Coverage will begin at 12:01 A.M. Eastern Standard Time on the latest of the following: 1) The date and time your enrollment form and correct premium are received by Global Underwriters Agency; or 2) The effective date requested on the enrollment form; 3) The moment You departure from your Home Country; Coverage will end at 11:59 P.M. Eastern Standard Time on the earlier of the following: 1) The moment You return to your Home Country, except as provided under the Home Country Coverage; or 2) Twelve months after your coverage's effective date; or 3) The termination date shown on the enrollment form, for which premium has been paid; 4) The date You are no longer considered an Eligible Person. The minimum period of coverage that can be purchased is 15 days, the maximum is twelve months. Age 70-79, medical maximum limited to $100,000; age 80+ $20,000. Medical Maximum is a Life Time limit.
DEFINITIONS The Term Benefit Period means the allowable time period You have from the date of Injury of onset of Illness to receive Treatment for a Covered Injury or Illness. If Your Plan terminates during Your Benefit Period, You will still be eligible to receive Treatment so long as the Treatment is within Your Benefit Period and outside Your Home Country (except as provided under the Optional Home Country Coverage). The term "Home Country" shall mean, the country where an eligible person(s) has his/her fixed and permanent home establishment and to which he/she has the intention of returning. The Term "Common Carrier" means any motorized land, sea, and/or air conveyance operating under a valid license for the transportation of passenger for hire. The Term "Company" will be the company shown on the declarations page. The Term "Domestic Partner" means a same or an opposite sex partner who has met all of the following requirements for at least 12 consecutive months immediately preceding the Effective Date of Coverage: (1) resides with the Insured; (2) shares financial assets and obligations with the Insured; (3) is not related by blood to the Insured. The term "Home Country" shall mean, the country where an eligible person(s) has his/her fixed and permanent home establishment and to which he/she has the intention of returning. The term "Hospital" as used in this Policy [means except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision.[means a place that 1.) is legally operated for the purpose of providing medical care and treatment to sick or injured persons for which a charge is made that the Insured is legally obligated to pay in the absence of insurance 2.) provides such care and treatment in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) operates under the supervision of a staff of one or more Doctors. Hospital also means a place that is accredited as a hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Heath Care Organizations (JCAHO). Hospital does not mean: -a convalescent, nursing, or rest home or facility, or a home for the aged; -a place mainly providing custodial, educational, or rehabilitative care; or-a facility mainly used for the treatment of drug addicts or alcoholics. The term "Injury" wherever used in this Policy [means bodily Injury caused solely and directly by violent, Accidental, external, and visible means occurring while this Policy is in force means Accidental bodily Injury or Injuries caused by an Accident. The Injury must be the direct cause of the Loss, independent of disease or bodily infirmity. Any Loss due to Injury must begin after the Effective Date of this Policy. The term "Immediate Family Member" means a person who is related to the Insured in any of the following ways: spouse, Domestic Partner, brother-in-law, sister-in-law, daughter-in-law, son-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild). The Term "Automobile" means a self propelled private passenger motor vehicle with four or more wheels which is a type both designed and required to be licensed for use on the highways of any state or country. Automobile includes but is not limited to a sedan, station wagon, or jeep type vehicle and a motor vehicle of the pickup, panel, van camper or motor home type. Automobile does not include a mobile home or any motor vehicle used in mass or public transit. The term "Physician" as used in this Policy means a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed, however, such definition will exclude chiropractors and physiotherapists. The term "Pre Existing Condition" means any Injury or Illness which was contracted or which manifested itself, or for which treatment or medication was prescribed in the 18 months prior to the effective date of this insurance. The Term "Reasonable and Customary" means the maximum amount that the Company determines is Reasonable and Customary for Covered Costs the Insured Person receives, up to but not to exceed charges actually billed. The Company's determination considers: 1) amounts charged by other Service Providers for the same or similar service in the locality were received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; 2) any usual medical circumstances requiring additional time, skill or experience; and 3) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale. For a Service Provider who has a reimbursement agreement, the Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company. If a Service Provider accepts as full payment an amount less than the negotiated rate under a reimbursement agreement, the lesser amount will be the maximum Reasonable and Customary charge. The Reasonable and Customary charge is reduced by any penalties for which a Service Provider is responsible as a result of its agreement with the Company "Supplemental Restraint System" means an air bag which inflates for added protection to the chest and head areas. "Felonious Assault" means any willful or unlawful use of force upon the Insured 1) with the intent to cause bodily injury to the Insured and 2) that results in bodily harm to the Insured and 3) that is a felony or a misdemeanor in the jurisdiction in which it occurs. "Coma/Comatose" means a profound state of unconsciousness from which the Insured cannot be aroused to consciousness , even by powerful stimulation , as determined by a Physician. "Covered Home Alteration and Vehicle Modification Costs" - means one-time Costs that: 1) are charged for: (a)alterations to the Insured Person's residence that are necessary to make the residence accessible and habitable for a wheelchair-confined person; or (b)modifications to a motor vehicle owned or leased by the Insured Person or modifications to a motor vehicle newly purchased for the Insured Person that are necessary to make the vehicle accessible to and/or drivable by the Insured Person; and 2) do not include charges that would not have been made if no insurance existed; and 3) do not exceed the usual level of charges for similar alterations and modifications in the locality where the Cost is incurred; but only if the alterations to the Insured Person's residence and the modifications to his or her motor vehicle are: (a) made on behalf of the Insured Person; (b) recommended by a nationally-recognized organization providing support and assistance to wheelchair users; (c) carried out by individuals experienced in such alterations and modifications; and (d) in compliance with any applicable laws or requirements for approval by the appropriate government authorities.
Accidental Death and Dismemberment
If within 365 days after the date of a covered accident, the Insured Person's Injury results in death or dismemberment, this Plan provides the following benefits for loss of:
The amount of the Principal Sum is listed above.
| Description of Loss | Indemnity |
|---|---|
| Life | Principal Sum |
| Both Hands or Both Feet or Sight of Both Eyes or One Hand and One Foot or Either Hand or Foot and Sight of One Eye | Principal Sum |
| Speech and Hearing in both Ears | Principal Sum |
| Speech or Hearing in both Ears | One-half the Principal Sum |
| Either Hand or Foot or Sight of One Eye | One-Half the Principal Sum |
| Thumb and index finger of same hand | One-Quarter of the Principal Sum |
The term "Loss" in reference to quadriplegia, paraplegia, hemiplegia, and uniplegia, means the complete and irreversible paralysis of such limbs and with regard to hands and feet, actual severance through and above the wrist or ankle joints, and with regard to eyes, entire irrecoverable Loss of sight and with regard to thumb and index finger, actual severance through or above the joint that meets the finger at the palm. Loss in reference to other coverages means injury or damage sustained by the Insured in consequence of happening of one or more of the accidents against which the Company has undertaken to indemnify the Insured
Enhanced AD&D Benefit Selections (If Benefit is purchased) It is understood and agreed to increase limits from the $25,000 up to a maximum of $1,000,000.00 under Principal Sum, selections are made as follows and additional rates for the increase in AD&D are (The enhanced AD&D benefit is not available to children under 18 years of age. The maximum AD&D benefit for children under age 18 is limited to a maximum of $25,000 per child under this policy):
| AD&D Principal Sum | Additional Rate |
|---|---|
| $25,000 | $ 2.00 Per Person Per Month |
| $50,000 | $ 4.00 Per Person Per Month |
| $75,000 | $ 6.00 Per Person Per Month |
| $100,000 | $ 8.00 Per Person Per Month |
| $200,000 | $ 16.00 Per Person Per Month |
| $250,000 | $ 20.00 Per Person Per Month |
| $300,000 | $ 24.00 Per Person Per Month |
| $400,000 | $ 32.00 Per Person Per Month |
| $500,000 | $ 40.00 Per Person Per Month |
| $600,000 | $ 48.00 Per Person Per Month |
| $700,000 | $ 56.00 Per Person Per Month |
| $750,000 | $ 60.00 Per Person Per Month |
| $800,000 | $ 64.00 Per Person Per Month |
| $900,000 | $ 72.00 Per Person Per Month |
| $975,000 | $ 80.00 Per Person Per Month |
Paralysis Benefit - If Injury to the Insured results, within 365 days of the date of the accident that caused the Injury, in any one of the types of paralysis specified below, The Company will pay the percentage of the Maximum Amount shown below for that type of paralysis:
| Type of Paralysis | Percentage of the Principal Sum |
|---|---|
| Quadriplegia | 100% |
| Paraplegia | 75% |
| Hemiplegia | 50% |
| Uniplegia | 25% |
The Term "Quadriplegia" means the complete and irreversible paralysis of both upper and both lower limbs. "Paraplegia" means the complete and irreversible paralysis of both lower limbs. "Hemiplegia" means the complete and irreversible paralysis of the upper and lower limbs of the same side of the body. "Uniplegia" means the complete and irreversible paralysis of one limb. "Limb" means entire arm or entire leg. If the Insured suffers more than one type of paralysis as a result
of the same accident, only one amount, the largest, will be paid.
Disappearance -- If the body of an Insured Person has not been found within one year of the disappearance, forced landing, stranding, sinking or wrecking of a conveyance in which such person was an occupant, then it shall be deemed, subject to all other terms and provisions of the plan, that such Person shall have suffered loss of life within the meaning of the plan.
If the Insured suffers more than one type of paralysis as a result of the same accident, only one amount, the largest, will be paid.
Coma Benefit - If a covered Injury renders an Insured Person Comatose within 90 days of the date of the accident that caused the Injury, and if the Coma continues for a period of 30 consecutive days, The Company will pay a monthly benefit equal to 1% of the Principal Sum. No benefit is provided for the first 30 days of the Coma. The benefit is payable monthly as long as the Insured remains Comatose due to that Injury, but ceases on the earliest of
1) the date the insured ceases to be Comatose due to the Injury;
2) the date the Insured dies;
3) the date the total amount of monthly Coma benefit paid for all Injuries caused by the same accident equals $50,000.
The Company will pay benefits calculated at a rate of 1/30th of the monthly benefit for each day for which The Company is liable when the Insured is Comatose for less than a full month. Only one benefit is provided for any one month of Coma, regardless of the number of Injuries causing the Coma. The Company reserves the right , at the end of the first 30 consecutive days of Coma and as often as it may reasonably require thereafter, to determine on the basis of all the facts and circumstances, that the Insured is Comatose, including but not limited to, requiring an independent medical examination provided at the Cost of The Company.
Seat Belt Benefit - The Company will pay a benefit when the Insured Person suffers accidental death such that an Accidental Death benefit is payable under the plan and the accident causing death occurs while the Insured Person is operating , or riding as a passenger in an Automobile and wearing a properly fastened seat belt, properly installed by a factory authorized dealer. The additional amount payable under this benefit is the lesser of $50,000 or 10% of the Insured Person's Principal Sum.
Air Bag Benefit- The Company will pay a benefit if the Insured Person is positioned in a seat protected by a properly functioning Supplemental Restraint System, properly installed by a factory authorized dealer that inflates on impact. The additional amount payable under this benefit is the lesser of $50,000 or 10% of the Insured Person's Principal Sum. Verification of the actual use of the seat belt at the time of the accident, and that the Supplemental Restraint System inflated properly upon impact must be part of an official report of the accident or be certified, in writing by the investigating officer(s).
Felonious Assault Benefit - The Company will pay 100% of the Principal Sum up to a Maximum benefit of $50,000 when an Insured Person suffers one or more losses for which benefits are payable under the Accident al Death & Dismemberment Benefit or Coma Benefit provided by the plan as a result of a Felonious Assault. (this benefit is in addition to any other Costs of the program): 1)That is not a moving violation as defined under the applicable government motor vehicle laws; and 2)That is not an act of an immediate Family Member, another insured or an individual who resides with the insured on a permanent basis.
Only one benefit is payable for all losses as a result of the same Felonious Assault.
Home Alteration and Vehicle Modification - If an Insured Person: 1. suffers an accidental dismemberment or paralysis for which an Accidental Dismemberment and Paralysis benefit is payable under the Policy; 2. did not, prior to the date of the Accident causing such loss(es), require the use of a wheelchair to be ambulatory; and 3. as a direct result of such loss(es) is now required to use a wheelchair to be ambulatory; The Company will pay Covered Home Alteration and Vehicle Modification Costs that are incurred within one year after the date of the accident causing such loss(es), up to a maximum of $2,500 for all such losses caused by the same accident.
Covered Home Alteration and Vehicle Modification Costs - As used in this Rider, means one-time Costs that: 1. are charged for: (a) alterations to the Insured Person's residence that are necessary to make the residence accessible and habitable for a wheelchair-confined person; or
(b) modifications to a motor vehicle owned or leased by the Insured Person or modifications to a motor vehicle newly purchased for the Insured Person that are necessary to make the vehicle accessible to and/or drivable by the Insured Person; and 2. do not include charges that would not have been made if no insurance existed; and 3. do not exceed the usual level of charges for similar alterations and modifications in the locality where the Cost is incurred; but only if the alterations to the Insured Person's residence and the modifications to his or her motor vehicle are: 1. made on behalf of the Insured Person; 2. recommended by a nationally-recognized organization providing support and assistance to wheelchair users; 3. carried out by individuals experienced in such alterations and modifications; and 4. in compliance with any applicable laws or requirements for approval by the appropriate government authorities.
Beneficiary Designation and Change The beneficiary or beneficiaries of an Insured Person shall be that person or those persons designated by the Insured Person and filed with the Plan Administrator. Any Insured Person who has not made an irrevocable designation of beneficiary may designate a new beneficiary at any time, without the consent of the beneficiary, by filing with the Plan Administrator a written request for such change but such change shall become effective only upon receipt of such request by Plan Administrator. When such request is received by the Plan Administrator, whether the Insured Person be then living or not, the change of beneficiary shall relate back to and take effect as of the date of execution of the written request, but without prejudice to the Company on account of any payment theretofore made by it.
MEDICAL COST
Covered Costs Per Insured Person Per Policy Period We will pay Reasonable and Customary charges for Covered Costs, 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. All bodily disorders existing simultaneously which are due to the same or related causes will 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 will be considered a continuation of the prior Disablement and not a separate Disablement. The initial Treatment of an Injury or Illness must occur within 30 days of the date of Injury or onset of Illness. Only such costs which are specifically enumerated in the following list of charges and incurred within 180 days from the date of accident or onset of Illness, and which are not excluded will be considered. For a covered Disablement, after you pay the Per Person Deductible, the plan pays 80% up to $5,000 of eligible costs, then 100% to the policy maximum. There will be an additional $250 deductible for each emergency room visit as a result of an illness. The deductible will be waived if hospital admittance is within twelve (12) hours of the incident.
Covered Costs - Only the Costs incurred for the medical care and supplies which are (a) necessary and customary; (b) prescribed by a physician for the therapeutic treatment of a disablement; and (c) are not excluded under this policy (d)are not more than the reasonable and customary charges (as determined by the company); and (e) are incurred as the result of and within 180 days from the disablement, and which are specifically enumerated in the following list: 1) Costs made by a Hospital for room and board, floor nursing and other services, including costs for professional services, except personal services of a non-medical nature, provided, however, that Costs do not exceed the Hospital's average charge for semi-private room and board accommodation, 2) Charges made for Intensive Care or Coronary Care charges and nursing services; 3) Costs 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, Physician's Outpatient visits/examinations, clinic care, and Surgical opinion consultations; 6) Costs made for administration of anesthetics; 7) Costs for medication, x-ray services, laboratory tests and services, the use of radium and radio-active isotopes, oxygen, blood transfusions, iron lungs, and medical treatment; 8) Costs for physiotherapy, if recommended by a Physician, for the treatment of a specific Disablement and administered by a licensed physiotherapist; With regards to chiropractic care, eligible charges up to $50.00 per visit, with a maximum of 10 visits per Injury or Illness is allowable. 9) Dressings, drugs, and medicines that can only be obtained upon written prescription of a Physician. 10). Hotel room charge, when the insured, otherwise necessarily confined in a Hospital, shall be under the care of a duly qualified Physician in a hotel room owing to the unavailability of a Hospital room by reason of capacity or distance or to any other circumstances beyond the control of the insured; The charges enumerated above shall in no event include any amount in excess of the reasonable and customary charges (as determined by the company). To determine if costs are reasonable and customary, the company will consider the following: the medical care or supplies usually given and the fees usually accepted for like cases in the area. "Area" means a region large enough to get a cross section of providers or medical care or supplies. All costs are deemed to be incurred on the date such service is received. Emergency Dental Treatment (Palliative) - Benefits are paid for Reasonable and Customary Costs in excess of the chosen Deductible and Coinsurance of up to [$100] for the emergency Treatment for the relief of pain to natural teeth. Emergency Medical Evacuation and Repatriation: Benefits are paid for Covered Costs incurred up to $500,000, for any covered Injury or Illness commencing during the Period of Coverage that result in a Medically Necessary Emergency Medical Evacuation or Repatriation. The decision for an Emergency Medical Evacuation or Repatriation must be pre-approved and arranged by the Assistance Company in consultation with Your local attending Physician. Emergency Medical Evacuation or Repatriation means: a. Your medical condition warrants immediate transportation from the place where You are located (due to inadequate medical facilities) to the nearest adequate medical facility where medical Treatment can be obtained. b. After being treated at a local medical facility, Your medical condition warrants transportation with a qualified medical attendant to Your Home Country to obtain further medical Treatment or to recover; Or c. Both a. and b. above. Covered Costs are Costs for transportation, medical services and medical supplies necessarily incurred in connection with Emergency Medical Evacuation or Repatriation. All transportation arrangements must be by the most direct and economical route. Costs for special transportation and medical supplies and services must be: a. Pre-approved and ordered by the Assistance Company and b. Required by the standard regulations of the conveyance transportation. Transportation means any land, water or air conveyance required to transport You. Special transportation includes, but is not limited to, licensed ground and air ambulances, commercial airlines, and private motor vehicles. Non emergency use of special transportation is excluded from this policy. Costs for special transportation must be: a) recommended by the attending physician, or b) required by the standard regulations of the conveyance transporting the Insured Person. Costs for medical services and supplies must be recommended by the attending physician. Transportation means any land, water or air conveyance required to transport the Insured Person during an emergency evacuation. Special Transportation includes, but is not limited to, air ambulance, land ambulance, and private motor vehicles. Return of Mortal Remains: If You should die Benefits will be paid for Reasonable and Customary Covered Costs incurred up $50,000, to return Your remains to Your Home Country. Covered Costs include, but are not limited to, Costs for embalming or Cremation, a minimally necessary container appropriate for transportation, shipping costs, and the necessary government authorizations. All Covered Costs in connection with a Return of Mortal Remains or Cremation must be pre-approved and arranged by the Assistance Company. Emergency Medical Reunion: When the Assistance Company and Your attending Physician determine that it is necessary and prudent for You to have an Emergency Medical Evacuation or Repatriation, this Plan will arrange to bring an individual of Your choice, from Your current Home Country, to be at Your side while You are hospitalized and then accompany You during Your return to Your current Home Country. Benefits will be paid up to $50,000 for a round trip economy air fare ticket as well as for reasonable travel and accommodation Costs up to a maximum of 10 days, as pre-approved and arranged by the Assistance Company. Return of Minor Child(ren): Should You be traveling alone and are hospitalized because of a covered Illness or Injury and Your Minor Child(ren) is left unattended, the Assistance Company will arrange for a one way economy fare(s) to Your current Home Country. If an attendant/escort is necessary to ensure the safety and welfare of Your Minor Child(ren), the Assistance Company will also arrange these services. The Plan will pay for these services up to a maximum of $50,000 provided all transportation and services are pre-approved and arranged by the Assistance Company. Meals and lodging are Your responsibility. Incidental Trips Coverage is provided up to a maximum of fifteen (15) days for *IncidentalTripstoCanada,Mexico, and the Caribbean Islands only. "Incidental Trip" - Means temporary travel (not more than fifteen (15) days) outside the UnitedStatestoCanada,Mexico,and Caribbean Islands only. NOTE: "Incidental Trip" does not extend coverage beyond the coverage dates of the policy.
Interruption of Trip: If Your trip is interrupted due to one of the following reasons: 1. Death of a Family Member. 2.Serious damage to Your principal residence from fire, flood or similar natural disaster (tornado, earthquake, hurricane, etc.). Benefits will be paid up to $5,000 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. Loss of Baggage: This plan will reimburse You for loss, theft or damage to Your baggage or personal effects, checked with a Common Carrier provided You have taken all reasonable measures to protect, save and/or recover Your property at all times. This plan is secondary to any coverage provided by a Common Carrier and all other valid and collective insurance. This plan will pay the lesser of: 1. The actual cash value (cost less proper deduction for depreciation at the time of loss, theft or damage). 2. The cost to repair or replace the article with material of a like kind and quality; or 3. $50 per article, to a maximum of $250. Security and Natural Disaster Evacuation -The Assistance Company must make all arrangements and must authorize all Costs in advance for any benefits to be payable. Coverage is provided up to a maximum of $100,000 for all reasonable Costs incurred for transportation to the nearest place of safety or for repatriation to your Home Country (utilizing the most direct and economical route and conveyance). Provided that one of the following events has occurred: (1) the insured person is expelled or declared persona non-grata by written authority of the host country; (2) political or military event involving civil insurrection or military coup in the Host Country; (3) the United States Department of State, Bureau of Consular Affairs or other Appropriate Authorities issues an order Advisory stating thainsured is in imminent physical danger (must be verified by designated security consultant or appropriate authorities). Athletic, Sports, & Hazardous Activity (If Benefit is Purchased) - It is understood and agreed that the following Athletic, Sport, and Hazardous Activities as named on the application received by Global Underwriters are covered, with additional premium, and a $20,000 medical maximum for intercollegiate or interscholastic athletics, club, and organized amateur sports only. All other athletic, sports, and hazardous activities are covered up to the selected policy maximum and subject to reporting and additional premium. Any sport and hazard not expressly covered hereunder is excluded from this policy. Scuba Diving, Bobsledding, Kayaking, Jet, Snow and Water Skiing, Whitewater Rafting (up to and including Class V Rapid only), Surfing, Parasailing, Snowboarding, Trekking, High Diving, Mountain Biking, Snowmobiling, wind surfing, zip lining, Piloting any aircraft, Bungee Jumping, Canopying, Equestrian, Spelunking, Martial Arts, Motorcycling & Motor Scooter, Mountain Climbing (under 14,000 feet), Skydiving; Hang Gliding, Paragliding, BMX; Safari; Heli-skiing. Mountain Climbing (if over 14,000 feet/use of guide mandatory); Diving with sharks; Running with Bulls; MX; Aerial Photography (use of proper restraints required); Safari & Big Game Hunting (use of firearms); flying in any chartered or leased aircraft/helicopter; Security detail (use of firearm); BMX; For intercollegiate or interscholastic athletics, club, and organized amateur sports only: Tennis; Swimming; Diving; Cross Country; Track & Field Events; Baseball; Softball; Volleyball; Basketball; Cheerleading ; Equestrian; Field Hockey; Ice Hockey; Football (no division one); Gymnastics; Lacrosse; Polo Horse; Polo Water; Rugby; Soccer; Wrestling; Martial Arts; Golf; Fencing; Competitive Cycling (Road, Track, CX); skiing; slalom, giant slalom and downhill skiing .
EXCLUSIONS AND LIMITATIONS
No Benefit will 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.Any Pre-existing Condition as defined hereunder. This exclusion does not apply to Emergency Evacuation/Repatriation. 2. Injury or Illness which is not presented to Us for payment within 90 days of receiving Treatment. 3. Charges for Treatment which is not Medically Necessary. 4. Charges provided at no cost to You.5. Charges for Treatment which exceed Reasonable and Customary charges. 6.Charges incurred for Surgery or Treatments which are, Experimental/Investigational, or for research purposes. 7. Services, supplies or Treatment, including any period of Hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician. 8. Suicide or any attempt thereof, while sane or self destruction or any attempt thereof, while insane. 9.Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with: a. War, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war. b. Mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power. c. Acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence. d. Martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the "Occurrences"). Any consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, arising in connection with, any of the said Occurrences will be deemed to be consequences for which the Plan will not be liable for except to the extent that You prove that such consequence happened independently of the existence of such abnormal conditions, except as provided under the War Risk Coverage Rider. 10. Injury sustained while participating in professional athletics. 11.Injury sustained while participating in Amateur or Interscholastic Athletics, except as provided under the Athletic, Sports, and Hazardous Activity Coverage Rider. 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 will be considered a cosmetic condition.17.Elective Surgery which can be postponed until You returns to Your Home County, 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 while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician for a condition which is covered hereunder, but not for the Treatment of drug addiction. 22. Any Mental and Nervous disorders or rest cures. 23. Congenital abnormalities and conditions arising out of or resulting therefrom. 24. Costs which are non-medical in nature. 25. Costs as a result or in connection with intentionally self-inflicted Injury or Illness. 26. Costs as a result or in connection with the commission of a felony offense. 27.Injury sustained while taking part in mountaineering where ropes or guides are normally used; hang gliding, parachuting, bungee jumping, racing by horse, motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding, scuba diving, involving underwater breathing apparatus, unless PADI or NAUI certified, scuba diving, involving underwater breathing apparatus, snorkeling, water skiing, snow skiing, spelunking, parasailing and snow boarding:mountaineering where ropes or guides are normally used (4500 meter limit); parachuting, bungee jumping, snowmobiling, scuba diving, involving underwater breathing apparatus, must be PADI or NAUI certified, snorkeling, water skiing, snow skiing, spelunking, and snow boarding; except as provided under the Athletic, Sports, and Hazardous Activity Coverage Rider 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 program or facility set up for Treatment without cost to any 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. Including but not limited to: Organ Transplants, Marrow procedures, and chemotherapy. 36. Costs incurred while in Your Home Country, except as provided under the Home Country Coverage.37. Costs incurred during a Hospital emergency visit which is not of an emergency nature; 38. Covered Costs incurred for which the Trip to the Host Country was undertaken to seek medical Treatment for a condition; 39.Covered Costs incurred during a Trip after Your Physician has limited or restricted travel. 40. Sex change operations, or for Treatment of sexual dysfunction or sexual inadequacy. 41. Weight reduction programs or the surgical Treatment of obesity. 42. Costs resulting from Acquired Immune Deficiency Syndrome (AIDS), Aids-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV). 43. For any violent or unlawful act of an Immediate Family Member, another insured, or an individual that resides with the insured on a permanent basis. 44. For the ordinary cost of a one-way airplane ticket used in the transportation back to the insured's country where an air ambulance benefit is provided.
No Benefit will 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 will occur through an accidental cut or wound. 3.Hernia of
any kind. 4. Injury sustained while You are riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting from, any type of aircraft.
5.Injury sustained while You are riding as a passenger in any aircraft. a. Not having a current and valid Airworthy Certificate and b. Not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft. 6. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with: a. War, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war. b. Mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power. c. Acting on behalf of or in
connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence. d. Martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the "Occurrences"). Any consequence happening or arising during the existence of 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 will be deemed to be consequences for which the Plan will not be liable except to the extent that the You can 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; Flying in any rocket-propelled aircraft; 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; 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. 9. Sickness of any kind. 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 You are committing or attempting to commit a felony or to which a contributing cause was You being engaged in an illegal occupation. 12. While riding or driving in any kind of competition. 13. Pregnancy, childbirth, miscarriage or abortion. 14. This plan does not insure against loss or damage (including death or Injury) and any associated cost or expense resulting directly or indirectly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or radioactive force, or chemical, biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act, regardless or any other cause or event contributing concurrently or in any other sequence thereto. 15. For any violent or unlawful act of an Immediate Family Member, another insured, or an individual that resides with the insured on a permanent basis. 16.While riding or driving in any competition.
No Benefit will be payable for Baggage Loss and Delay as the result of - 1. Aircraft, automobiles, automobile equipment, motors, motorcycles, bicycles (except bicycles when checked as baggage with a common carrier,) boats or other conveyances or their accessories.2. Animals. 3. Artificial teeth or limbs, hearing aids. 4. Sunglasses, contact lenses or eyeglasses. 5. Documents of any kind, including but not limited to documents, bills, currency, deeds, evidences of debt, letters of credit, stamps, credit cards, money, notes, securities, transportation or other tickets.6. Household furniture or furnishings. No Benefit will be payable for Trip Interruption as the result of - 1. You, Your Traveling Companion or Your Traveling Companion's family has made changes to personal plans; having business or contractual obligations; being unable to obtain necessary travel documents (passports, visas, etc.); being detained or having property confiscated by customs authorities; carrier caused delays (including bad weather). 2. Prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which You have purchased Your trip arrangements. No Benefit will be payable for Home Alteration and Vehicle Modification, as the result of any condition for which the Insured Person is entitled to benefits under any Workers' Compensation Act or similar law. Excess Benefits - All coverage, except Accidental Death and Dismemberment, shall be in excess of all other valid and collectible insurance indemnity and shall apply only when such benefits are exhausted. The policy is not in lieu of and does not affect any requirement for coverage by Worker's Compensation insurance. Refund of Premium -- Less a $25 processing fee, will be considered only when written request is received by Global Underwriters prior to the Effective Date of Individual coverage. After the Effective Date of Individual coverage, premium is considered fully earned and non-refundable. Partial refunds are not available. DISCLAIMER: This Description of Coverage and evidence of insurance provides a summary of the policy features only and does not cover all the terms, conditions and limitations of the Master Policy. The Master Policy (on file with Global Underwriters) contains the actual terms, conditions, and limitations, of the coverage to be provided. If there is any conflict between this description of coverage and the Master Policy the Master Policy will govern in all cases. ON CALL INTERNATIONAL SERVICES Inside US and Canada 866-509-7715 Outside US and Canada 603-328-1728 (collect) CLAIM PAYMENT / CLAIMS ADMINISTRATOR Mail claims with original receipts and completed claim form to: Global Claims Administration 3195 Linwood Rd Suite 201 Cincinnati OH 45208 Inside US and Canada 800-513-2981 Outside US and Canada 513-533-1330 9am -- 5pm Eastern Standard Time Monday through Friday Notice of Claim: Written notice of claim must be given to the Company within 60 days after the occurrence or commencement of any Disablement covered by the Policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the claimant to Global Underwriters, or to any authorized agent of the Company, with information sufficient to the identify the Insured Person will be deemed notice to the Company. Claim Forms - The Company, upon receipt of a written notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this Plan by submitting, within the time fixed in this Plan for filing proofs of loss, written proof showing the occurrence, nature and extent of the loss for which claim is made. Claim forms can be obtained by calling 800-513-2981 or online at www.globalunderwriters.com. One claim form is needed for each Injury or Illness for which a claim is being made. Proofs of Loss - Written proof of loss must be furnished to The Company at its said office in case of claim for loss for which this plan provides any periodic payment contingent upon continuing loss within 90 days after termination of each period for which The Company is liable and in case of claim for any other loss within 90 days after the date of such loss. Failure to furnish proof within the time required shall not invalidate nor reduce any claim if it is not reasonably possible to give proof within such time, provided proof is furnished as soon as reasonably possible. Time of Payment of Claims - Indemnities payable under the plan for any loss other than loss for which the plan provides any periodic will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which the plan provides periodic payment will be paid at the expiration of each four weeks during the continuance of the period for which The Company is liable, and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof. Payment of Claims - Indemnity for loss of life will be payable in accordance without the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the Insured Person. Any other accrued indemnities unpaid at the Insured Person's death may, at the option of The Company, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the Insured Person. If any indemnity of the policy shall be payable to the estate of an Insured Person, or to an Insured Person who is a minor or otherwise not competent to give a valid release, The Company may pay such indemnity, up to an amount not exceeding $1000 to any relative by blood or connection by marriage of the Insured Person who is deemed by The Company to be equitably entitled thereto. Any payment made by The Company in good faith pursuant to this provision shall fully discharge The Company to the extent of such payment. Subject to any written direction of the Insured Person all or a portion of any indemnities provided by this plan on account of Hospital, nursing, medical or surgical service may, at The Company's option and unless the Insured Person requests otherwise in writing not later than at the time for filing proof of such loss, be paid directly to the Hospital or person rendering such services, but it is not required that the service be rendered by a particular Hospital or person. 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. 2/12