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INTERNATIONAL MEDICAL INSURANCE
DESCRIPTION OF PROPOSED PROGRAM & PREMIUMS

 ELIGIBILITY

Eligible Persons shall be participants, employees, or members of the Assured Group, while traveling outside of their Home Country whose name and travel dates have been submitted on the Group Application and have been accepted by the Administrator.  Dependents are considered to be the Primary Insured Person’s spouse and natural or legally adopted unmarried children over 14 (fourteen) days and under 19 years of age while traveling outside of their Home Country.   

Home Country is defined as - The country where an Insured person(s) has his/her true, fixed and permanent home and principal establishment.  Coverage shall apply worldwide excluding/including the United States. 

SCHEDULE OF BENEFITS 

See rate sheet   Accident / Sickness Medical Limit per Insured Person Per Policy Period.

See rate sheet   Deductible.  For travel outside the US, the policy pays 100% of eligible expenses after the Deductible. Inside the US the policy pays 80% of the first $5,000 of eligible expenses after the deductible, then 100%.

$300,000         Emergency Medical Evacuation / Repatriation Expense

$50,000           Return of Mortal Remains Expense

$50,000           Emergency Reunion Expense

$50,000           Return of Minor Child(ren) Expense

$5,000             Local Ambulance Expense

$25,000           Accidental Death and Dismemberment Principal Sum

$50,000           Common Carrier Accidental Death and Dismemberment Principal Sum

$5,000             Interruption of Trip Expense

$250                Loss of Checked Luggage Expense

$150                Hospital Indemnity (Traveling outside the U.S. and Canada) in addition to any other covered expense. 

Terrorism        Usual, reasonable and customary to the selected Policy Maximum.

 

DESCRIPTION OF MEDICAL BENEFITS 

Medical Expenses:  International Travel Medical Insurance shall pay Reasonable and Customary charges for Covered Expenses, excess of  the chosen Deductible and Coinsurance up to the selected Medical Maximum, incurred by You due to an Accidental Injury or Illness which occurred during the Period of Coverage outside Your Home Country (except as provided under the Home Country Coverage).  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 and are incurred within one hundred eighty (180) days from the date of accident or onset of Illness and which are not excluded, shall be considered Covered Expenses:

1)         Charges made by a Hospital for 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 semi-private room and board accommodations.

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, 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 $5,000, 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. 

Pre-Notification / Referral:  In order to ensure Your claims are addressed as efficiently as possible, You or the provider of service must contact the Assistance Company for pre-notification prior to: any medical Treatment in the U.S. as well as hospital admissions and inpatient / outpatient surgeries incurred worldwide.  The Assistance Company has trained personnel available twenty-four (24) hours a day, seven (7) days a week throughout the year to answer Your questions, provide assistance, and guide You to an appropriate facility if necessary.  In the case of an Emergency Admission, the Assistance Company must be contacted within forty-eight (48) hours, or as soon as reasonably possible.  Pre-notification does not guarantee that benefits will be paid.   

Please be aware that this is not a general health insurance policy, but an interim, limited benefit period, travel medical plan intended for use while away from Your Home Country.  The plan cannot guarantee payment to an individual or a facility for medical expenses until it has been determined that it is an eligible expense and a signed agreement has been received from the appropriate medical facility. 

Unexpected Recurrence of a Pre-Existing Condition:  This plan shall pay, up to $20,000 (Age 65+, up to $2,500) subject to the chosen Deductible and Coinsurance, for Covered Expenses resulting from a sudden, unexpected recurrence of a Pre-existing Condition while traveling outside the United States.  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.  This benefit is payable to U.S. citizens when traveling outside the United States and Canada. 

Hospital Indemnity (Class 1):  If You are confined to a Hospital as a registered Inpatient as the result of an Illness or Injury which occurs during Your Period of Coverage, this plan will pay Benefits up to $150 per day of confinement, in addition to any other covered expense, up to a maximum of thirty (30) days.  This benefit is payable ONLY when traveling outside the United States and Canada. 

Dental Accident Coverage:  This plan shall pay in excess of the chosen Deductible and Coinsurance of up to a maximum of $500, for emergency treatment to repair or replace sound natural teeth damaged as the result of a covered accident. (*Only available to programs purchased for 1 month or more.) 

Dental Emergency Relief of Pain (Class 1):  This plan shall pay in excess of the chosen Deductible and Coinsurance up to a maximum of $250, for emergency treatment for the relief of pain to natural teeth. (*Only available to programs purchased for 1 month or more.) 

EMERGENCY MEDICAL EVACUATION / REPATRIATION 

The plan will pay Covered Expenses incurred if any covered Injury or Illness commences during the Period of Coverage that results in the Medically Necessary Emergency Medical Evacuation or Repatriation (Your medical condition warrants immediate transportation from the medical facility where You are located to the nearest adequate medical facility where medical Treatment can be obtained).  This benefit must be approved and arranged by the Assistance Company in consultation with the local attending Physician.   

RETURN OF MORTAL REMAINS 

The Company will pay the reasonable Covered Expenses incurred up to the limit stated in the Schedule of Benefits to return the Insured Person's remains to his/her then current Home Country, if he or she dies.

This benefit must be approved and arranged by the Assistance Company. 

EMERGENCY MEDICAL REUNION 

When Emergency Medical Evacuation or Repatriation is ordered and the attending Physician recommends that a family member travel with You, the plan will arrange and pay, up to the amount listed in the schedule of benefits, for a round trip economy-class transportation for one individual of Your choice, from Your Home Country, to be at Your side while You are hospitalized.  This benefit must be approved and arranged by the Assistance Company. 

RETURN OF MINOR CHILD(REN) 

Should You be traveling alone with a Minor Child(ren) and are hospitalized because of a covered Illness or Injury and the Minor Child(ren), under age nineteen (19), is left unattended, the plan will arrange and pay up to the amount stated in the Schedule of Benefits for a one way economy fare to their Home Country (including the cost of an attendant/escort, if necessary to insure the safety and welfare of a Minor Child(ren).  This benefit must be approved and arranged by the Assistance Company. 

INTERRUPTION OF TRIP 

If You are unable to continue the trip due to the death of an Immediate Family member (parent, spouse, sibling or child) or due to serious damage to Your principal residence from fire, flood or similar natural disaster (tornado, earthquake, hurricane, etc.), the plan will reimburse (up to the amount 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 benefit must be approved and arranged by the Assistance Company. 

LOSS OF CHECKED LUGGAGE 

This plan will reimburse You for lost baggage and personal effects checked with a Common Carrier provided You have taken all reasonable measures to protect, save and/or recover his/her property at all times.  The baggage and personal effects must be owned by and accompany You at all times.  There will be a per article limit of $50 to a maximum benefit limit of $500 as per the Schedule of Benefits.  The plan will pay the lesser of the following:

1.       The actual cash value (cost less proper deduction for depreciation at the time of loss);

2.       The cost to repair or replace the article with material of a like kind and quality; or

3.    $50 per article. 

This coverage is secondary to any coverage provided by a Common Carrier.  You must furnish proof to the Company that full reimbursement has been obtained from the airline. 

ACCIDENTAL DEATH AND 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%

Common Carrier Accidental Death

200%

 ASSISTANCE SERVICES 

Upon enrollment, you are eligible to use any of the assistance services provided by the Assistance Services Provider.  Additional information is contained in the plan summary.  Open 24 hours/day, 365 days a year • Multi-lingual personnel • Physicians / Nurses on staff • Locate local facilities • Help with emergency situations. 

OPTIONAL COVERAGE:

Hazardous Sport Coverage - multiply rates by 1.15 (when applicable)-To cover motorcycle/motor scooter riding (whether as a passenger or a driver), hang gliding, parachuting, bungee jumping, water skiing, snow skiing, snowmobiling, and snowboarding, and spelunking.

Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.

               

EXCLUSIONS AND LIMITATIONS 

No Benefit shall be payable for Accident Medical, Sickness Medical, In-Hospital Indemnity, Unexpected Recurrence, Dental, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Return of Minor Child, Emergency Medical Reunion,
as the result of:

1.    Pre-existing Conditions:  Any Injury or Illness which meets the following criteria (unless covered under the Unexpected Recurrence benefit):  1) a condition that would have caused a person to seek medical advice, diagnosis, care or treatment during the thirty-six (36) months 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 thirty-six (36) months prior to the Effective Date of coverage under this policy.  For U.S. citizens traveling outside the United States and Canada, the Pre-existing Condition period is twelve (12) months instead of thirty-six (36) months.  This exclusion does not apply to Emergency Evacuation/Repatriation or Return of Mortal Remains.

Note:  U.S. citizens traveling outside the United States and Canada shall receive up to $20,000 (Age 65+, up to $2,500) subject to the chosen Deductible and Coinsurance, for Covered Expenses resulting from a sudden, unexpected recurrence of a Pre-existing Condition while traveling outside the United States.  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.

2.    Injury or Illness which is not presented to the Company for payment within 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 exceeds 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 attempt thereof, while sane or self destruction or any attempt thereof, while sane;

9.   War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the insured person or the country in, or over, which the act occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the insured person whether war be declared with that state or not, Terrorist activity.  For the purpose of this Exclusion;  i) Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).  ii) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals.  iii) Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals.  iv) Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals.  Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;

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.  Note:  A sponsored and/or organized Amateur or Interscholastic Athletic event includes training camps, team sports, or any formal grouping of people participating in one or multiple events that may/may not require a fee for participation.

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.  Treatment of the temporomandibular joint;

14.  Vocational, speech, recreational or music therapy;

15.  Services or supplies performed or provided by a relative of Yours, or anyone who lives with You;

16.  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;

17.  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;

18.  Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids;

19.  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;

20.  Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent;

21.  Injury sustained or Disablement due wholly or partly to the Insured being intoxicated as defined and determined by the laws of the state where the Injury occurred; or to the Insured being under the influence of any narcotic, unless administered on the advice of a Physician;

22.  Any Mental and Nervous disorders or rest cures;

23.  Congenital abnormalities and conditions arising out of or resulting there from;

24.  Expenses which are non-medical in nature;

25.  Expenses as a result of or in connection with intentionally self-inflicted Injury or Illness;

26.  Expenses as a result of or in connection with the commission of a felony offense;

27.  Injury sustained while taking part in mountaineering; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; snowmobiling; motorcycle/motor scooter riding (whether as a driver or passenger); scuba diving, involving underwater breathing apparatus (unless PADI or NAUI certified); water skiing; snow skiing; spelunking; parasailing and snowboarding.  Hazardous Sport Coverage:  the following are covered if the required premium has been paid: motorcycle/motor scooter riding (whether as a driver or passenger), hang gliding, parachuting, bungee jumping, waterskiing, snow skiing, snowmobiling, snowboarding and spelunking.

28.  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 plan or facility set up for treatment without any cost to You;

29.  Treatment of venereal disease;

30.  Dental care, except as the result of Injury to natural teeth caused by Accident, unless otherwise covered under this plan;

31.  Routine Dental Treatment;

32.  For Pregnancy or Illness resulting from Pregnancy, childbirth, or miscarriage;

33.  For miscarriage resulting from Accident;

34.  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;

35.  Treatment for human organ tissue transplants and their related treatment;

36.  Expenses incurred while in Your Home Country, except as provided under the Home Country Coverage;

37.  Expenses incurred during a Hospital emergency visit which is not of an emergency nature;

38.  Covered Expenses incurred for which the Trip to the Host Country was undertaken to seek medical treatment for a condition;

39.  Covered Expenses incurred during a Trip after Your Physician has limited or restricted travel;

40.  This plan does not insure against loss or damage (including death or injury) and any associated cost or expense resulting directly 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.

41.  Sex change operations, or for treatment of sexual dysfunction or sexual inadequacy;

42.  Weight reduction programs or the surgical treatment of obesity;

43.  Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), Aids-Related Complex (ARC) or  the Human Immunodeficiency Virus (HIV).

44.  Expenses incurred in the United States unless the expenses pertain to the Home Country Coverage Benefit. 

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)  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 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 abnormal 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 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 abnormal 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 You being engaged in an illegal occupation;

15.  While riding or driving in any kind of competition;

16.  Pregnancy, childbirth, miscarriage or abortion;

17.  This plan does not insure against loss or damage (including death or injury) and any associated cost or expense resulting directly 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. 

For Interruption of Trip, this insurance does not cover:  (1) war or any act of war, whether declared or not; participation in a felony, riot or insurrection; participation in contests of speed; a Pre-existing Condition existing prior to the Insured’s departure from their Home Country that has the likelihood of causing death; the Insured Person or Traveling Companion or Traveling Companion’s family making 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); prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which the Insured Person purchased their trip arrangements. 

For Lost of Checked Luggage, this insurance does not cover:  animals; automobiles or automobile equipment; boats; motors; motorcycles; other conveyances or their appurtenances (except bicycles while checked as baggage with a Common Carrier); household furniture; eye-glasses or contact lenses; artificial teeth or dental bridges; hearing aids; prosthetic limbs; musical instruments; money or securities; tickets or documents; or sporting equipment if loss or damage results from the use thereof. 

NOTE:             This is only a brief description of the plan benefits.  The policy shall provide the only basis for coverage and claim. 

PAYMENT OF PREMIUM & GROUP ENROLLMENT 

Premium should be made payable to Seven Corners, Inc. and can be paid either by check or credit card (Visa, MasterCard, Discover, Diners Club).  Premium is due in advance, meaning that prior to the insured’s departing on their international trip, payment should be sent to SEVEN CORNERS so that is properly credited and coverage is in place.

In order to enroll insured persons under the group program, SEVEN CORNERS will need to receive a group census along with the premium amount.  The census would need to include the following: 

1.                  Name of Insured

2.                  Effective Date

3.                  Expiration Date

4.                  Date of Birth or Age

5.                  Premium Amount Submitted for the Insured 

INFORMATION

            1.         Marketed by:

                        Insurance Services of America

                        1757 E. Baseline Rd., Ste 126

                        Gilbert, AZ  85233

                        1-800-647-4589 (USA & Canada) / 1-480-821-9052 (Worldwide)

                        1-866-793-4779 (Toll Free FAX)

                       

            2.         International 24 hour assistance services provided by:

                        Seven Corners Assist

                        Carmel, IN  USA

                        Refer to group number (assigned when policy is issued) when calling

                        If in the United States or Canada: 1-800-690-6295

                        If outside the United States or Canada: 0-317-818-2808 (collect)

 

            3.         Policy and claims administration to be provided by:

                        Seven Corners Inc.

                        303 Congressional Blvd.

                        Carmel, IN  46032

 

THE INSURANCE COMPANY

Certain Underwriters at Lloyds, London, rated A “Excellent” by AM Best.

Group Enrollment Procedures

Assured:  

1.      Complete the Group Enrollment Form.  By completing the Group Enrollment page and 
submitting the total premium, the group plan will commence.
 

2.      Enrolling Individuals or Teams.  Communicating the names, birth dates, start and end dates, and 
plan option selection via fax, email, or regular mail is all that is necessary.  Payment is to be included 
at time of enrollment for all covered members. Effective date cannot be earlier than the date received 
by SCI. Note: Binding coverage for the entire group and the initial covered travelers can be done 
simultaneously.  

3.      What you will receive.  Upon execution of the group contract and receipt of the required items 
above, an instructional summary will be provided containing emergency phone numbers, claims 
procedures, program benefits and definitions, the group policy number, and other related 
information. This information can be copied and distributed by the client at their discretion.  
(Most commonly a single representative or group leader will retain this information and be the 
sole contact for the group).
 

4.      Flexibility.  SCI will try to accommodate requests to modify these administrative procedures.

International Provider Group Premiums

Medical Maximum

(Per Policy Period)

$25,000

$50,000

$100,000

 

Plan A

Plan B

Plan C

Plan D

Plan E

Plan F

Plan G

Plan H

Plan I

Deductible
(Per Policy Period)

$50

$250

$500

$50

$250

$500

$50

$250

$500

Monthly Premium

 

To the US

 

Outside the US

 
 

 

$79.00

 


$57.69

 

 

 
$65.51 

 
 

$49.17

 

 


$59.33

 


$43.27

 

 


$87.75

 


$64.90

 

 


$76.04

 


$55.07

 

 


$65.89

 


$48.51

 

 


$107.84

 


$74.08

 

 


$89.82

 


$62.94

 

 


$77.68

 


$55.73

Daily Premium

 

To the US

 

Outside the US

 

 

 
$2.63


 

$1.93

 

 

 
$2.29 
 

 

$1.64

 

 


$1.98

 


$1.45

 

 


$2.93

 


$2.16

 

 


$2.53

 


$1.83

 

 


$2.19

 


$1.62

 

 


$3.60

 


$2.47

 

 


$2.99

 


$2.10

 

 


$2.59

 


$1.86

 

Medical Maximum

(Per Policy Period)

                            $500,000

                               $1,000,000

 

Plan J

Plan K

Plan L

Plan M

Plan N

Plan O

Deductible
(Per Policy Period)

$50

$250

$500

$50

$250

$500

Monthly Premium  

To the US

 

Outside the US

 
 

$135.05

 


$86.87

 

 
$112.43

 
 

$73.76

 

 
$88.34

 


$64.90

 

 
$153.41

 


$99.65

 

 
$127.84

 


$84.57

 

 
$110.79

 


$74.73

Daily Premium  

To the US

 

Outside the US

 

  
$4.50


 

$2.89

 

  
$3.75
 

 

$2.46

 

 
$3.26

 


$2.16

 

 
$5.11

 


$3.32

 

 
$4.26

 


$2.82

 

 
$3.69

 


$2.49

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Insurance Services of America
1757 E. Baseline Road, Suite 126
Gilbert, AZ 85233
1-800-647-4589 ( N. America)
1-480-821-9297 (Worldwide)