This information relates to sports equipment loss or delay as well as trip costs for sporting activities that are not refunded due to cancellation or interruption.
This information relates to sports equipment loss or delay as well as trip costs for sporting activities that are not refunded due to cancellation or interruption.
There is no Sports Equipment & Fees coverage with this plan.
The term “Acute Onset of a Pre-Existing Condition(s)” shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.
The term “Administrator” shall mean Seven Corners, Inc.
The term “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.
The term “Airworthiness Certificate” or “Airworthy Certificate” shall mean the “Standard” Airworthiness Certificate issued by the Federal Aviation Agency of the United States or its foreign equivalent issued by the government authority having jurisdiction over civil aviation in the country of its registry.
The term “Benefit Period” shall mean the one hundred and eighty days (180) following the onset of 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).
The term “Company” shall mean Certain Underwriters at Lloyd’s, London
The term “Coinsurance” shall mean the percentage amount of eligible Covered Expenses, after the Deductible, which are the responsibilities of the Insured Person and must be paid by the Insured Person. The Coinsurance amount is stated in Section II, Schedule of Benefits, under each stated benefit.
The term “Common Carrier” shall mean any public air conveyance operating under a valid license providing for the transportation of passengers for hire.
The term “Covered Expense” shall mean “Eligible Benefit”.
The term “Custodial Care” shall mean Care as provided primarily for maintenance of the covered person or which is designed essentially to assist the covered person in meeting his activities of daily living. Custodial Care includes but is limited to: help in walking, bathing, dressing, feeding, preparation of special diets and supervision over self-administration of medications. Such services shall be considered Custodial Care without regard to the provider by whom or by which they are prescribed, recommended or performed.
The term “Deductible” shall mean 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.
The term “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.
The term “Eligible Benefit(s)” 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.
Eligible Dependent Child shall mean the Insured Person’s unmarried children over fourteen (14) days and under nineteen (19) years of age.
Eligible Spouse shall mean the Insured Person’s legal spouse.
The term “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.
The term “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.
The term “Hospital” as used in this Policy shall mean, except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision.
The term “Home Country” shall mean the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.
The term “Home Health Care” shall mean services or supplies needed as the result of a medical condition which is eligible under the Policy. The Insured must be physically unable to obtain needed medical services on an Outpatient basis and it must be in lieu of hospitalization or confinement in an extended care facility. The treatment plan must be prescribed by a licensed Physician who is required to provide updates to the insurer at the appropriate intervals. Home Health Care is Medically Necessary health care provided in the patient’s home by health care professionals at the direction of a licensed Physician. Health care professionals may include part-time or intermittent nursing care provided under the supervision of a registered nurse, physical therapy, occupational therapy, medications and laboratory services as well as a home health aide.
The term “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.
The term “Injury” wherever used in this Policy shall mean bodily Injury caused solely and directly by violent, Accidental, external, and visible means occurring while this Policy is in force and resulting directly and independently of all other causes in Disablement covered by this Policy.
The term “Insured” or “Insured Person” shall mean a person eligible for benefits under the Policy who has applied for coverage and is named on the application and for whom the Company has accepted premium.
The term “Intensive Care” shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
The term “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.
The term “Medically Necessary” shall mean services and supplies received while insured that are determined by the Company to be: (1) appropriate and necessary for the symptoms, diagnosis, or direct care and treatment of the Insured Person’s medical conditions; (2) within the standards the organized medical community deems good medical practice for the Insured Person’s condition; (3) not primarily for the convenience of the Insured Person, the Insured Person’s Physician or another Service Provider or person; (4) not Experimental/Investigational or unproven, as recognized by the organized medical community, or which are used for any type of research program or protocol; and (5) not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person is receiving or the severity of the Insured Person’s condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe, order, recommend, or approve a service, supply, or level of care does not, of itself, make such treatment Medically Necessary or make the charge of a Covered Expense under this Policy.
The term “Mental Illness” and “Mental and Nervous Disorder” shall mean any mental, nervous, or emotional Illness which generally denotes an Illness of the brain with predominant behavioral symptoms; or an Illness of the mind or personality, evidenced by abnormal behavior; or an Illness or disorder of conduct evidenced by socially deviant behavior. Mental or Nervous Disorders include without limitation: psychosis; depression; schizophrenia; bipolar affective disorder; any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of the International Classification of Diseases as published by the U.S. Department of Health and Human Services; and those psychiatric and other Mental Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders published by the American Psychiatric Association. Mental Illness and Mental and Nervous Disorder does not mean or include learning disabilities, attitudinal disorders or disciplinary problems. For purposes of this insurance, Mental Illness and Mental and Nervous Disorder do not include Substance Abuse.
The term “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 4,500 meters or above.
The term “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.
The term “Parachuting” shall mean an activity involving the breaking of a free fall from an airplane using a parachute.
The term “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 one hundred and eighty-seven (187) days.
The term “Physician” as used 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.
The term “Pre-existing Condition(s)” 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 any time during the 36* months prior to the effective date of coverage under this 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 36 month period immediately preceding the effective date of coverage under this policy. *For Insured Persons traveling outside the United States and Canada, the period is 12 months instead of 36 months.
The term “Reasonable and Customary” shall mean the maximum amount that the Company determines is Reasonable and Customary for Covered Expenses the Insured Person receives, up to but not to exceed charges actually billed. The Company’s determination considers: (1) amounts charged by other Service Providers for the same or similar service in the locality where received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; (2) any usual medical circumstances requiring additional time, skill or experience; and (3) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale. For a Service Provider who has a reimbursement agreement, the Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company.
The term “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.
The term “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.
The term “Substance Abuse” shall mean a condition brought about when an individual uses alcohol, chemicals or any other drug(s) in such a manner that his/her health and/or judgement is impaired and/or ability to control actions is lost.
The term “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.
The term “Traveling Companion” shall mean spouse, parent, sibling, child, grandparent, grandchild, step-parent, step-child, step-sibling, in-laws (parent son, daughter, brother, or sister), aunt, uncle, niece, nephew, legal guardian, ward, or business partner of the Insured Person.
The term “You” or “Your” shall mean the Primary Insured Person and the Primary Insured’s Spouse or Dependent.
For Medical benefits, this Insurance does not cover:
1. Pre-existing Conditions which are excluded under this policy. This means that any claims for Pre-existing Conditions will not be covered for the duration of this policy.
a) If You are a United States citizen, this exclusion is waived for the first $20,000 in eligible medical expenses incurred outside the United States and Canada (for persons age 70 and over, the amount is $5,000), minus Your Deductible and selected Coinsurance option (Plan E or F). This waiver does not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program. Any exclusion specifically listed in Medical Benefits exclusions, 2 through 23, will not receive benefits from this waiver.
b) If you are a non-U.S. citizen under age 70, this exclusion is waived for eligible medical expenses for an Acute Onset of a Pre-existing Condition(s) (as defined herein) up to the first $15,000 in eligible medical expenses incurred in the United States, minus Your Deductible and selected Coinsurance option (Plan A or B). For persons age 70 and over, there is no benefit. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program. Any exclusion specifically listed in Medical Benefits exclusions, 2 through 23, will not receive benefits from this waiver.
2. Charges for treatment which exceed Reasonable and Customary charges; or charges incurred for Surgeries or treatments which are Investigational, Experimental, or for research purposes; expenses which are non-medical in nature; expenses for Vocational, Speech, Recreational or Music Therapy, or durable medical equipment;
3. Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
4. Suicide or any attempt there of, while sane or self destruction or any attempt there of, while insane; intentionally self-inflicted Injury or Illness; or expenses as a result of, or in connection with, the commission of a felony offense;
5. 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;
6. Injury sustained while participating in professional, sponsored and/or organized Amateur or Interscholastic Athletics; A sponsored and/or organized Amateur or Interscholastic Athletic event includes training camps, team sports, or any formal grouping of people participating in one or multiple events that may/may not require a fee for participation.
7. Routine physicals, inoculations, or other examinations where there are no objective indications or impairment in normal health;
8. Treatment of the Temporomandibular joint;
9. Chiropractic care or acupuncture
10. Services or supplies performed or provided by a Relative of the Insured Person, or anyone who lives with the Insured Person;
11. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids, cosmetic or plastic Surgery (including deviated nasal septum), routine dental expenses, eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye-glasses or for the fitting thereof, unless caused by Accidental bodily Injury incurred while insured hereunder;
12. Treatment in connection with alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency or use of any drug or narcotic agent; any Mental and Nervous Disorder or rest cures; Injury sustained while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor, chemicals, or drugs;
13. Learning disabilities, attitudinal disorders, or disciplinary problems;
14. Congenital abnormalities and conditions arising out of or resulting therefrom;
15. Expenses incurred during a Hospital emergency room visit which is not of an Emergency nature;
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 (except as provided under the Optional Hazardous Sports Coverage) 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. Treatment paid for or furnished under any other individual, government, or group policy or charges provided at no cost to the Insured Person;
18. Treatment of venereal or sexually transmitted disease;
19. Pregnancy expenses or Illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an Accident or complications of Pregnancy;
20. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof;
21. Expenses incurred while the Insured Person is in their Home Country (except as provided under the Home Country Coverage Benefit);
22. Expenses incurred for which travel was undertaken to seek medical treatment for a condition; or incurred after the Insured Person’s physician has limited or restricted travel.
23. Expenses for Home Health Care does not include food, housing, homemaker services, or Physician charges which are covered elsewhere in the Policy, Therapy services which are covered elsewhere in the Policy and environmental supplies such as: hand rails, ramps, special telephones, air conditioners, home delivered meals, etc. The caregiver cannot be a Relative of the Insured Person, and the care must not be provided primarily for therapeutic value and not to assist in activities of daily living or Custodial Care.
EXCLUSIONS FOR ACCIDENTAL DEATH AND DISMEMBERMENT, EMERGENCY MEDICAL EVACUATION/REPATRIATION, RETURN OF MORTAL REMAINS, EMERGENCY MEDICAL REUNION, RETURN OF MINOR CHILD
With regards to Accidental Death and Dismemberment, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Emergency Medical Reunion, and Return of Minor Child, this Insurance does not cover:
1. Suicide or attempt thereof by the Insured Person while sane, or self destruction or any attempt thereof by the Insured Person while insane;
2. Disease or sickness of any kind; (only applicable to AD&D)
3. Bacterial infections except pyogenic infection which shall occur through an Accidental cut or wound; (only applicable to AD&D)
4. Hernia of any kind; (only applicable to AD&D)
5. Injury sustained while the Insured Person is riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting, from any type of aircraft;
6. Injury sustained while the Insured Person is riding as a passenger in any aircraft (a) not having a current and valid Airworthy Certificate and (b) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft;
7. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with: a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war; b) mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power. c) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence; d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the “Occurrences”). Any consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed to be consequences for which the Company shall not be liable under this Policy except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such abnormal conditions;
8. Service in the military, naval or air service of any country;
9. Flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing, endurance tests, rocket-propelled aircraft, crop dusting or seeding or spraying, fire fighting, exploration, pipe or power line inspection, any form of hunting or herding, aerial photography, banner towing or any experimental purpose;
10. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified Physician or surgeon;
11. Injury occasioned or occurring while the Insured Person is committing or attempting to commit a felony or to which a contributing cause was the Insured Person being engaged in an illegal occupation;
12. Riding or driving in any kind of competition;
13. Pregnancy, childbirth, miscarriage or abortion;
14. Covered Expenses incurred after the Insured Person’s Physician has limited or restricted travel; or Covered Expenses incurred as a result of a change in prescribed treatment during, or within the three months prior to the effective date of coverage.
For Interruption of Trip, this insurance does not cover: (1) war or any act of war, whether declared or not; participation in a felony, riot or insurrection; participation in contests of speed; a Pre-existing Condition existing prior to the Insured’s departure from their Home Country that has the likelihood of causing death; the Insured Person or Traveling Companion or Traveling Companion’s family making changes to personal plans; having business or contractual obligations; being unable to obtain necessary travel documents (passports, visas, etc.); being detained or having property confiscated by customs authorities; carrier caused delays (including bad weather); prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which the Insured Person purchased their trip arrangements.
For Lost of Checked Luggage, this insurance does not cover: animals; automobiles or automobile equipment; boats; motors; motorcycles; other conveyances or their appurtenances (except bicycles while checked as baggage with a Common Carrier); household furniture; eye-glasses or contact lenses; artificial teeth or dental bridges; hearing aids; prosthetic limbs; musical instruments; money or securities; tickets or documents; or sporting equipment if loss or damage results from the use thereof.