Co-Insurance is the percentage of Eligible Expenses, after the deductible, which is the responsibility of the insured.
Co-Insurance
- Plan pays 80% of first $5,000 after deductible, then 100%
What is Co-Insurance?
What am I covered for?
Claims incurred In US or Canada
For the Certificate Period, underwriters will pay 80% of the next $5,000 of Eligible Expense after the Deductible, then 100% up to the Overall Maximum Limit.
Coinsurance will be waived if expenses are incurred within the PPO and expenses are submitted to Underwriters for review and payment directly to the provider.
Claims incurred outside US or Canada
For the Certificate Period, underwriters will pay 100% of the Eligible Expenses after the Deductible up to the Overall Maximum Limit.
Deductibles: $0, $100, $250, $500, $1,000 or $2,500 per Certificate Period
Hospital Room and Board: Average Semi-private room rate, including nursing services.
Local Ambulance: Usual, Reasonable and Customary charges, when covered Illness or Injury results in hospitalization as Inpatient
Intensive Care: Unit Usual, Reasonable and Customary charges
Hospital Indemnity: $100 per day of Inpatient hospitalization (not subject to Deductible or Coinsurance)
Physical Therapy: $50 Maximum per visit
All Other Eligible Medical Expenses: Usual, Reasonable and Customary charges
Acute Onset of Pre-existing Condition: $15,000 Lifetime Maximum for Eligible Medical Expenses
$25,000 Lifetime Maximum for Emergency Medical Evacuation
Only available to Members under age 70
Emergency Dental (Acute Onset of Pain): $100 limit per Certificate Period (not subject to Deductible or Coinsurance)
Emergency Medical Evacuation: $500,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing Condition (not subject to Deductible or Coinsurance)
Return of Minor Children: $5,000 per Certificate Period (not subject to Deductible or Coinsurance)
Repatriation of Remains: Overall Maximum Limit (not subject to Deductible or Coinsurance)
Emergency Reunion: $15,000 limit per Certificate Period, subject to a maximum of 15 days (not subject to Deductible or Coinsurance)
Definitions
Accident: A sudden, unintentional and unexpected occurrence caused by external, visible means and resulting in physical Injury to the Member. The cause or one of the causes of such Accident is external to the victim’s own body and occurs beyond the victim’s control.
Accidental Death: A sudden, unintentional and unexpected occurrence caused by external, visible means resulting in physical Injury to the Member and subsequently death of the Member. Death must occur within 30 days of the sudden, unintentional and unexpected occurrence.
Accidental Dismemberment: A sudden, unintentional and unexpected occurrence caused by external, visible means and resulting in complete severance from the body of one or more Limbs or eyes. For purposes of the Accidental Death and Dismemberment benefit provided by this insurance, the term “Limb” shall mean: the arm when the severance is at or above (toward the elbow) the wrist, or the leg when the severance is at or above (toward the knee) the ankle. Loss of eye(s) shall mean: complete, permanent, irrevocable loss of sight.
Acute Onset of Pre-existing Condition: A sudden and unexpected outbreak or recurrence of a Pre-existing Condition, which occurs spontaneously and without advance warning, either in the form of Physician recommendation or symptoms which would have caused a prudent person to seek medical attention prior to the outbreak or recurrence. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence.
Acute Onset of Pain (Emergency Dental): A sudden and unexpected occurrence of pain which occurs spontaneously and without advance warning, either in the form of Physician or Dentist recommendation or symptoms, including pain, which
would have caused a prudent person to seek medical or dental attention prior to the onset of pain. Treatment must be obtained within 24 hours of the sudden and unexpected occurrence of pain.
AIDS: Acquired Immune Deficiency Syndrome as that term is defined by the United States Centers for Disease Control.
ARC: AIDS Related Complex as that term is defined by the United States Centers for Disease Control.
Amateur Athletics: A sport or other athletic activity that is organized and/or sanctioned, involving regular or scheduled practices and/or regular or scheduled games. This definition does not include athletic activities that are non-contact and engaged in by a Member solely for recreational, entertainment or fitness purposes and not for wage, reward or profit.
Application: The fully answered and signed Application which is attached to the Master Policy and the fully answered and signed Application submitted to Underwriters by the Member.
Assured: The Atlas/International Citizen Group Insurance Trust, Hamilton, Bermuda.
Beneficiary: The individual named in the Member’s Application to be the recipient of any Accidental Death or Common Carrier Accidental Death benefit. For Members who do not designate Beneficiary on the Application, the Beneficiary is automatically as follows: Members age 18 or older: 1. Spouse (if any), 2. Children (if any) equally, 3. Estate of the Member. Members under age 18: 1. Custodial Parent(s) (if any), 2. Siblings (if any) equally, 3. Estate of the Member.
Benefits: The eligible expenses that will be paid under this Certificate for covered costs incurred during the Certificate Period.
Certificate: The document issued to the Member that provides evidence of benefits payable under the Master Policy and that will confirm the plan type, period of cover, Home Country, certificate number, special terms and/or conditions, Deductible, chosen benefit list, and geographical area of cover.
Certificate Period: The period of time beginning on the date and time of the Certificate Effective Date and ending on date and time of the Certificate Termination Date. The maximum Certificate Period is 12 months. For Atlas International policies that have renewed coverage, the Certificate Period is defined as period of time beginning on the date and time of the Certificate renewal effective date and ending on the date and time of the earlier of the Certificate Termination Date or 12 months from the Certificate renewal effective date.
Coinsurance: The payment by the Member of Eligible Expenses at the percentage specified in the Schedule of Benefits and Limits.
Common Carrier: An airplane, bus, train or watercraft operating for commercial purposes and carrying fare-paying passengers on regularly scheduled and published routes.
Complications of Pregnancy: Illnesses whose diagnoses are distinct from Pregnancy, but are adversely affected by Pregnancy or caused by Pregnancy and not associated with a normal Pregnancy. This includes: ectopic Pregnancy, spontaneous abortion, hyperemesis gravidarum, pre-eclampsia, eclampsia, missed abortion and conditions of comparable severity. Complications of Pregnancy does not include: false labor, edema, prolonged labor, prescribed rest during the
period of Pregnancy, morning sickness and conditions of comparable severity associated with management of a difficult Pregnancy, and not constituting a medically distinct condition.
Contact Sports: A sport or other athletic activity that necessarily involves physical contact with opposing players as part of normal play. Contact Sports include but are not limited to American football, boxing, ice hockey, rugby, soccer, and wrestling.
Custodial Care: That type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist a Member in performing the activities of daily living. Custodial Care also includes non-acute care for the
comatose, semi-comatose, paralyzed or mentally incompetent patients.
Declaration: The Declaration is attached to and forms a part of the Master Policy.
Deductible: The dollar amount of Eligible Expenses, specified in the Schedule of Benefits and Limits, that the Member must pay per Certificate Period before Eligible Expenses are paid.
Dental Treatment: The care of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.
Displaced: Required to depart a destination due to an evacuation ordered by prevailing authorities.
Durable Medical Equipment: A standard basic hospital bed and/or a standard basic wheelchair.
Educational or Rehabilitative Care: Care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy.
Emergency: A medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Member’s life or limb in danger if medical attention is not provided within 24 hours.
Extended Care Facility: An institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a Physician; and provides each patient with active treatment of an Illness or Injury. Extended Care Facility does not include a facility primarily for rest, the aged, Substance Abuse treatment, Custodial Care, nursing care or for care of Mental Health Disorders or the mentally incompetent.
HIV+: Laboratory evidence defined by the United States Centers for Disease Control as being positive for Human Immunodeficiency Virus infection.
Home Country: For US Citizens, Home Country is the United States of America, regardless of the location of the Member’s Principal Residence. For non-US Citizens, Home Country is the country where the Member principally resides
and receives regular mail.
Home Health Care Agency: A public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse, and maintains a daily
record on each patient, and provides each patient with a planned program of observation and treatment by a Physician.
Home Nursing Care: Services provided by a Home Health Care Agency and supervised by a Registered Nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of Medically Necessary
Inpatient care in a Hospital.
Hospital: An institution which operates as a hospital pursuant to law, and is licensed by the State or Country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as Inpatients; and provides 24-hour nursing service by Registered Nurses on duty or call; and has a staff of one or more Physicians available at all times; and provides organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, long-term care facility, Extended Care Facility, nursing, rest, Custodial Care or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.
Illness: A sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. For purposes of this insurance, Illness includes Complications of Pregnancy during the first 26 weeks of Pregnancy. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.
Incurred: A charge is incurred on the date the service is provided or supply is purchased.
Injury: An unexpected and unforeseen harm to the body caused by an Accident that requires Medical Treatment.
Inpatient: A patient who occupies a Hospital bed for more than 24 hours for medical treatment and whose admission was recommended by a Physician.
Intensive Care Unit: A Cardiac Care Unit or other unit or area of a Hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Investigational, Experimental or for Research Purposes: Terms used to describe procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current
medical practice.
Medically Necessary: A service or supply which is necessary and appropriate for the diagnosis or treatment of an Illness or Injury based on generally accepted current medical practice as determined by Underwriters. A service or supply will not be considered Medically Necessary if is provided only as a convenience to the Member or provider, and/or is not appropriate for the Member’s diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which
is needed to provide safe, adequate and appropriate diagnosis or treatment of an Illness or Injury.
Member: An individual who is covered under this insurance.
Mental Health Disorder: A mental or emotional disease or disorder which generally denotes a disease of the brain with predominant behavioral symptoms; or a disease of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. Mental Health Disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, and those psychiatric illnesses listed in the current edition of the diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.
Natural Disaster: Any event or force of nature caused by environmental factors that has catastrophic consequences. Covered Natural Disasters are: avalanche, earthquake, flood, hurricane, impact event, landslides, mudslides, tornado, tsunami, tropical cyclone, typhoon, volcanic eruption, and wildfire.
Outpatient: A Member who receives Medically Necessary treatment by a Physician for Injury or Illness that does not require overnight stay in a Hospital.
Physician: A doctor of Medicine (MD), doctor of Dental Surgery (DDS), doctor of Dental Medicine (DDM) or a licensed Physical Therapist of Physiotherapist. Physician does not include a doctor of Chiropractic (DC), doctor of Osteopathy
(DO), a doctor of Psychology (Ph.D), a doctor of Psychiatry (Psy.D) or any other degree or designation. A Physician must be currently licensed by the urisdiction in which the services are provided, and the services provided must be within the scope of that license. A Physician must be a person other than the Member, the Member’s Relative, or one who ordinarily resides with the Member.
Plan Administrator: HCC Medical Insurance Services, LLC, 251 North Illinois Street, Suite 600, Indianapolis, Indiana 46204, Telephone (317) 262-2132, Fax (317) 262-2140.
Pre-existing Condition: Any (1) condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 2 years immediately preceding the Certificate Effective Date; (2) condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 2 years immediately preceding the Certificate Effective Date; (3) injury, illness, sickness, disease, or other physical, medical,mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 2 years immediately preceding the Certificate Effective Date. For the purposes of the Complications of Pregnancy coverage offered hereunder, Pregnancy will not be included within the definition of a Preexisting Condition.
Pregnancy: The physical condition of being pregnant.
Proof of Claim: A completed and signed Claimant’s Statement and Authorization form, together with any/all required attachments, original itemized bills from Physicians, Hospitals and other medical providers, original receipts for any
expenses which have already been paid by or on behalf of the Member, and any other documentation that is deemed necessary by the Underwriters.
Registered Nurse: A graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters “RN” after his or her name.
Relative: Biological or step parent; biological or step child; current spouse; biological or stepsiblings; or parent, children, or sibling in law.
Routine Physical Exam: Examination of the physical body by a Physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition.
Substance Abuse: Alcohol, drug or chemical abuse, overuse or dependency.
Surgery or Surgical Procedure: An invasive diagnostic procedure, or the treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
US: The United States of America including all states, districts, territories and possessions.
Usual, Reasonable and Customary: The most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are Reasonable. What is defined as Usual, Reasonable and Customary Charges will be determined by Underwriters. In determining whether a charge is Usual, Reasonable and Customary, Underwriters may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the Illness or Injury
being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; such other factors as Underwriters, in the reasonable exercise of discretion, determine are appropriate.
Exclusions
WAR, TERRORISM, BIOLOGICAL, CHEMICAL, NUCLEAR EXCLUSION
Notwithstanding any provision to the contrary within this insurance or any endorsement or rider attached hereto, it is agreed that this insurance excludes loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, damage, cost or expense:
1. war, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power; and
2. the use of any biological, chemical, radioactive or nuclear agent, material, device or weapon; however, this exclusion shall not apply where the Member is exposed to nuclear radioactive and/or radioactive material for the purpose of medical treatment; and
3. any Act of Terrorism, except as follows: Underwriters will pay Eligible Medical Expenses for treatment of Injuries and Illnesses resulting from an Act of Terrorism, up to the limit set forth in the Schedule of Benefits and Limits, provided all of the following conditions are met:
a. The Injury or Illness does not result from the use of any biological, chemical, radioactive or nuclear agent, material, device or weapon; and
b. The Member has no direct or indirect involvement in the Act of Terrorism; and
c. The Act of Terrorism is not in a country or location where the United States government has issued a travel warning that has been in effect within the 6 months immediately prior to the Member’s date of arrival; and
d. The Member has not unreasonably failed or refused to depart a country or location following the date a warning to leave that country or location is issued by the United States government.
For the purpose of this insurance, an “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.
This insurance also excludes coverage for loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (1), (2) or (3) above.
If Underwriters allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance,the burden of proving the contrary shall be upon the Member.
In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.
OTHER EXCLUSIONS
Charges for the following treatments and/or services and/or supplies and/or conditions are excluded from coverage hereunder:
1. Pre-existing Conditions – Charges resulting directly or indirectly from any Pre-existing Condition, as herein defined, are excluded from this insurance, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, are covered subject to the limits set forth in the Schedule of Benefits and Limits.
2. Routine pre-natal care, Pregnancy, child birth, and post natal care.
3. False labor, edema, prolonged labor, prescribed rest during the period of Pregnancy, morning sickness and conditions of comparable severity associated with management of a difficult Pregnancy, and not constituting a medically distinct Complication of Pregnancy as herein defined, and all charges related to Pregnancy after the 26th week of Pregnancy.
4. Charges incurred by or for any child under the age of 14 days.
5. Treatment related to birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions.
6. Charges for treatment of Mental Health Disorders, as defined herein.
7. Charges which are not Incurred, as herein defined, by a Member during his/her Certificate Period.
8. Charges for treatment of any condition(s) when the purpose of departing the Home Country was to obtain treatment in the destination country/countries.
9. Charges for any benefit hereunder which are not presented to Underwriters for payment within 60 days beginning on the last day of the Certificate Period.
10. Treatment, services or supplies that are not administered by or under the supervision of a Physician, and products that can be purchased without a doctor’s prescription.
11. Treatment, services or supplies which are not Medically Necessary as herein defined.
12. Treatment, services or supplies provided at no cost to the Member.
13. Charges which exceed Usual, Reasonable and Customary as herein defined.
14. Telephone consultations or failure to keep a scheduled appointment.
15. Surgeries, treatments, services or supplies which are Investigational, Experimental or for Research purposes.
16. All charges Incurred while confined primarily to receive Custodial Care, Educational or Rehabilitative Care, or any medical treatment in any establishment for the care of the aged.
17. Weight modification or surgical treatment of obesity, including but not limited to wiring of the teeth and all forms of intestinal bypass Surgery.
18. Modifications of the physical body intended to improve the psychological, mental or emotional well-being of the Member, including but not limited to sex-change Surgery.
19. Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is directly related to and follows a Surgery which was covered hereunder.
20. Treatment of Members who are HIV+, have AIDS or ARC, and all diseases caused by and/or related to HIV.
21. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal of sterilization.
22. Any drug, treatment or procedure that either promotes, enhances or corrects impotency or sexual dysfunction.
23. Abortions, except in connection with covered Complications of Pregnancy.
24. Dental Treatment, except for Emergency Dental Treatment necessary to replace sound natural teeth lost or damaged in an Accident covered hereunder or for the Emergency relief of Acute Onset of pain.
25. Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.
26. Eye surgery, such as radial keratotomy, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
27. Treatment of the temporomandibular joint.
28. Injury resulting from participation in the following activities:
a. Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, club, and professional sports or athletic activities. Non-contact and non-organized/non-sanctioned amateur sports or athletic activities engaged in
by the Member solely for leisure, recreational, entertainment or fitness purposes are not excluded unless they are excluded by (b) through (j) of this provision; and
b. mountaineering where a reasonably prudent person would use ropes or guides or at elevations of 4,500 meters or higher; and
c. aviation (except when traveling solely as a passenger in a commercial aircraft); and
d. hang gliding, sky diving, parachuting or bungee jumping; and
e. snow skiing or snowboarding, except for recreational downhill and/or cross country snow skiing or snowboarding (no cover provided whilst skiing away from prepared and marked in-bound territories and/or against the advice of
the local ski school or local authoritative body); and
f. racing by any animal or motorized vehicle; and
g. spelunking; and
h. subaqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, accompanied by a certified instructor, and at depths of less than 10 meters; and
i. jet skiing; and
j. any other sport or activity which is undertaken for thrill seeking and exposes the Member to abnormal risk of Injury.
29. Injury sustained while under the influence of or 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 but not for the treatment of Substance Abuse.
30. Costs resulting from self-inflicted Injury or Illness and/or suicide or attempted suicide whether sane or insane.
31. Venereal disease, including all sexually transmitted diseases and conditions, and consequences thereof.
32. Routine medical examinations, including but not limited to vaccinations, immunizations, annual check-ups, the issue of medical certificates and attestations, and examinations as to the suitability of employment or travel.
33. Treatment by a chiropractor.
34. Charges resulting from or occurring during the commission of a violation of law by the Member, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
35. Medical treatment for Substance Abuse or addiction or conditions that may be attributed to Substance Abuse or addictions and direct consequences thereof.
36. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
37. Any services, supplies, or treatment performed or provided by a Relative of the Member or any family member of the Member or any person who ordinarily resides with the Member.
38. Orthoptics and visual eye training.
39. Services, supplies, or treatment that are not included as Eligible Expenses as described herein.
40. The following care, treatment or supplies for the feet: orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
41. Services, supplies, or and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician.
42. Treatment of sleep disorders.
43. Exercise programs, whether or not prescribed or recommended by a Physician.
44. Treatment required as a result of complications or consequences of a treatment or condition not covered hereunder.
45. Charges for travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical or Political Evacuation, Repatriation of Remains, Return of Minor Children, Emergency Reunion, Natural Disaster, and Trip
Interruption sections of this insurance.
46. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
47. Organ or Tissue Transplants or related services.
48. Treatment for acne, other acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified
disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.
49. Treatment of all forms of cancer / neoplasm.
50. All expenses of any cyro preservation and implantation or re-implantation of living cells.
51. All Emergency Medical Evacuation costs not approved or arranged in advance by Underwriters.
52. Medical conditions while on duty as a member of a police or military force or unit.