| 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.
|
|
| PLAN INFORMATION |
| Deductible |
Your choice of $0, $100,
$250, $500, $1,000 or $2,500 |
| Your premium rate is
dependent on the deductible you choose. |
| 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. |
| 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 or group. |
| Sports & Activities
Coverage |
Up to Policy Maximum for
basic sports Coverage as described below |
Each Patriot GoTravel 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.
|
| Accidental Death &
Dismemberment |
$25,000 principal sum |
| Each Patriot GoTravel 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 GoTravel 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 GoTravel 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
|
| (U.S. citizens only) Up to $15,000 will be paid for the eligible expenses of a sudden and unexpected recurrence of a Pre-existing Condition (defined on page 16) while traveling outside of the U.S. |
|
Indemnity
|
| (U.S. citizens only) Patriot GoTravel 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. |
| |
You may seek treatment under Patriot GoTravel Medical Insurance Plan worldwide, including in the United States, with the hospital or doctor of your choice. When seeking treatment in the U.S., you may use the independent Preferred Provider Organization (PPO) contracted by IMG, a separately organized network (First Health Group) of approximately 500,000 physicians and 4,700 privately owned and operated hospitals. * This PPO network includes a large number of hospitals including some of the most well recognized university medical centers and transplant facilities.
When a U.S. hospital outside the network is used, a co-payment of US $250 is required in addition to the regular deductible and coinsurance. This co-payment is waived, however, if there is not a network provider within 50 miles of the location of treatment.
Each proposed hospital admission, inpatient or outpatient surgery, and certain other medical procedures must be Pre-certified for medical necessity. This means the insured person or their attending physician must call the number listed on the IMG identification card prior to admittance to a hospital or performance of a surgery, or medical procedure. In the case of an emergency hospital admission, the Pre-certification call must be made within 48 hours of the admission, or as soon as reasonably possible. For a complete list of procedures requiring Pre-certification, please refer to your certificate wording.
If Pre-certification guidelines are not followed, eligible claims and expenses will be reduced by 50%.
The following rates are based on a $250 deductible in all the policy maximum options.
