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DESCRIPTION OF PROPOSED PROGRAM &
PREMIUMS
ASSURED
Insurance Services of
America
1757 E. Baseline Road, Suite
126
Gilbert, AZ
85233
ELIGIBILITY
Class 1: Participants of the assured
traveling outside their home country.
POLICY PERIOD
From:
12:01 a.m. LST, Date to
be Agreed
To:
12:01 a.m. LST, Date to
be Agreed
SCHEDULE OF BENEFITS
See Options Accident / Sickness
Medical Limit per Insured Person Per Policy Period.
See Options Deductible. The Insured pays the first $___ of
eligible expenses per policy period.
Thereafter, if travel is Inside he US, the policy pays 80% up to
the first $5,000, then
100% to the Medical Limit. If travel is 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 Principle 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 SRI 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
SRI 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 SRI
Assist with questions). A listing of network facilities can be
found at www.sevencorners.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, SRI 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
Virginia
Surety Company, Inc. is ranked “A” (Excellent)
by AM Best.
PAYMENT OF PREMIUM &
GROUP ENROLLMENT
Premium should be made payable to Specialty Risk
International, 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 insureds departing on their
international trip, payment should be sent to
SRI so that is properly credited and coverage is in place.
In order to enroll insured persons under the group
program, SRI 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 Road, Suite 126
Gilbert,
AZ
85233
1-800-647-4589 (N. America)
1-480-821-9297
(Worldwide)
2.
International 24 hour assistance services provided by:
SRI Assist
Indianapolis,
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 State
or Canada: 0-317-818-2808 (collect)
3.
Policy and claims administration to be provided by:
Specialty Risk International, Inc. (SRI)
Indianapolis,
IN
46240
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 SRI. 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.
SRI will try to accommodate requests to modify these
administrative procedures.
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