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International
Provider Group Insurance
DESCRIPTION
OF PROPOSED PROGRAM & PREMIUMS ASSURED
Insurance Services of ELIGIBILITY
From:
SCHEDULE OF BENEFITS See rate sheet Accident / Sickness Medical Limit per Insured Person Per Policy Period. See rate sheet Deductible. The Insured pays the first $250 of eligible expenses per policy period. Thereafter, if travel outside the US, the policy pays 100% after the Deductible. $300,000 Emergency Medical Evacuation / Repatriation Expense $50,000 Return of Mortal Remains Expense $10,000 Emergency Reunion Expense $5,000 Return of Minor Child(ren) Expense $2,500 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. DESCRIPTION OF MEDICAL BENEFITS When a covered Injury or Illness is incurred by the Insured Person the Company will pay Reasonable and Customary medical charges for Covered Expenses, excess of the Deductible and Coinsurance as stated in the Schedule of Benefits. In no event shall the Company's maximum liability exceed the maximum stated in the Schedule of Benefits. The Deductible and Coinsurance amount consists of Covered Expenses which would otherwise be payable under this Policy. These expenses must be borne by the Insured Person. Only such expenses, incurred as the result of a disablement, which are specifically enumerated in the following list of charges, and which are not excluded in the Exclusions, shall be considered as 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 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, if recommended by a Physician for the treatment of a specific Disablement and administered by a licensed physiotherapist. 9. Hotel room charge, when the Insured Person, otherwise necessarily confined in a Hospital, shall be under the care of a duly qualified Physician in a hotel room owing to unavailability of a Hospital room by reason of capacity or distance or to any other circumstances beyond control of the Insured Person. 10. Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or Surgeon. 11. Charges made for artificial limbs, eyes, larynx, and orthotic appliances, but not for replacement of such items. 12. 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, within the metropolitan area in which the Insured Person is located at that time the service is used. If the Insured Person is in a rural area, then licensed ground ambulance transportation to the nearest metropolitan area shall be considered a Covered Expense. Only those expenses specifically described above which are incurred within 180 days from the onset of an Injury or Illness and which are not excluded (see “Exclusions”) are considered Covered Expenses. Initial treatment must occur within 60 days of the incident. Illness must first manifest itself during the Period of Coverage. EMERGENCY MEDICAL EVACUATION / REPATRIATION The Company shall pay benefits for Covered Expenses incurred up to the limit as stated in the Schedule of Benefits, if any covered Injury or Illness commencing during the Period of Coverage results in the Medically Necessary Emergency Medical Evacuation or Repatriation of the Insured Person. The Emergency Medical Evacuation or Repatriation must be ordered by the Company’s appointed Assistance Company in consultation with the Insured Person’s local attending Physician. Emergency Medical Evacuation or Repatriation means: a) the Insured Person's medical condition warrants immediate transportation from the place where the Insured Person is located to the nearest adequate medical facility where medical treatment can be obtained; or b) after being treated at a local medical facility as a result of a Medical Evacuation, the Insured Person's medical condition warrants transportation with a qualified medical attendant to his/her Home Country to obtain further medical treatment or to recover; or c) both a) and b) above. All transportation arrangements must be by the most direct and economical route. 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. EMERGENCY MEDICAL REUNION When Emergency Medical Evacuation or Repatriation occurs, the Company will arrange and pay, up to the limit stated in the Schedule of Benefits, for round trip economy-class transportation for one individual selected by the Insured Person, from the Insured Person’s Home Country to the location where the Insured Person is hospitalized and returned to the Home Country. Emergency Medical Reunion must be recommended by the attending Physician. The benefits payable will include: 1. The cost of a round trip economy air fare; 2. Reasonable travel and accommodation expenses (not to exceed $200 per day) incurred in relation to the maximum of $10,000. 3. The period of Emergency Medical Reunion is not to exceed 10 days, including travel. RETURN OF MINOR CHILD(REN) Should the Insured Person be traveling alone with a Minor Child(ren) and is hospitalized because of a covered Illness or Injury and the Minor Child(ren), under age 19, is left unattended, the Company will arrange and pay, up to the limit stated in the Schedule of Benefits, for one way economy fares to their Home Country. These arrangements will be made at no cost to the Insured Person. Meals and lodging are the responsibility of the Insured Person. If an attendant/escort is necessary to insure the safety and welfare of Minor Child(ren), the Company will arrange and pay for these services to the limit stated in the Schedule of Benefits. INTERRUPTION OF TRIP If the Insured is 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 the Insured's principal residence from fire, flood or similar natural disaster (tornado, earthquake, hurricane, etc.), the program will reimburse (up the amount stated in the Schedule of Benefits) the Insured for the cost of travel (economy), less the value of applied credit from an unused return travel ticket, to return home to their area of principal residence. LOSS OF CHECKED LUGGAGE If the Insured's checked luggage is permanently lost by the airline, the program will reimburse the Insured for the replacement of clothing and personal hygiene items lost to a maximum per article limit of $50 (up to the maximum stated in the Schedule of Benefits). This benefit is secondary to any other (including airline) coverage available. The insured must furnish proof to the Company that full reimbursement has been obtained from the airline. HOSPITAL INDEMNITY Should the insured person be hospitalized while traveling outside the United States or Canada, and the hospitalization is considered a Covered Expense, the Company will indemnify the insured $150 for each nigh spent in the hospital. ACCIDENTAL DEATH AND DISMEMBERMENT Principal Sum: See Schedule of Benefits For Primary Insured only. Loss of Life... The Principal sum Loss of Two or More Members... The Principal sum Loss of One Member... 50% The Principal sum "Member" Means Hand, Foot, or Eye. “Loss” means with regard to hand or foot, actual severance through or above the wrist or ankle joint, and with regard to eye, entire and irrecoverable loss of sight. Only one benefit, the largest to which you are entitled, will be paid for losses resulting from the same accident. *Aggregate Limits may apply. NOTE: In the event of an Emergency Medical Evacuation Repatriation, Return of Mortal Remains, Emergency Medical Reunion, Return of Minor Child(ren), Interruption of Trip, or Loss of Checked Luggage benefit is needed, arrangements must be made by the Assistance Service Provider. Details about the Assistance Service Provider are given in the Information section below. ASSISTANCE SERVICES The travel assistance benefits described below are provided by SEVEN CORNERS Assist. The office is staffed 24 hours a day, 7 days a week with multilingual representatives. Medical Assistance While Traveling 24-Hour telephone contact for travel medical emergencies help in locating medical care; Arranging telephone conferences between your attending and home physicians; Arranging second medical opinions in hospital cases; Relaying emergency messages to family and employer during medical emergencies; Guarantee or payment of medical bills using your available financial resources; 24-Hour ticketing service to arrange family visits; Arranging emergency medical evacuation from medically under served areas; Arranging evacuation for catastrophic claims; Arranging medical transportation home after treatment; Arranging escorts and transportation for unaccompanied children; Arranging transfer of medical records; Arranging repatriation of remains for deceased travelers; Notify your health insurer of a claim. Pre-Notification / Referral Seven Corners Assist must be contacted prior to: (1) any medical treatment being received in the United States; or (2) hospital admissions worldwide; or (3) inpatient or outpatient surgeries worldwide. Additionally, the Company’s appointed network provider must be utilized for medical expenses incurred inside the United States (when available – contact Seven Corners Assist with questions). A listing of network facilities can be found at www.specialtyrisk.com/ppo on the worldwide web. Pre-notification does not guarantee that benefits will be paid. Failure to follow Pre-Notification / Referral will result in a 20% reduction of Eligible Benefits. (For Emergency admissions and situations, Seven Corners Assist must be contacted within 48 hours, or as soon as reasonably possible.) OPTIONAL COVERAGE: Hazardous Sport Coverage - multiply rates by 1.15: To cover motorcycle/motor scooter riding, mountaineering (4500 meter limit), hang gliding, parachuting, bungee jumping, water skiing, snow skiing, snowmobiling, and snow boarding. PRE-EXISTING CONDITIONS For Medical Expense Benefits covered under this policy, this insurance does not cover: Any Injury or Illness which meets the following criteria a) condition(s) that would have caused a person to seek medical advise, diagnosis, care or treatment during the 36 months prior to the Effective Date of coverage under this Policy; b) condition(s) for which manifestation, medical advise, diagnosis, care or treatment was recommended, received, or noticed during the 36 months prior to the Effective Date of coverage under this Policy; If the Injury or Illness is an Unexpected Recurrence and the Insured Person is traveling outside the United States, the program will reimburse up to $1000 for treatment of that particular condition. An Unexpected Recurrence is a sudden and unexpected outbreak or recurrence of a condition defined in a & b above. The condition must occur spontaneously and without advanced warning, for example: prior symptoms, Physician visit, failing to take medication. For Insured Persons traveling outside the United States and Canada, the period is 12 months instead of 36 months. EXCLUSIONS For Medical benefits, this Insurance does not cover: 1. Any Injury or Illness which meets the following criteria: (a) condition(s) that would have caused a person to seek medical advice, diagnosis, care or treatment during the 36 months prior to the Effective Date of coverage under this Policy; (b) condition(s) for which manifestation, medical advice, diagnosis, care or treatment was recommended, received, or noticed during the 36 months prior to the Effective Date of coverage under this Policy; For Insured Persons traveling outside the United States and Canada, the period is 12 months instead of 36 months. If the Insured Person is a United States citizen, this exclusion is waived for the first $15,000 in eligible medical expenses incurred outside the United States and Canada (for persons age 65 and over, the amount is $2500). This waiver does not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program. 2. Charges for treatment which exceed Reasonable and Customary charges; or Charges incurred for Surgeries or treatments which are Investigational, Experimental, or for research purposes; expenses which are non-medical in nature; expenses for Vocational, Speech, Recreational or Music Therapy; 3. Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician; 4. Suicide or any attempt there at, while sane or self destruction or any attempt there at, while insane; intentionally self-inflicted Injury or Illness; or expenses as a result or in connection with the commission of a felony offense; 5. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war; 6. Injury sustained while participating in professional, sponsored and/or organized Amateur or Interscholastic Athletics; 7. Routine physicals, inoculations, or other examinations where there are no objective indications or impairment in normal health; 8. Treatment of the temporomandibular joint. 9. Services or supplies performed or provided by a Relative of the Insured Person, or anyone who lives with the Insured Person. 10. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids, cosmetic or plastic Surgery (including deviated nasal septum), routine dental expenses, eye care or eye related expenses, unless caused by Accidental bodily Injury incurred while insured hereunder; 11. Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent; any Mental and Nervous disorders or rest cures; Injury sustained while under the influence of or Disablement due to wholly or partly to the effects of intoxicating liquor or drugs; 12. Congenital abnormalities and conditions arising out of or resulting therefrom; 13. Expenses incurred during a hospital emergency room visit which is not of an emergency nature; 14. Injury sustained while taking part in mountaineering where ropes or guides are normally used, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, snowmobiling, motorcycle / motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI certified), water skiing, snow skiing and snow boarding;* 15. Treatment paid for or furnished under any other individual, government, or group policy or charges provided at no cost to the Insured Person. 16. Treatment of venereal or sexually transmitted disease. 17. Pregnancy expenses or Illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from Accident. 18. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth; 19. Expenses incurred while the Insured Person is in their Home Country (except after approved Emergency Evacuation / Repatriation or if treatment is a follow-up to a covered disablement during coverage); 20. Expenses incurred for which travel was undertaken to seek medical treatment for a condition; or incurred after the Insured Person’s physician has limited or restricted travel. *Option is available to include all or part of these risks. With regards to Accidental Death and Dismemberment (AD&D), Emergency Medical Evacuation / Repatriation, Return of Mortal Remains, Emergency Medical Reunion, and Return of Minor Child, this Insurance does not cover: 1. Suicide or attempt thereof by the Insured Person while sane or self destruction or any attempt thereof by the Insured Person while insane; 2. Disease or sickness of any kind; (only applicable to AD&D) 3. Bacterial infections except pyogenic infection which shall occur through an accidental cut or wound; (only applicable to AD&D) 4. Hernia of any kind; (only applicable to AD&D) 5. Injury sustained while the Insured Person is riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting, from any type of aircraft; 6. Injury sustained while the Insured Person is 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. 7. 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 no 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. 8. Service in the military, naval or air service of any country. 9. Flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing, endurance tests, rocket-propelled aircraft, 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. 10. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified physician or surgeon. 11. Injury occasioned or occurring while the Insured Person is committing or attempting to commit a felony or to which a contributing cause was the Insured Person being engaged in an illegal occupation. 12. While riding or driving in any kind of competition. 13. Pregnancy, childbirth, miscarriage or abortion. 14. Covered Expenses incurred after the Insured Person’s physician has limited or restricted travel; or Covered Expenses incurred as a result of a change in prescribed treatment during, or within the three months prior to the effective date of coverage. 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. For Loss 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. THE INSURANCE COMPANY PAYMENT OF PREMIUM & GROUP ENROLLMENT
Premium should be made payable to Seven Corners International (SCI) and
can be paid either by
In order to enroll insured persons under the group program, SCI will need
to receive a group 1. Name of Insured 2. Effective Date 3. Expiration Date 4. Date of Birth or Age 5. Premium Amount Submitted for the Insured
1.
Marketed by:
2.
International 24 hour assistance services provided by:
3.
Policy and claims administration to be provided by: Group Enrollment Procedures Assured:
1.
Complete the Group Enrollment Form. By
completing the Group Enrollment page and 2.
Enrolling Individuals or Teams. Communicating
the names, birth dates, start and end dates, and 3.
What you will receive. Upon
execution of the group contract and receipt of the required items 4.
Flexibility. SCI will try to accommodate
requests to modify these administrative procedures. |
Virginia Surety Company, Inc. is ranked “A” (Excellent ) by AM Best.
International Provider Group Premiums
|
Medical Maximum (Per Policy Period) |
$25,000 |
$50,000 |
$100,000 |
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Plan A |
Plan B |
Plan C |
Plan D |
Plan E |
Plan F |
Plan G |
Plan H |
Plan I |
|
Deductible |
$50 |
$250 |
$500 |
$50 |
$250 |
$500 |
$50 |
$250 |
$500 |
|
Monthly Premium
To the US
Outside the US |
$79.00
|
$49.17 |
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|
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|
Daily Premium
To the US
Outside the US |
$1.93 |
$1.64 |
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|
Medical Maximum (Per Policy Period) |
$500,000 |
$1,000,000 |
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Plan J |
Plan K |
Plan L |
Plan M |
Plan N |
Plan O |
|
Deductible |
$50 |
$250 |
$500 |
$50 |
$250 |
$500 |
|
Monthly Premium To the US
Outside the US |
$135.05
|
$73.76 |
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Daily Premium To the US
Outside the US |
$2.89 |
$2.46 |
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Gilbert,
1-800-647-4589 (
1-480-821-9297 (Worldwide)