accidental Death and Dismemberment Benefit, We will pay an additional benefit equal to the least of the actual cost of the alterations or $5,000 for the one-time cost of alterations to your principal residence; and/or private Automobile to make the residence accessible and/or the private Automobile drivable or rideable. The costs must be incurred within one year from the date of accident and alterations are made by a person or persons with experience in such alterations.
Primary Benefits- We will pay Accident and Sickness Medical Expenses up to the Maximum Benefit as outlined in the Schedule of Benefits and after each Insured satisfies any Deductible, without regard to any other Health Care Plan benefits payable for the Insured. We will pay these benefits without regard to any Coordination of Benefits provision in any other Health Care Plan.
Covered Medical Expenses Benefit- If a covered Injury or Illness occurs during the period of coverage and you require medical or surgical treatment; this plan will pay, subject to the selected deductible, applicable co-insurance and benefit maximums, the following Covered Expenses, up to the selected policy maximum. The first charges must be incurred within 90 days after the date of the Covered Accident or Sickness. No benefits will be paid for any expenses incurred which are in excess of Usual and Customary Charges.
1. Hospital Room and Board Expenses: the average daily rate for a semi private room when a Covered Person is Hospital Confined and general nursing care is provided and charged for by the Hospital. In computing the number of days payable under this benefit, the date of admission will be counted but not the date of discharge.
2. Ancillary Hospital Expenses: services and supplies including operating room, laboratory tests, anesthesia and medicines when Hospital Con-fined. This does not include personal services of a non-medical nature.
3. Daily Intensive Care Unit Expenses: three times the average semi private room rate when a Covered Person is Hospital Confined in a bed in the Intensive Care Unit and nursing services other than private duty nursing services.
4. Medical Emergency Care (room and supplies) Expenses: incurred within 72 hours of an Accident or Sickness and including the attending Doctor’s charges, X-rays, laboratory procedures, use of the emergency room and supplies.
5. Doctor Non-Surgical Treatment and Examination Expenses including the Doctor’s initial visit, each Medically Necessary follow-up visit and consultation visits when referred by the attending Doctor.
6. Doctor’s Surgical Expenses.
7. Assistant Surgeon Expenses when Medically Necessary.
8. Anesthesiologist Expenses for pre-operative screening and administration of anesthesia during a surgical procedure whether on an inpatient or outpatient basis.
9. Physiotherapy Physical Medicine/Chiropractic Expenses on an inpatient or outpatient basis including treatment and office visits connected with such treatment when prescribed by a Doctor, including diathermy, ultrasonic, whirlpool, heat treatments, adjustments, manipulation, or any form of physical therapy and limited to $50 per visit, one visit per day and 10 visits per policy period.
10. X-ray Expenses (including reading charges).
11. Dental Expenses up to $250 due to Accidents or emergency alleviation of pain including dental x-rays for the repair or treatment of each tooth that is whole, sound and a natural tooth at the time of the Accident or emergency alleviation of dental pain.
12. Ambulance Expenses for transportation from the emergency site to the Hospital.
13. Prescription Drug Expenses including dressings, drugs and medicines prescribed by a Doctor.
14. Medical Services and Supplies: expenses for blood and blood transfusions; oxygen and its administration.
15. Emergency medical treatment of pregnancy up to $1,000 per policy period.
16. Mental or nervous disorders or rest cures up to $1,000 per policy period.
Emergency Medical Evacuation Benefit- We will pay 100% of Covered Expenses if you are traveling outside of your Home Country and suffer an Injury or Sickness during the course of the Trip which requires Emergency Medical Evacuation from the place where you suffer an Injury or Sickness to the nearest Hospital or other medical facility where appropriate medical treatment can be obtained; or transportation to your Home Country to obtain further medical treatment in a Hospital or other medical facility or to recover after suffering an Injury or Sickness.
An Emergency Medical Evacuation includes Medically Necessary medical treatment, medical services and medical supplies necessarily received in connection with such transportation. If after hospitalization or treatment for a covered Injury or Sickness, you are unable to continue your journey, Our designated assistance provider, in conjunction with the local attending Doctor and/or your habitual Doctor, will organize your return to your Home Country. If the gravity of the situation so dictates, Our designated assistance provider will ensure that appropriate medical care is provided to you during the return journey.
If Our designated assistance provider and the local attending medical practitioner consider you stable enough to be medically repatriated, without endangering your health, and you refuse repatriation, We will continue to pay medical expense benefits incurred after the date repatriation was recommended only up to the amount that would have been payable for the medical repatriation, subject to policy maximums and limitations.
Benefits will not be payable unless We authorize in writing or by an authorized electronic or telephonic means all expenses in advance.
Benefits will not be payable unless
1. the Doctor ordering the Emergency Medical Evacuation certifies the severity of your Injury or Sickness requires an Emergency Medical Evacuation;
2. all transportation arrangements made for the Emergency Medical Evacuation are by the most direct and economical conveyance and route possible;
3. the charges incurred are Medically Necessary and do not exceed the usual level of charges for similar transportation, treatment, services or supplies in the locality where the expense is incurred; and
4. do not include charges that would not have been made if there were no insurance.
Political Evacuation Benefit- up to $25,000 maximum for extrication from the Host Country due to an Occurrence which could result in grave physical harm or death. You are covered if an Occurrence takes place while coverage is in effect; and while you are traveling outside of your Home Country or country of residence.
Benefits will be paid for:
1. your Transportation and Related Costs to the Nearest Place of Safety, necessary to ensure your safety and well-being as determined by the Designated Security Consultant.
2. your Transportation and Related Costs within 14 days of the Political Evacuation to either to the country in which you are traveling while covered by the Policy; or your Home Country; or
3. consulting services by a Designated Security Consultant for seeking information on a Missing Person or kidnapping cases, if you are kidnapped or are reported as a Missing Person to local or international authorities.
Benefits will not be payable unless We (or Our authorized assistance provider) authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our assistance provider. Our assistance provider is not responsible for the availability of Transport services.
Where a Political Evacuation becomes impractical due to hostile or dangerous conditions, a Designated Security Consultant will endeavor to maintain contact with you until a Political Evacuation occurs. Political Evacuation Benefits are payable only once for any one Occurrence.
If, after a Political Evacuation is completed, it becomes evident that you were an active participant in the events that led to the Occurrence, We have the right to recover all Transportation and Related costs from you.
We will not pay Political Evacuation Expense Benefits for expenses and fees:
1. payable under any other provision of the Policy.
2. that are recoverable through your employer.
3. arising from or attributable to an actual fraudulent, dishonest or criminal act committed or attempted by you, acting alone or in collusion with other persons.
4. arising from or attributable to an alleged: a) violation of the laws of country in which you are traveling while covered under the Policy; or b) violation of the laws of your Home County or country of residence.
5. due to your failure to maintain and possess duly authorized and issued required travel documents and visas.
6. for repatriation of remains expenses.
7. for common or endemic or epidemic diseases or global pandemic disease as defined by the World Health Organization.
8. for medical services.
9. for monies payable in the form of a ransom, if a Missing Person case evolves into a kidnapping.
10. arising from or attributable, in whole or in part, to: a) a debt, insolvency, commercial failure, the repossession of any property by any title holder or lien holder or any other financial cause; b) non-compliance by you with regard to any obligation specified in a contract or license.
11. due to military or political issues if your Security Evacuation request is made more than 30 days after the Appropriate Authority(ies) Advisory was issued.
Repatriation of Remains Benefit- We will pay 100% of Covered Expenses Repatriation Benefits for preparation and return of your body to your Home Country if you die due to an Injury or Sickness. Benefits will not be payable unless We authorize in writing or by an authorized electronic or telephonic means all expenses in advance.
Covered expenses include:
1. expenses for embalming or cremation;
2. the least costly coffin or receptacle adequate for transporting the remains;
3. transporting the remains by the most direct and least costly conveyance and route possible.
Emergency Reunion Benefit- up to $15,000 maximum. Covers the cost of one economy airfare ticket and other local travel related expenses; or the reasonable expenses incurred for lodging and meals of your Immediate Family Member for a period of up to 10 days to accompany you to your Home Country or Hospital where you are confined if:
1. the Emergency Medical Evacuation Benefit is payable under the Policy; and
2. you are alone outside of your Home Country; and
3. the place of confinement is more than 100 miles from your Home Country; and 4. expenses were authorized in advance by the Company.
1. the death of an Immediate Family Member; or
2. your unforeseen Injury or Sickness or, the Injury or Sickness of a Traveling Companion or Immediate Family Member. The Injury or Sickness must be so disabling as to reasonably cause a Trip to be interrupted; or
3. substantial destruction of your principal residence by fire or weather related activity; or
4. a Medically Necessary covered Emergency Medical Evacuation to return you to your Home Country or to the area from which you were initially evacuated for continued treatment, recuperation and recovery.
Hospital Confinement Benefit- $50 per day per policy period, payable to you, when you are Hospital Confined, and all of the following conditions are met: 1. The Hospital stay is the direct result, from no other causes, of Injuries sustained in a Covered Accident, or Sickness that occurs while the Policy is in effect. 2. The Hospital stay begins within 3 days of a Covered Accident or Sickness and lasts for at least 3 days. We will pay this benefit retroactive to the first day of the Hospital stay. Benefit payments will end on the first of the following: 1. the date the Hospital stay ends; or 2. the date you die; 3. 10th day of hospitalization; or 4. the date the coverage terminates.
Return of Minor Child(ren) or Travel Companion Benefit- If you are the only person traveling with minor Dependent children who are under the age of 21 or a Travel Companion, and you suffer an Injury or Sickness and must be confined in a Hospital for at least 48 consecutive hours or are medically evacuated to another location, We will reimburse the cost of the Dependent or Travel Companion’s one way economy airfare ticket and/or ground transportation ticket to their Home Country, not to exceed $5,000. All transportation arrangements must be made by the most direct and economical route and conveyance possible and may not exceed the usual level of charges for similar transportation in the locality where the expense is incurred. Benefits will not be paid unless all expenses are approved in advance by Us, and services are rendered by the Company’s assistance provider.
EXCLUSIONS AND LIMITATIONS
We will not pay benefits for any Accidental Death and Dismemberment or Paralysis loss or Injury that is caused by, or results from:
1. intentionally self-inflicted Injury.
2. suicide or attempted suicide.
3. war or any act of war, whether declared or not (except as provided by the Policy).
4. service in the military, naval or air service of any country.
5. disease or bacterial infection except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food.
6. Sickness resulting from pregnancy, childbirth, miscarriage (except as provided by the Policy).
7. piloting or serving as a crewmember or riding in any aircraft except as a passenger on a regularly scheduled or charter airline.
8. commission of, or attempt to commit, a felony.
9. Injury or Sickness that occurs while the Covered Person has been determined to be legally intoxicated as determined according to the laws of the jurisdiction in which the Injury or Sickness occurred, or under the influence of any narcotic, barbiturate, or hallucinatory drug, unless administered by a Doctor and taken in accordance with the prescribed dosage.
10. flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing or endurance tests; flying in any rocket propelled aircraft; flying in any aircraft being used for or in connection with crop dusting, or seeding or spraying, firefighting, exploration, pipe or power line inspection, any form of hunting bird or fowl herding, aerial photography, banner towing or any test or experimental purpose; flying any aircraft which is engaged in flight which requires a special permit or waiver from the authority having jurisdiction over civil aviation, even if granted.
11. specific named hazards: Abseiling, Aviation (except when traveling as a passenger in a commercial aircraft), BASE Jumping, Bobsleigh, BMX, Bungee Jumping, Canopying, Canyoning, Caving, Extreme sports, High Diving, Hang Gliding, Heli-skiing, Hot Air Ballooning, Inline Skating, Jet Skiing, Kayaking, Luge, Motocross, Motorcycling, Moto-X, Mountaineering, Mountain biking, Mountain Climbing, Paragliding, Parasailing, Parascending, Piloting any Aircraft, Racing of any kind, Rock Climbing, Rodeo Activities, Rappelling, Scuba Diving, Ski Jumping, Skydiving Snow Skiing, Snowboarding, Snowmobiling, Spelunking, Surfing, Trekking, Water Skiing, Wind Surfing, White Water Rafting, Zip Lining, Zorbing.
12. All professional and semi-professional sports.
In addition to the exclusions above, We will not pay Medical Expense Benefits for any loss, treatment or services resulting from or contributed to by:
1. Pre-existing Condition, defined as: a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 3 year period before the Covered Person’s coverage became effective under the Policy. The term does not include genetic information in the absence of a diagnosis of the condition related to such information.
2. services, supplies or treatment, including any period of Hospital confinement, which were not recommended, approved and certified as necessary and reasonable by a Physician.
3. suicide or any attempt thereat while sane or self-destruction or any attempt thereat while insane.
4. declared or undeclared war or any act thereof.
5. Injury sustained while participating in a professional, semi-professional, amateur, club, intramural, interscholastic or intercollegiate sport (except as provided by the Policy).
6. Sickness resulting from pregnancy, childbirth, miscarriage (except as provided by the policy).
7. miscarriage resulting from Accident (except as provided by the Policy).
8. immunizations, routine physical or other examinations where there are no objective indications or impairment in normal health, or laboratory diagnostic or x-ray examinations except in the course of a disability established by the prior call or attendance of a Physician.
9. cosmetic or plastic surgery, except as the result of an accident.
10. elective surgery which can be postponed until the Covered Person returns to his or her Home Country.
11. any mental or nervous disorders or rest cures (except as provided by the Policy).
12. any dental treatment (except as provided by the Policy).
13. eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye glasses or for the fitting thereof, unless caused by accidental bodily Injury incurred while covered under the Policy.
14. congenital anomalies and conditions arising out of or resulting therefrom.
15. services, supplies, or treatment including any period of Hospital confinement which were not recommended, approved and certified as necessary and reasonable by a Doctor; or expenses which are nonmedical in nature.
16. the ordinary cost of a one-way airplane ticket used in the transportation back to the Covered Person’s country where an air ambulance benefit is provided.
17. expenses as a result of or in connection with intentionally self-inflicted Injury.
18. specific named hazards: Abseiling, Aviation (except when traveling as a passenger in a commercial aircraft), BASE Jumping, Bobsleigh, BMX, Bungee Jumping, Canopying, Canyoning, Caving, Extreme sports, High Diving, Hang Gliding, Heli-skiing, Hot Air Ballooning, Inline Skating, Jet Skiing, Kayaking, Luge, Motocross, Motorcycling, Moto-X, Mountaineering, Mountain biking, Mountain Climbing, Paragliding, Parasailing, Parascending, Piloting any Aircraft, Racing of any kind, Rock Climbing, Rodeo Activities, Rappelling, Scuba Diving, , Ski Jumping, Skydiving Snow Skiing, Snowboarding, Snowmobiling, Spelunking, Surfing, Trekking, Water Skiing, Wind Surfing, White Water Rafting, Zip Lining, Zorbing.
19. treatment paid for or furnished under any other individual or group policy, or other service or medical pre-payment plan arranged through an employer to the extent so furnished or paid, or under any mandatory government program or facility set up for treatment without cost to any individual.
20. pregnancy (except as provided by the Policy) or childbirth, birth control, artificial insemination, treatment for fertility or impotency, sterilization or reversal thereof or abortion.
21. organ transplants, marrow procedures and chemotherapy.
22. sexually transmitted diseases or immune deficiency disorders and related conditions.
23. treatment, service or supply not specifically covered by the Policy.
24. treatment by any Immediate Family Member or member of the Covered Person’s household.
25. treatment of hernia, Osgood-Schlatter’s Disease, osteochondritis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness whether or not caused by a Covered Accident.
26. expense incurred for treatment of Temporomandibular or craniomandibular joint dysfunction and associated myofacial pain.
27. elective treatment, surgery, health treatment, or examination including any service, treatment or supplies that: (a. are deemed by Us to be experimental; and (b. are not recognized and generally accepted medical practices in the United States.
28. contact lenses, hearing aids, wheelchairs, braces, appliances, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, orthotic devices, artificial eyes and larynx.
29. treatment or service provided by a private duty nurse or while confined primarily to receive custodial care, educational or rehabilitative care or nursing care.
30. covered medical expenses for which the Covered Person would not be responsible for in the absence of the Policy.
31. conditions that are not caused by a Covered Accident.
32. vocational, recreational, speech or music therapy.
33. traveling against the advice of a Physician, traveling while on a waiting list for inpatient Hospital or clinic treatment, or traveling for the purpose of obtaining medical treatment abroad.
34. any potential fatal condition which was diagnosed before the date your coverage became effective or any condition for which You are traveling to seek treatment.
35. expenses incurred in your Home Country.
Payment of loss under this policy shall only be made in full compliance with all United States of America economic or trade sanction laws or regulations, including, but not limited to sanctions, laws and regulations administered and enforced by the U.S. Treasury Department’s Office of Foreign Assets Control (“OFAC”).
1956-J University Blvd. S. #264 Mobile, Alabama 36609
Toll Free: 888-301-9289 Direct: 251-661-0924 Fax: 251-666-1806
Emergency Travel Assistance Services
Europ Assistance -Available 24 hours a day, 365 days a year
Toll free within the United States and Canada: 888-286-3768
Outside the United States and Canada, call direct or collect: 240-330-1517
GBG Administrative Services
26741 Portola Pkwy Ste. 1E #527
Foothill Ranch, CA. 92610
For claim status or questions please call Toll Free: 877-916-7920 or 949-916-7941 or email firstname.lastname@example.org
Notice of Claim: A claimant must give Us or Our authorized representative written (or authorized electronic or telephonic) notice of claim within 90 days after any loss covered by the Policy occurs. If notice cannot be given within that time, it must be given as soon as reasonably possible. This notice should identify the Covered Person and the Policy Number.
Claim Forms: Upon receiving written notice of claim, We will send claim forms to the claimant within 15 days. If We do not furnish such claim forms, the claimant will satisfy the requirements of written proof of loss by sending the written (or authorized electronic or telephonic) proof as shown below. The proof must describe the occurrence, extent and nature of the loss and give authorization to release medical records.
Proof Of Loss: Written (or authorized electronic or telephonic) proof of loss must be sent to the agent authorized to receive it. Written (or authorized electronic or telephonic) proof must be given within 90 days after the date of loss. If it cannot be provided within that time, it should be sent as soon as reasonably possible. In no event, except in the absence of legal capacity, will proof of loss be accepted if it is sent later than one year from the time proof is otherwise required.
Claimant Cooperation Provision: Failure of a claimant to cooperate with Us in the administration of a claim may result in the delay or termination of a claim. Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the actual benefit amount due.
Time Payment of Claims: Benefits for loss covered by the Policy, other than benefits that require periodic payment, will be paid not more than 60 days after We receive proper written proof of such loss. Benefits for loss covered by the Policy that require periodic payment shall be paid monthly provided that We receive proper written proof of such loss.
Payment of Claims: If the Covered Person dies, any death benefits or other benefits unpaid at the time of the Covered Person’s death will be paid to the beneficiary. If no beneficiary is on record with Us or Our authorized agent, payment will be made to the first surviving class of the following to the Covered Person’s:
2. children, in equal shares (If a child is a minor, benefits will be paid to the legal guardian);
3. mother or father;
All other benefits due and not assigned will be paid to the Covered Person, if living. Otherwise, the benefits may, at our option, be paid:
1. according to the beneficiary designation; or
2. to the Covered Person’s estate.
If a benefit due is payable to:
1.the Covered Person’s estate; or
2. the Covered Person or a beneficiary who is either a minor or is not competent to give a valid release for the payment, We may pay any amount due to some other person. The other person will be one who we believe is entitled to the payment and who is related to the Covered Person or the beneficiary by blood or marriage. We will be relieved of further responsibility to the extent of any payment made in good faith. We may pay benefits directly to any Hospital or person rendering covered services, unless the Covered Person requests otherwise in writing. The Covered Person must make the request no later than the time he or she files a written proof of loss.
Beneficiary: The Insured may designate a beneficiary. The Insured has the right to change the beneficiary at any time by written (or electronic and telephonic) notice. If the Insured is a minor, his or her parent or guardian may exercise this right for him or her. The change will be effective when We or Our authorized agent receive it. When received, the effective date is the date the notice was signed. We are not liable for any payments made before the change was received. We cannot attest to the validity of a change. The Insured is the beneficiary for any covered Dependent.
Assignment: At the request of the Covered Person or his or her parent or guardian, if the Covered Person is a minor, medical benefits may be paid to the provider of service. Any payment made in good faith will end our liability to the extent of the payment.
Physical Examinations And Autopsy: We have the right to have a Doctor of Our choice examine the Covered Person as often as is reasonably necessary. This section applies when a claim is pending or while benefits are being paid. We also have the right to request an autopsy in the case of death, unless the law forbids it. We will pay the cost of the examination or autopsy.
Legal Actions: No lawsuit or action in equity can be brought to recover on the Policy: 1. before 60 days following the date proof of loss was given to Us; or 2. after 3 years following the date proof of loss is required.
Recovery of Overpayment or Error: If benefits are overpaid, or paid in error, We have the right to recover the amount overpaid, or paid in error, by any or all of the following methods: 1. A request for lump sum payment of the amount overpaid, or paid in error. 2. Reduction of any proceeds payable under the Policy by the amount overpaid, or paid in error. 3. Taking any other action available to Us. Policy terms and conditions are briefly outlined in this Description of Coverage. Complete provisions pertaining to this insurance plan are contained in the Master Policy, which is on file with the Policyholder. In the event of a conflict between this Description of Coverage and the Master Policy, the Master Policy will govern.
Conformity With State Laws: On the effective date of the Policy, any provision that is in conflict with the laws in the state where it is issued is amended to conform to the minimum requirements of such laws.
Not In Lieu Of Workers’ Compensation: The Policy is not a Workers’ Compensation policy. It does not provide Workers’ Compensation benefits.