This coverage pays in the event of death or dismemberment while you are traveling on any form of public transport.
This coverage pays in the event of death or dismemberment while you are traveling on any form of public transport.
F. COMMON CARRIER ACCIDENTAL DEATH AND DISMEMBERMENT INDEMNITY
Accidental Death & Dismemberment Coverage shall apply only to covered accidents sustained by an Insured Person:
1. While riding as a passenger (but not as a pilot, operator or member of the crew) in or on (including getting in or out of, or on or off of):
A) any land, water or air conveyance operated under a license for the transportation of passengers for hire; or
B) any Military Air Transport Aircraft; or
2. By being struck down by any aircraft. The Company shall pay an indemnity determined from the Table of Losses below if an Insured Person sustains a loss stated therein resulting from Injury, provided that:
a) such loss occurs within three hundred and sixty five (365) days after the date of accident causing such loss; or
b) the indemnity payable for any such loss shall be the amount stated opposite such loss in said Table and the Principal Sum stated therein shall be the amount stated in the Schedule of Benefits, as applicable to such person and this Coverage; and
c) if more than one loss stated in said Table is sustained as the result of one accident, only one of the amounts so stated in said Table, the largest, shall be payable.
|For Loss of:||Indemnity|
|Both Hands or Both Feet or Sight of Both Eyes||Principal Sum|
|One Hand and One Foot||Principal Sum|
|Either Hand or Foot and Sight of One Eye||Principal Sum|
|Either Hand or Foot||One-Half the Principal Sum|
|Sight of One Eye||One-Half the Principal Sum|
The term “loss” as used herein shall mean with regard to hands and feet, actual severance through or above wrist or ankle joints, and with regard to eyes, entire irrecoverable loss of sight.
“ACCIDENT” or “ACCIDENTAL” shall mean an event,independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.
“BENEFIT PERIOD” shall mean the duration of time following an Eligible Accident, Injury or Illness in which to receive Medically Necessary Covered Expenses. 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 Home Country Coverage). Treatment due to an Injury must be performed by a Physician and meet the following conditions: a) begins within thirty (30) days after date of Injury; and b) is received within 12 months (32 weeks for Insured Persons age seventy (70) and over) after date of Injury; or Due to Sickness of an Insured Person provided Covered Medical Expenses are incurred within 12 months (32 weeks for Insured Persons age seventy (70) and over) after the date of first treatment for such Sickness.
“COMPANY” shall mean Certain Underwriters at Lloyd’s, London
“COVERED MEDICAL EXPENSES” means reasonable charges which are: 1) not in excess of the maximum benefit amount payable per service as specified in the Schedule of Benefits; 2) made for services and supplies not excluded under the policy; 3) made for services and supplies which are a Medical Necessity; 4) made for services included in the Schedule of Benefits; and 5) in excess of the amount stated as a deductible, if any. Covered medical expenses will be deemed “incurred” only: 1) when the covered services are provided; and 2) when a charge is made to the Insured Person for such services.
“DISABLEMENT” as used with respect to medical expenses shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician as defined in this Policy.
“DEDUCTIBLE” means the amount of eligible Covered Expenses which are the responsibility of each Insured Person and must be paid by each Insured Person before benefits under the Policy are payable by the Company. Such amount will be subtracted from the amount or amounts charged and otherwise payable as Covered Medical Expenses. The deductible will apply per occurrence (for each Injury or Sickness) as specified in the Schedule of Benefits.
“DEPENDENT CHILD” means a Named Insured’s dependent, unmarried children living with the Named Insured. This includes stepchildren, legally adopted children and children of adopting parents pending adoption procedures. Children shall cease to be dependent on the first occurrence of: (1) the end of the month in which they marry; or (2) the end of the month in which they attain the age of nineteen (19) years. The attainment of the limiting age will not operate to terminate the coverage of such child while the child is and continues to be both: (1) incapable of self-sustaining employment by reason of mental retardation or physical handicap; and (2) chiefly dependent upon the Insured Person for support and maintenance. Proof of such incapacity and dependency shall be furnished to the Company: 1) by the Named Insured; and 2) within thirty-one (31) days of the child’s attainment of the limiting age. Subsequently, such proof must be given to the Company upon request following the child’s attainment of the limiting age. If a claim is denied under the policy because the child has attained the limiting age for dependent children, the burden is on the Insured Person to establish that the child is and continues to be handicapped as defined by subsection (1) and (2).
“ELIGIBLE BENEFIT” shall mean benefits payable by the Company to reimburse expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed or ordered by a Physician; Reasonable and Customary charges; incurred while insured under this program and which do not exceed the maximum benefit.
“EMERGENCY” shall mean a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s life or limb in danger if medical attention is not provided within 24 hours.
“EXPERIMENTAL/INVESTIGATIONAL” means all services or supplies associated with: 1) treatment or diagnostic evaluation which is not generally and widely accepted in the practice of medicine in the United States of America or which does not have evidence of effectiveness documented in peer reviewed articles in medical journals published in the United States. For the treatment or diagnostic evaluation to be considered effective such articles should indicate that it is more effective than others available; or if less effective than other available treatments or diagnostic evaluations, is safer or less costly; 2) A drug which does not have FDA marketing approval; 3) A medical device which does not have FDA marketing approval; or has FDA approval under 21 CFR 807.81, but does not have evidence of effectiveness for the proposed use documented in peer reviewed articles in medical journals published in the United States. For the device to be considered effective, such articles should indicate that it is more effective than other available devices for the proposed use; or if less effective than other available devises, or is safer or less costly. The Company will make the final determination as to whether a service or supply is Experimental/Investigational.
“EXCESS PROVISION” means the plan benefits are payable for covered expenses not covered and payable by any other plan providing medical expense benefits. If there is no other valid and collectible benefits available from any other source, this plan will pay the covered expenses up to the limits of the policy.
“HOME COUNTRY” means the country where the Insured Person’s Passport was issued.
“HOSPITAL” means a licensed or properly accredited general Hospital which; 1) is open at all times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured person as inpatients; 3) is under the supervision of a staff of one or more legally qualified Physicians available at all times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; and 6) is not primarily a clinic, nursing, rest or convalescent home, or an institution specializing in or primarily treating Mental and Nervous Disorders.
“HOSPITAL CONFINED/HOSPITAL CONFINEMENT” means confined in a Hospital for at least eighteen (18) hours by reason of an Injury or Sickness for which benefits are payable.
“ILLNESS” wherever used in this Policy shall mean any medical condition, sickness, disease, disability, birth defect, congenital defect , chronic infirmity or disorder of any kind. Provided, however, that Illness does not include any learning disabilities or attitudinal or disciplinary problems. All Illnesses that exist simultaneously or which arise subsequent to a prior Illness and which directly or indirectly relate to or result or arise from the same or related causes or as a consequence thereof or from one another are considered to be one Illness. Further, if a subsequent Illness results or arises from causes or consequences that are the same as or related to the causes or consequences of a prior Illness, the subsequent Illness will be deemed to be a continuation of the prior Illness and not a separate Illness.
“INJURY” means bodily Injury: 1) directly and independently caused by specific accident which is unrelated to any pathological, functional, or structural disorder or Injury; 2) treated by a Physician within thirty (30) days after the date of accident; and 3) which causes loss during the term of the policy.
“INSURED PERSON” means: 1) the Named Insured; and 2) Dependent Child(ren) of the Named Insured, if: 1) the Dependent Child(ren) is properly enrolled in the program; and 2) the appropriate dependent premium has been paid. The term “Insured” also means Insured Person.
“INTENSIVE CARE” means (1) a specifically designated facility of the Hospital that provides the highest level of medical care; and (2) which is restricted to those patients who are critically ill or injured. Such facility must be separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement.
“LOSS” in reference to quadriplegia, paraplegia, hemiplegia, and uniplegia, shall mean 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.
“MEDICAL EMERGENCY” means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of immediate medical attention, a reasonable person could believe this condition would result in: (1) Death; (2) Permanent placement of the Insured’s health in jeopardy; (3) Serious impairment of bodily functions; or (4) Serious and permanent dysfunction of any body organ or part. Expenses incurred for “Medical Emergency” will be paid only for Sickness or Injury which fulfills the above conditions. These expenses will not be paid for minor injuries or minor Sicknesses.
“MEDICAL NECESSITY/MEDICALLY NECESSARY” means those services or supplies provided or prescribed by a Hospital or Physician which are: (1) Essential for the symptoms and diagnosis or treatment of the Sickness or Injury; (2) Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury; (3) In accordance with the standards of good medical practice; (4) Not primarily for the convenience of the Insured, or the Insured’s Physician; and (5) The most appropriate supply or level of service which can safely be provided to the Insured. The Medical Necessity of being Hospital Confined means that: 1) the Insured requires acute care as a bed patient; and 2) the Insured cannot receive safe and adequate care as an outpatient. The policy only provides payment for services, procedures and supplies which in the judgement of the Company are a Medical Necessity. No benefits will be paid for expenses which are determined not to be a Medical Necessity, including any or all days of Hospital Confinement.
“MENTAL AND NERVOUS DISORDER” means a Sickness that is a mental, emotional or behavioral disorder.
“NAMED INSURED” means an eligible person who: 1) has completed an application; and 2) that application and the appropriate premium for coverage has been paid and accepted by the Administrator.
“NEWBORN INFANT” means any child born of an Insured while that person is insured under the policy. Newborn Infants will be covered under the policy for the first thirty-one (31) days after birth ONLY IF the Newborn Infant’s mother was both a) insured under the policy when the Newborn Infant was born and b) her pregnancy was a covered condition under the policy. Coverage for such child will be for Injury or Sickness, including medically diagnosed congenital defects, birth abnormalities, prematurity and nursery care; benefits will be the same as for the Insured Person who is the child’s parent. The Insured will have the right to continue such coverage for the child beyond the first thirty-one (31) days. To continue coverage the Insured must, within the thirty-one (31) days after the child’s birth:1) submit an application for the Newborn child (ren); and 2) pay the required additional premium for the continued coverage. If the Insured does not use this right as stated here, all coverage as to that child will terminate at the end of the first thirty-one (31) days after the child’s birth.
“OUTPATIENT” shall mean an Insured Person who receives care in a Hospital or another institution, including: ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for an Illness or Injury, but who is confined and is not charged for room and board.
“PHYSICIAN” means a person, other than the Insured or a member of the Insured’s family, who holds a medical license or medical certificate. In this Policy shall mean 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.
“PHYSIOTHERAPY” means any form of the following: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage administered by a Physician.
“POLICY PERIOD OR PERIOD OF COVERAGE” shall mean the period of coverage issued by the Company to the Insured Person, typically beginning with the Effective Date and ending with the Termination Date or the date coverage is renewed by the Company. Maximum Period of Coverage is 12 months.
“PRE-EXISTING CONDITION” shall mean any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or within the one hundred and eighty (180) days (three hundred and sixty five (365) days for Insured Persons 70 and older) immediately prior to the Insured Person’s Effective Date under the policy, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, sickness, Injury , Illness, disease , Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the one hundred and eighty (180) days (three hundred and sixty five (365) days for Insured Persons 70 and older)immediately preceding the effective date of coverage under this policy.
“PRESCRIPTION DRUGS” means: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a Physician; and 4) injectable insulin.
“RELATIVE” shall mean spouse, parent, sibling, child, grandparent, grandchild, step-parent, step-child, step-sibling, in-laws (parent, son, daughter, brother and sister), aunt, uncle, niece, nephew, legal guardian, ward, or cousin of the Insured Person.
“SERVICE PROVIDER” shall mean a Hospital, convalescent/skilled nursing facility, ambulatory surgical center, psychiatric Hospital, community mental health center, residential treatment facility, psychiatric treatment facility, alcohol or drug dependency treatment center, birthing center, Physician, dentist, chiropractor, licensed medical practitioner, nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves.
“SICKNESS” means Sickness or disease of the Insured Person which causes loss, and originates while the Insured Person is covered under the policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.
“SOUND, NATURAL TEETH” means natural teeth, the major portion of the individual tooth is present, regardless of fillings or caps; and is not carious, abscessed or defective.
“SURGERY” shall mean 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.
“TREATMENT(S)” shall mean medical or surgical management of a patient designed to resolve the Illness(es) or Injury(ies) based on standard and accepted medical practice. For purposes of this Certificate, the course of action will only include those scheduled and approved benefits, for which the Insured Person(s) is eligible.
EXCLUSIONS AND LIMITATIONS
No benefits will be paid for loss or expense caused by, contributed to, or resulting from:
1) Pre-Existing Conditions; as defined
2) Any loss that occurs while traveling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician;
3) Maximum benefit is reduced to $50,000 for any illness or injury occurring while on an incidental trip to the Insured Person’s Home Country;
4) Routine physical, inoculations or other examinations where there are no objective indications of impairment of normal health, or well baby care;
5) Eye examinations; prescriptions or fitting of eyeglasses and contact lenses; or other treatment for visual defects and problems. “Visual Defects” means any physical defect of the eye which does or can impair normal vision;
6) Hearing examinations or hearing aids; or other treatment for hearing defects and problems. “Hearing Defects” means any physical defect of the ear which does or can impair normal hearing;
7) Dental treatment, except as the result of Injury to Sound, Natural Teeth as stated in the Schedule of Benefits;
8) Services or supplies not necessary for the medical care of the patient’s Injury or Sickness,
9) Weak, strained or flat feet, corns, calluses, or toenails;
10) Cosmetic surgery, or treatment for congenital anomalies (except as specifically provided), except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a
deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness;
11) Elective surgery and elective treatment;
12) Treatment, drugs, diagnostic or surgical procedures in connection with infertility, impotency, artificial insemination, sterilization or reversal thereof, unless infertility is a result of a covered
Injury or Sickness;
13) Birth control, including surgical procedures and devices;
14) Routine new-born baby care, well-baby nursery and related Physician charges;
15) Injury sustained while participating in professional, sponsored, and/or organized amateur or intercollegiate athletics;
16) Injury sustained while taking part in Mountaineering, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, snowmobiling, motorcycle / motor scooter
riding (whether as a passenger or driver), scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, wakeboard riding, jet skiing, windsurfing, snow skiing and snow boarding;
Mountaineering shall mean the sport, hobby or profession of walking, hiking, and climbing up mountains either:
1) utilizing harnesses, ropes, crampons or ice axes; or
2) ascending 4500 meters or above.
17) Injury or Sickness for which benefits are paid or payable under any Worker’s Compensation or Occupational Disease Law or Act, or similar legislation;
18) Organ and tissue transplants and related services and supplies;
19) War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the Insured Person or the country in, or over, which the act
occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the Insured Person whether war be declared with that state or not, Terrorist activity. For the purpose of this Exclusion; i) Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s). ii) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals. iii) Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals. iv) Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals. Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;
20) Suicide or attempted suicide (including drug overdose) while sane or insane (while sane in Missouri); or intentionally self-inflicted Injury;
21) Charges of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;
22) Treatment of nervous or mental disorders, or Treatment of alcohol, chemical, or drug addiction, dependency, use or abuse including illness(es) caused by such addiction, dependency, use
or abuse, injuries incurred while under the influence of or resulting from the use of alcohol, chemicals or drugs, unless prescribed by a Physician, except as stated in the Schedule of
Benefits for mental or nervous disorders;
23) Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;
24) Treatment, services, supplies or facilities in a Hospital owned or operated by: a) the Veteran’s Administration; or b) a national government or any of its agencies. (This exclusion does not
apply to treatment when a charge is made which the Insured is required by law to pay);
25) Duplicate services actually provided by both a certified nurse-midwife and Physician;
26) Expenses payable under any prior policy which was in force for the person making the claim;
27) Expenses incurred during a Hospital emergency room visit which are not of an emergency nature;
28) Expenses incurred for outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human
body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral
29) Injury sustained as the result of the Insured operating a motor vehicle while not properly licensed to do so in the jurisdiction the motor vehicle accident occurs;
30) Voluntary or elective abortion;
31) Expenses covered by any other valid and collectible medical, health or accident insurance;
32) Expenses incurred after the date insurance terminates for an Insured Person except as may be specifically provided;
33) Sexually transmitted and venereal disease(s);
34) Treatment(s) which is incurred by an Insured Person(s) who is HIV Positive (i.e., infected with the human immunodeficiency virus, the cause of acquired immunodeficiency syndrome) at the
time of Application for this Insurance, whether or not the Insured Person(s) was asymptomatic or symptomatic or had knowledge of his/her HIV status on the initial Effective Date of Coverage, or any associated diagnostic tests or charges for HIV infection, seropositivity to the AIDS virus, AIDS related Illness(es), ARC Syndrome, AIDS, and all diseases caused by and/or related to HIV.
35) Treatment(s) for HIV, the AIDS virus, AIDS related Illness(es), ARC Syndrome, AIDS, and all diseases and illnesses caused by and/or related to HIV or arising as complications from these conditions including but not limited to the cost of testing for these conditions and/or charges for drug treatment(s) or surgeries;
36) Treatment for tuberculosis, malaria, cholera, dengue fever and parasitic-sourced illnesses, including but not limited to treatment required as a result of complications from those same diseases, whether or not previously manifested or symptomatic prior to the effective date of the Policy.
37) Charges incurred for treatment or surgeries which are Experimental / Investigational, or for research purposes; expenses which are non-medical in nature, expenses for custodial care, vocational, speech, recreational or music therapy, or durable medical equipment;
38) Expenses for services or supplies which are not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
39) Chiropractic care or complementary medicine including but not limited to acupuncture and massage;
40) Services performed or supplies provided by a Relative of the Insured Person, or anyone who lives with the Insured Person;
41) Treatment of the Temporomandibular joint;
42) Treatment required as a result of complications or consequences of a treatment or for a condition not covered under this Policy;
43) Expenses for home health care, custodial care and/ or daily living, including but not limited to food, housing, or home maker services;
44) Expenses for environmental supplies, including but not limited to handrails, ramps, special telephones, air conditioners, or home delivered meals.
THERE ARE NO BENEFITS PROVIDED FOR THE FOLLOWING:
Elective Surgery and Elective Treatment: including but is not limited to surgery and/or treatment for acne; acupuncture; allergy; including allergy testing; alopecia; biofeedback-type services; birth control; breast implants; breast reduction; circumcision; corns, calluses and bunions; cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under the policy; family planning; fertility tests; gynecomatia; hirsutism; impotence, organic or otherwise; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; learning disabilities; nasal and sinus surgery; nicotine addiction; nonmalignant warts, moles and lesions; obesity and any condition resulting therefrom (including hernia of any kind); patient controlled anesthesia treatment of a covered Injury; sexual reassignment surgery; skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; sleep disorders, including testing thereof; temporomandibular joint dysfunction, tubal ligation; vasectomy; and weight reduction. Elective surgery and elective treatment includes any service, treatment; or supplies that: 1) are deemed by the company to be researched or experimental; or 2) are not recognized and generally accepted medical practices in the United States.