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is descriptive text, not a Policy. Upon receipt of your Certificate of Insurance,
please read it carefully as it will describe the provisions of the Master Policy
which will prevail. Your benefit limits depend upon your choice of Plan
A or Plan B, plus your purchase of the Optional Benefits.
Included
Benefits Optional Benefits
Policy Exclusions Medical
Expense A: $50,000* / B: $100,000* per incident
No Per Policy Maximum Limit If
Injury or Illness occurs during the Period of Coverage and you, your insured spouse
or dependent children require medical or surgical treatment, the policy will pay,
after you pay the selected deductible per period of coverage, 80 percent of all
reasonable and customary charges per incident for Covered Expenses up to $5000,
then 100 percent up to the maximum amount applicable to the insurance plan selected. *The
Medical Expense Benefit Limit is reduced to $10,000 for Insureds who are age 80+
on the effective date.
Covered Expenses
- Charges made by a hospital for room and board, floor nursing
and other services, including charges for professional services 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.
- Charges made for diagnosis, treatment and surgery by a physician.
- Charges made for the cost and administration of anesthetics.
- 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.
- Charges for physiotherapy, if recommended by a physician for the treatment of a specific
disablement and administered by a licensed physiotherapist.
- Dressings, drugs and medicines that can only be obtained upon a written prescription of a
physician or surgeon.
Illness must be contracted
and manifest itself, or Injury must occur, during the Period of Coverage. The
first expense must be incurred within 30 days of the commencement of covered Injury
or Illness. Benefit period is 26 weeks. However, all benefits will cease when
an Insured Person arrives in his home country from the United States, or from
Incidental Travel (14 days maximum) to Canada, Mexico, or U.S. territories. To
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Emergency Medical Evacuation Expense A: $50,000 / B: $100,000
If Injury or Illness commencing during the Period of Coverage requires emergency
evacuation to either the nearest medical facility where appropriate medical treatment
can be obtained, or to the Country of Residence, all expenses incurred are covered
up to the maximum benefit selected. An emergency evacuation must be recommended
by a legally licensed physician who certifies that the severity of Injury or Illness
necessitates such emergency evacuation and agreed to by you or your representative.
Arrangements must be made by AIGAssist.
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Accidental Death &
Dismemberment (AD&D) A: $50,000 / B: 100,000
If an Injury occurs during your Period of Coverage and results in one of the following
losses within 365 days after an accident, the Policy will pay as follows:
| Benefit | Plan A Limit | Plan
B Limit | | Loss of Life | $50,000
| $100,000 | | Loss of
two Members | $50,000 | $100,000 |
| Loss of one Member | $25,000 | $50,000 |
Regarding this Included coverage, “Member”
means hand, foot or eye. Only one amount, the largest to which you are entitled,
will be paid for all losses resulting from one accident.
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Repatriation of Remains Expenses A: $10,000 / B: $20,000
If Injury or Illness commencing during the Period of Coverage results in death, all reasonable
expenses incurred for preparation and return of the remains to the Country of
Residence will be paid up to the maximum selected. Arrangements must be made by
AIGAssist.
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Family Travel Benefit A: $10,000 / B: $10,000
- When covered Emergency Medical Evacuation is necessary and the attending physician
considers it beneficial for the Insured Person to have a family member join him,
the Company will pay for the family member’s economy fare travel and lodging
(maximum $5,000).
- When covered hospitalization of the
Insured Person causes accompanying minor child(ren) to be unattended, the Company
will pay up to the one way economy fare (maximum $5,000) less the applied value
of the child’s/children’s unused travel tickets to their country of
origin.
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Emergency Travelers Assistance VISIT USA-HEALTHCARE™
includes a special service. You are eligible to use any of these assistance services
during the Period of Coverage:
- 24-hour
verification of medical coverage for hospitals and physicians.
- 24-hour
medical care location service.
- Medical case monitoring, arranging communication between patient, family, physicians, employer, consulate or embassy.
- Emergency medical transportation arrangements.
- Emergency message service for medical situations.
- Multilingual services.
- 24-hour contact for legal emergencies.
- Legal referral, to help you locate a consular official or attorney.
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Optional Benefit: Additional Accidental Death & Dismemberment
Flight Only AD&D
- $250,000 and AD&D - $100,000 This optional benefit
may be purchased in addition to Basic Plan A or Plan B. If the optional benefit
is selected and the premium paid in advance of the Period of Coverage, the policy
will pay, in addition to Basic Plan limits, as follows:
| Flight Only AD&D | Benefit | Limit |
| In the event injury is sustained
while riding as a fare paying passenger on a scheduled airline: | Loss
of Life | $250,000 |
| Loss of two Members | $250,000 |
| Loss of one Member | $125,000 |
| | | |
| AD&D | Loss
of Life | $100,000 |
| In the event injury is sustained by any
other cause, and not otherwise excluded from the policy: | Loss
of two Members | $100,000 |
| Loss of one Member | $50,000 |
| | | |
Regarding this Optional coverage, “Member”
means hand, foot or eye. Only one amount, the largest to which you are entitled,
will be paid for all losses resulting from one accident.
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Optional Benefit: Hazardous Activity Coverage
This optional benefit may be purchased in addition to Basic Plan A or Plan B. If the optional benefit
is selected and the premium paid in advance of the Period of Coverage, Medical
Expense Coverage will be provided for motorcycling, scuba diving, jet, snow and
water skiing, mountain climbing, sky diving, amateur racing, piloting an aircraft,
bungee jumping, spelunking, whitewater rafting, surfing or parasailing.
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Exclusions
For Medical Expense Benefit, this insurance does NOT cover:
- Pre-Existing Conditions, defined as any injury or illness
which was contracted or which manifested itself, or for which treatment or medication
was prescribed within three years prior to the effective date of this insurance.
- Services, supplies or treatment, including any period of hospital confinement, which are
not recommended, approved and certified as necessary and reasonable by a physician,
or expenses which are non-medical in nature.
- Expenses incurred as a result of or in connection with: a) Declared or undeclared war,
or any act thereof; b) Injury sustained while participating in professional athletics;
c) Intentionally self-inflicted injury, suicide while sane or attempted suicide
while insane; d) Motorcycling, scuba diving, jet, snow and water skiing, mountain
climbing, sky diving, professional or amateur racing, piloting an aircraft, bungee
jumping, spelunking, whitewater rafting, surfing or parasailing; or e) Commission
of a felony.
- Expenses for: a) Pregnancy, childbirth,
or miscarriage; b) Routine physicals; c) Cosmetic or plastic surgery, except as
the result of an accident; d) Elective surgery; e) Any mental and nervous disorders
or rest cures; f) Dental care, except as the result of injury to natural teeth
caused by accident; g) Eye refractions or eye examinations for the purpose of
prescribing corrective lenses for eyeglasses or contact lenses or for the fitting
thereof, unless caused by accidental bodily injury incurred while insured hereunder;
h) Alcoholism, drug addiction, or use of any drug or narcotic agent; i) Treatment
by the Insured’s Immediate Family; or j) Expenses incurred within the Insured’s
home country.
- Traveling expressly for the purpose of obtaining medical treatment.
- All coverages, 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.
For
Accidental Death and Dismemberment, this insurance does NOT cover:
Any
loss, fatal or non-fatal, caused by or resulting from: a) Intentionally self-inflicted
injury, suicide while sane or attempted suicide while insane; b) War or any act
of war, declared or undeclared, or service in the military, naval or air service
of any country; c) Piloting or acting as a crew member, or riding in any aircraft
except as a fare paying passenger on a scheduled airline; d) Illness, disease,
pregancy, childbirth, miscarriage; e) Any bacterial infection other than one occuring
from an accidental cut or wound; f) Hernia; or g) The insured being under the
influence of drugs (unless taken under the advice of a physician and within the
amounts prescribed by a physician) or intoxicants of any type including alcohol.
For Emergency Medical Evacuation and Repatriation of
Remains Expense, this insurance does NOT cover:
Any loss fatal or non-fatal
caused by or resulting from (a), (b) or (c) above.
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