| SCHEDULE OF BENEFITS (all amounts listed are in U.S. dollars) |
| MEDICAL BENEFITS |
Usual, reasonable and customary charges, subject to deductible and coinsurance |
| Hospital Room and Board |
Up to Policy Maximum for average semi-private room rate |
|
| Intensive Care |
Up to Policy Maximum |
|
| Medical Expenses |
Up to Policy Maximum |
|
| Outpatient Medical |
Up to Policy Maximum |
|
| Local Ambulance |
Up to Policy Maximum |
|
| Prescription Drugs |
Up to Policy Maximum |
|
|
| Emergency Room |
As described below |
Charges incurred for the use of the Emergency Room due to an accident are covered up to the Policy Maximum.
Charges incurred for the use of the Emergency Room for treatment of an illness are subject to an additional (extra)
$250 deductible if treatment does not require admittance to the hospital. |
| Dental |
As described below |
Injury due to an accident: Each Patriot plan covers the cost of emergency
dental treatment and dental procedures necessary to restore sound natural teeth lost or damaged in an accident up to the
Policy Maximum.
Sudden dental pain: Each plan will pay up to $100 for the necessary treatment of sudden, unexpected pain to sound natural teeth. |
|
| INTERNATIONAL EMERGENCY CARE (when coordinated through the Plan Administrator) |
| Emergency Evacuation |
Up to $500,000 lifetime maximum (independent of policy maximum) |
| Each Patriot plan includes coverage for Emergency Medical Evacuations to the nearest qualified medical
facility; expenses for reasonable travel and accommodations resulting from the evacuation; and the cost of returning to either
the home country or the country where the evacuation occurred, up to $500,000. |
| Emergency Reunion |
Up to $50,000 |
| Each Patriot plan also provides emergency reunion coverage, up to $50,000 for a maximum of 15 days,
for the reasonable travel and lodging expenses of a relative or friend during an Emergency Medical Evacuation: either the cost
of accompanying the insured during the evacuation or traveling from the home country to be reunited with the insured. |
| Return of Mortal Remains |
Up to $50,000 |
| If a covered illness/injury results in death, expenses for Repatriation of bodily remains or ashes
to the home country will be covered up to a maximum of $50,000. |
| Returning Minor Children |
Up to $50,000 |
| If an insured person is hospitalized due to a covered illness/injury and is traveling alone with
child(ren) 19 or under that otherwise would be left unattended, the Patriot plans will pay up to $50,000 for one way economy
fare to their home country, including a chaperone, if necessary, for the safety of the child(ren). |
| Political Evacuation |
Up to $10,000 |
| If the United States Department of State, Bureau of Consular Affairs issues a travel advisory
that becomes effective on or after the Insured Person´s date of arrival in the Host Country, the Company will pay up to
$10,000 for transportation to the nearest place of safety or for repatriation to the Insured Person´s home country or
country of residence provided that: |
- The Insured Person contacts the Company within 10 days of the United States Department of State, Bureau of Consular
affairs issues the travel advisory;
- Political Evacuation and Repatriation is approved and coordinated by the Company.
|
To be eligible for the Evacuation, Reunion and Return benefits, these must be recommended by the attending physician
in critical medical situations, and approved in advance and coordinated by IMG.
|
| |
| PLAN INFORMATION |
| Deductible |
Your choice of $0, $100, $250, $500, $1,000 or $2,500 |
| On the Application Form, you will be asked to circle your choice of a deductible. Your
premium rate is dependent on the deductible you choose. Please see the Application Form for more information. |
| Coinsurance |
As described below |
For treatment received outside the U.S. & Canada: No coinsurance
For treatment received within the U.S. & Canada:
In the PPO Network: The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Policy Maximum
Outside the PPO Network: The plan pays 80% of eligible expenses up to $5,000, then 100% up to the Policy Maximum |
| Benefit Period |
Six months |
| If a covered injury or illness requires continuing treatment after the Period of Coverage
expires, the six-month Benefit Period may provide continued coverage. When the certificate expires, the Company will
review the date of initial treatment for the covered injury or illness. If treatment began less than six months before
the Period of Coverage expired, benefits for the covered injury or illness will continue subject to the Policy Limits
and the other terms of the plan until there have been six months of continuous coverage for the covered injury or illness. |
|
| ADDITIONAL BENEFITS |
| Home Country Coverage |
As described below |
Incidental Home Country Coverage - During the Period of Coverage an insured
person may return to their home country for incidental visits up to a cumulative two weeks total, subject to: a. The insured person must have left their home country, b. The total Period of Coverage must be for a minimum
of 30 days, and c. The return to the home country may not be taken to receive treatment for an illness or
injury incurred while traveling.
End of Trip Home Country Coverage - For every five months of continuous coverage you purchase,
you can purchase one additional month of home country coverage as an accommodation and supplemental travel benefit,
up to a maximum of two months. To purchase this special home country extension coverage, please check the
appropriate box on the Application Form, and calculate your premium to include the additional month(s). |
| Natural Disaster |
$100 per day for five days |
| This benefit is available in the event an insured person is required to depart his/her
destination due to an evacuation order issued by prevailing authorities in connection with a Natural Disaster.
Natural Disaster is defined as widespread disruption of human lives by disasters such as flood, drought, tidal
wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe or event
resulting in migration of the population for its safety. |
| Trip Interruption |
Up to $5,000 |
| If, during a covered trip, there is a death of an immediate family member (spouse,
child, parent or sibling) or the substantial destruction of the insured´s principal residence, each Patriot plan
will pay to return the insured to the area of principal residence. The plan will pay for a one way air or ground
transportation ticket of the same class as the unused travel ticket, less the value of the unused return ticket. |
| Lost Luggage |
Up to $50 per item of personal property; maximum of $250 per Period of Coverage |
| This benefit will be paid in the event that the Common Carrier permanently loses an
insured person´s checked luggage. This coverage is secondary to any other available coverage, including the Carrier´s. |
| Common Carrier Accidental Death |
$50,000 to Beneficiary; maximum of $250,000 per family |
| If accidental death should occur while traveling on a commercial Common Carrier,
$50,000 will be paid to the designated beneficiary, to a maximum of $250,000 per family. |
| Sports & Activities Coverage |
Up to Policy Maximum for basic sports Coverage as described below |
Each Patriot plan covers injuries incurred during amateur athletic activities which
are non-contact and engaged in by the insured person solely for leisure, recreation, entertainment or fitness
purposes. However, activities not covered include amateur or professional sports or other athletic activity
which is organized and/or sanctioned, or which involves regular or scheduled practices, games or competition.
The following hazardous activities are excluded unless the Extreme Sports Rider is purchased: abseiling,
aviation (except when traveling as a passenger in a commercial aircraft), BMX, bobsleigh, bungee jumping,
canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning, inline skating, jet skiing,
kayaking, mountain biking, paragliding, parascending, rappelling, rock climbing, sky diving, snow skiing,
snowboarding, snowmobiling, spelunking, surfing, trekking, wind-surfing and whitewater rafting.
Racing of any kind, BASE jumping, mountaineering, climbing or trekking above elevation 4500 meters above
ground level or without proper ropes or guides; luge, motocross, Moto-X, rodeo activity, ski jumping,
whitewater rafting exceeding Class V difficulty; and/or extreme sports not expressly covered hereunder
are excluded regardless of which plan or rider is selected.
Optional Extreme Sports Rider: Please see the brochure for more information. |
| Accidental Death & Dismemberment |
$25,000 principal sum |
| Each Patriot plan includes $25,000 principal sum benefit for Accidental Death
and Dismemberment occurring during the Period of Coverage: • Accidental Loss of life - principal sum; •
Accidental Loss of two Members - principal sum; • Accidental Loss of one Member - 50% of principal sum.
"Member" means hand, foot or eye. |
| Terrorism Coverage |
Up to $50,000 lifetime maximum |
| Each Patriot plan provides coverage for injuries and illness incurred
as a result of an act of Terrorism, limited in amount and by circumstances. If an insured person is
injured as a result of an act of Terrorism, and the insured person has no direct or indirect
participation in the act, the plan will reimburse eligible medical claims subject to a $50,000
lifetime maximum. However, claims incurred as a result of radiological, nuclear, chemical or
biological weapons or events are not covered.
Terrorism is defined as the systematic or planned use of violence, fear, or threat of
violence in order to intimidate a population or government, especially as a means of coercion
or to obtain a granting of any demand. However, this benefit does not cover an act of Terrorism
in any country or location where the United States government has issued a travel advisory that
has been in effect within the 6 months prior to the insured person's date of arrival.
This benefit also does not cover an act of Terrorism in the event that an advisory to leave
a certain country or location is issued by the United States government after the insured person's
arrival date, and the insured person unreasonably fails or refuses to depart the country or location. |
| Identity Theft Assistance |
Up to $500 per Period of Coverage |
| If an imposter obtains key personal information such as a Social Security
or Driver's License number, or other method of identifying an insured person in order to impersonate or
obtain credit, merchandise or services in the insured person´s name, the Patriot plans will provide
coverage for the reasonable, customary and necessary costs incurred by the insured for: re-filing a
loan or other credit application that is rejected solely as a result of the stolen identity event;
notarization of legal documents, long-distance telephone calls, and postage that has resulted solely
as a result of reporting, amending and/or rectifying records as a result of the stolen identity event;
up to three credit reports obtained within one year of the insured person´s knowledge of the stolen
identity event; and stop payment orders placed on missing or unauthorized checks as a result of the stolen identity event.
The identity theft event must occur during the Period of Coverage and must be reported within 6
months of the termination of coverage date. |
|
| Additional Benefits for U.S. Citizens |
| Sudden Recurrence of a Pre-existing Condition |
| Up to $15,000 will be paid for the eligible expenses of a sudden and
unexpected recurrence of a Pre-existing Condition while traveling outside of the U.S.. In addition,
up to $25,000 will be paid for the eligible costs and expenses of an Emergency Medical Evacuation
arising or resulting from a sudden and unexpected recurrence of a Pre-existing Condition. For the
definition of a Pre-existing Condition, please see Exclusion number 1 in the Patriot Travel Medical
Insurance brochure. |
| Indemnity |
| Patriot International will pay directly to the insured person $100 for each
night of a required overnight stay in a hospital. However, the hospital stay must be covered under this
plan in order to receive this benefit. |
| |
Rates:
Patriot America The
following rates are on base of $250 deductible in all the policy maximum
options
|
Options: Other lower and Higher deductible options
available as following to improve the deductible or reduced the
cost. please use this rate factors. |
| Deductible |
Rate Factors. |
Deductible |
Rate Factors. |
| US $ Zero |
1.25 |
US $500 |
.90 |
| US $100 |
1.10 |
US $1,000 |
.80 |
| US $250 |
1.00 |
US $2,500 |
.70 |
Patriot America provides coverage for non-U.S. citizens traveling outside their home country for a minimum of five days up
to a maximum of two years. If the plan is purchased for a minimum of three months, coverage may be renewed (without break in
coverage) for a total of up to two years.
If you or other family members applying for coverage are age 65 or older, please see the Eligibility section in the
brochure for additional information.
All premium rates are in U.S. dollars. Rates include surplus lines
tax where applicable. A dependent child is your child shown on the Application Form over 14 days and under 18 years of
age, traveling with you, and for whom premium has been paid. The following rates are on base of $250 deductible in all the policy maximum options
| POLICY LIMIT |
$50,000 |
$100,000 |
$500,000 |
$1,000,000 |
| |
| AGE |
Monthly Rates |
| 18-29 |
$39.00 |
$46.00 |
$59.00 |
$71.00 |
| 30-39 |
$52.00 |
$62.00 |
$78.00 |
$91.00 |
| 40-49 |
$78.00 |
$90.00 |
$119.00 |
$133.00 |
| 50-59 |
$113.00 |
$138.00 |
$169.00 |
$194.00 |
| 60-64 |
$142.00 |
$174.00 |
$207.00 |
$248.00 |
| 65-69 |
$162.00 |
$208.00 |
$226.00 |
$270.00 |
| 70-79 |
$219.00 |
N/A |
N/A |
N/A |
| 80+* |
$381.00 |
N/A |
N/A |
N/A |
| DEP. CHILD |
$38.00 |
$45.00 |
$58.00 |
$65.00 |
| CHILD ALONE |
$39.00 |
$46.00 |
$59.00 |
$66.00 |
| |
| |
Daily Rates (Minimum length of coverage is 5 days) |
| 18-29 |
$1.30 |
$1.55 |
$2.00 |
$2.40 |
| 30-39 |
$1.75 |
$2.10 |
$2.60 |
$3.05 |
| 40-49 |
$2.60 |
$3.00 |
$4.00 |
$4.45 |
| 50-59 |
$3.80 |
$4.60 |
$5.65 |
$6.50 |
| 60-64 |
$4.80 |
$5.85 |
$6.95 |
$8.35 |
| 65-69 |
$5.45 |
$7.00 |
$7.60 |
$9.05 |
| 70-79 |
$7.35 |
N/A |
N/A |
N/A |
| 80+* |
$12.75 |
N/A |
N/A |
N/A |
| DEP. CHILD |
$1.30 |
$1.50 |
$1.95 |
$2.20 |
| CHILD ALONE |
$1.30 |
$1.55 |
$2.00 |
$2.25 |
* $10,000 Maximum
Quality Guarantee
Your satisfaction is very important to IMG and the plan underwriter. If you are not pleased with this product,
for any reason, you may submit a written request, prior to your effective date, for cancellation and refund of
your premium. In order to be considered for a full refund, your request for cancellation must be received by
IMG prior to your effective date. If you do not have any claims filed with IMG, you may cancel your plan after
your effective date, however, the following conditions will apply: 1) you will be required to pay a $50
cancellation fee and 2) only full month premiums will be considered for refunds (e.g., if you choose to
cancel your coverage two months and two weeks prior to the date your coverage ends, IMG will only consider
the two full months for a refund). If you have filed claims, your premium is non-refundable.
Precertification, Emergency Evacuation and Return of Mortal Remains
For precertification, emergency evacuation and return of mortal remains, please call: IMG in the US: 1-800-628-4664
(toll free) or 1-317-655-4500. Call IMG outside the US: 001-317-655-4500 (collect if necessary). This information
will also be provided on your ID card.
IMG must be notified prior to treatment or within 48 hours of an emergency.
To Report Claims
Please mail completed claim forms to International Medical Group, P.O. Box 88500, Indianapolis,
IN 46208-0500 USA. All IMG contact numbers, claim forms and Certificate Wordings will be included
in the fulfillment kit. IMG may also be contacted by fax: 317-655-4505 or e-mail: insurance@imglobal.com.
