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.
Accidental Death & Dismemberment – Benefits shall be paid to You if You sustain an Accidental Injury. The Injury must occur during the Period of Coverage and death or dismemberment as a result of that Accident must occur within 365 days from the date of Accident. Benefits payable for any such loss shall be in accordance with the following table: If You incur more than one Loss stated in the following Table as the result of one Accident, only the largest amount, shall be payable.
The Common Carrier Accident benefit noted in the schedule will be paid to You if You sustain an Accidental Death. Death must occur during the Period of Coverage while You are riding as a passenger (but not a pilot, operator, or member of the crew) in or on a Common Carrier.
|Description of Loss||Percent of Principal Sum|
|Both Hands or Both Feet or Sight of Both Eyes||100%|
|One Hand and One Foot||100%|
|Either Hand or Foot and Sight of One Eye||100%|
|Either Hand or Foot||50%|
|Common Carrier Accidental Death||200%|
Accident or Accidental means an event, independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.
Administrator shall mean Seven Corners, Inc.
Benefit Period shall mean the allowable time period You have from the date of Injury or onset of Illness to receive Treatment for a Covered Injury or Illness. 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).
Coinsurance shall mean the percentage amount of Covered Expenses, after the Deductible, which is Your responsibility to pay.
Common Carrier shall mean any motorized land, sea, and/or air conveyance operating under a valid license for the transportation of passengers for hire.
Company shall mean United States Fire Insurance Company.
Covered Expenses shall mean expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed of ordered by a Physician; Reasonable and Customary charges; incurred while insured under this Policy
Deductible shall mean the amount of eligible Covered Expenses which is Your responsibility to pay before benefits under the plan are payable.
Disablement (as used with respect to medical expenses) shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician.
Eligible Dependent Child shall mean Your unmarried children over fourteen (14) days and under nineteen (19) years of age.
Eligible Spouse shall mean Your legal spouse.
Hospital 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 means a place that 1.) is legally operated for the purpose of providing medical care and treatment to sick or injured persons for which a charge is made that the Insured is legally obligated to pay in the absence of insurance 2.) provides such care and treatment in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) operates under the supervision of a staff of one or more Doctors. Hospital also means a place that is accredited as a hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Health Care Organizations (JCAHO).
Hospital does not mean:
-a convalescent, nursing, or rest home or facility, or a home for the aged;
-a place mainly providing custodial, educational, or rehabilitative care; or
-a facility mainly used for the treatment of drug addicts or alcoholics.
Home Country shall mean the country where You have Your true, fixed and permanent home and principal establishment.
Illness shall mean sickness or disease of any kind contracted and commencing after the Effective Date of this Policy.
Injury shall mean accidental bodily injury or injuries caused by an accident which occurs after the Effective Date of this policy. The Injury must be the direct cause of the loss, independent of disease or bodily infirmity.
Inpatient shall mean if You are confined in an institution and are charged for room and board.
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.
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.
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.
Outpatient shall mean if You receive 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.
Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.
Period of Coverage or Policy Period shall mean the Period of Coverage issued by the Company to the Insured Person, typically beginning with the Effective Date and ending with the Expiration Date or the date coverage is renewed by the Company.
Physician 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.
Pre-existing Condition shall mean any Injury or Illness which meets the following criteria: 1) a condition that would have caused a person to seek medical advice, diagnosis, care, or treatment during the thirty-six (36)* months prior to the Effective Date of coverage under this Policy; 2) a condition for which manifestation, medical advice, diagnosis, care, or treatment was recommended, received, or noticed during the thirty-six (36)* months prior to 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.
Reasonable and Customary shall mean the maximum amount that the plan determines is Reasonable and Customary for Covered Expenses You receive, up to but not to exceed charges actually billed. The 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 included but not limited to, a resource based relative value scale.
Treatment means a specific in-office or Hospital physical examination of or care rendered to You, consultation, diagnostic procedures and services, Surgery, medical services and supplies including medication prescribed or provided by a Service Provider.
You or Your shall mean the Primary Insured Person and the Primary Insured’s Spouse or Dependent.
No Benefit shall be payable for Accident Medical, Sickness Medical, In-Hospital Indemnity, Unexpected Recurrence, Dental, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, Return of Minor Child, Emergency Medical Reunion as the result of:
1. Pre-existing Condition(s) as defined under this policy. This exclusion does not apply to Emergency Evacuation/Repatriation.
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. 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 below in 2 through 41, will not receive benefits from this waiver.
b) If you are a non-U.S. citizen under age 70, this exclusion is waived 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. 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 below in 2 through 41, will not receive benefits from this waiver.
2. Injury or Illness which is not presented to the Company for payment within ninety (90) days of receiving Treatment;
3. Charges for Treatment which is not Medically Necessary;
4. Charges provided at no cost to You;
5. Charges for Treatment which exceeds Reasonable and Customary charges;
6. Charges incurred for Surgery or treatments which are, Experimental/Investigational, or for research purposes;
7. Services, supplies or treatment, including any period of Hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
8. Suicide or any attempt thereof, self destruction or attempt thereof while sane or insane (may vary by state of residence);
9. Any consequence, whether proximately or remotely occasioned 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 du jure or de facto. d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of marital law or state of siege.
10. Injury sustained while participating in professional athletics;
11. Injury sustained while participating in amateur or interscholastic athletics; this exclusion does not apply to non-competitive, recreational or intramural activities. Note: 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.
12. Routine physicals, immunizations or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a disablement established by a prior call or attendance of a Physician;
13. Treatment of the temporomandibular joint;
14. Vocational, speech, recreational or music therapy;
15. Services or supplies performed or provided by a relative of Yours, or anyone who lives with You;
16. Cosmetic or plastic Surgery, except as the result of a covered Accident; for the purposes of this plan, treatment of a deviated nasal septum will be considered a cosmetic condition;
17. Elective Surgery which can be postponed until You return to Your Home Country, where the objective of the trip is to seek medical advice, treatment or Surgery;
18. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids;
19. Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eyeglasses or for the fitting thereof, unless caused by Accidental bodily Injury incurred while covered hereunder;
20. Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent;
21. Injury sustained or Disablement due wholly or partly to the effects of being intoxicated or drug use, other than drugs taken in accordance with treatment prescribed and directed by a Physician;
22. Any Mental and Nervous disorders or rest cures; may vary by state of residence
23. Congenital abnormalities and conditions arising out of or resulting there from;
24. Expenses which are non-medical in nature;
25. Expenses as a result of or in connection with intentionally self-inflicted Injury or Illness;
26. Expenses as a result of or in connection with the commission of a felony offense;
27. Injury sustained while taking part in mountaineering; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; snowmobiling; motorcycle/motor scooter riding (whether as a driver or passenger); scuba diving, involving underwater breathing apparatus (unless PADI or NAUI certified); snorkeling; water skiing; snow skiing; spelunking; parasailing and snowboarding. Hazardous Sport Coverage: the following are covered if the required premium has been paid: motorcycle/motor scooter riding (whether as a driver or passenger), hang gliding, parachuting, bungee jumping, water skiing, snow skiing, snowmobiling, snowboarding, snorkeling and spelunking.
28. Treatment paid for or furnished under any other individual or group policy or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government plan or facility set up for treatment without any cost to You;
29. Dental care, except as the result of Injury to natural teeth caused by Accident, unless otherwise covered under this plan;
30. Routine Dental Treatment;
31. Pregnancy or Illness resulting from Pregnancy, childbirth, or miscarriage;
32. Miscarriage resulting from Accident
33. 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;
34. Treatment for human organ tissue transplants and their related treatment;
35. Expenses incurred while in Your Home Country, except as provided under the Home Country Coverage;
36. Expenses incurred during a Hospital emergency visit which is not of an emergency nature;
37. Covered Expenses incurred for which the Trip to the Host Country was undertaken to seek medical treatment for a condition;
38. Covered Expenses incurred during a Trip after Your Physician has limited or restricted travel;
39. This Policy does not insure against loss or damage (including death or injury) and any associated cost or expense resulting directly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or radioactive force, or chemical, biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act.
40. Sex change operations, or for treatment of sexual dysfunction or sexual inadequacy;
41. Weight reduction programs or the surgical treatment of obesity;
No Benefit shall be payable for Accidental Death and Dismemberment as the result of:
1. Suicide or any attempt thereof, self destruction or attempt thereof while sane or insane (may vary by state of residence);
2. Disease of any kind; Bacterial infections except pyogenic infection which shall occur through an accidental cut or wound;
3. Hernia of any kind;
4. Injury sustained while You are riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting from, any type of aircraft;
5. Injury sustained while You are 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;
6. Any consequence, whether proximately or remotely occasioned 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 du jure or de facto.
d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of marital law or state of siege.
7. Service in the military, naval or air service of any country;
8. Flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing or endurance tests;
9. Flying in any rocket-propelled aircraft;
10. Flying in any aircraft being used for or in connection with 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;
11. Flying in any aircraft which is engaged in any flight which requires a special permit or waiver from the authority having jurisdiction over civil aviation, even though granted;
12. Sickness of any kind;
13. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified Physician or surgeon;
14. Injury occasioned or occurring while You are committing or attempting to commit a felony or to which a contributing cause was You being engaged in an illegal occupation;
15. While riding or driving in any kind of competition;
16. Pregnancy, childbirth, miscarriage, or abortion;
17. This plan does not insure against loss or damage (including death or injury) and any associated cost or expense resulting directly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or radioactive force, or chemical, biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act.
No Benefit shall be payable for the following items under the Loss of Checked Baggage Benefit:
1. Aircraft, automobiles, automobile equipment, motors, motorcycles, bicycles (except bicycles when checked as baggage with a common carrier), boats or other conveyances or their accessories;
3. Artificial teeth or limbs, hearing aids;
4. Sunglasses, contact lenses or eyeglasses;
5. Documents of any kind, including but not limited to documents, bills, currency, deeds, evidences of debt, letters of credit, stamps, credit cards, money, notes, securities, transportation or other tickets;
6. Household furniture or furnishings.