Provides reimbursement for prepaid, non-refundable trip payments and deposits if a trip is cancelled due to involuntary layoff or termination of employment. Conditions apply.
Provides reimbursement for prepaid, non-refundable trip payments and deposits if a trip is cancelled due to involuntary layoff or termination of employment. Conditions apply.
There is no Employment Layoff coverage in this plan.
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.
An “Act of Terrorism” is defined as: 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.
The term “Airworthiness 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.
The term “Company” shall mean The Insurance Company of the State of Pennsylvania.
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 “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. If Medicare is the primary payer, Eligible Benefit(s) does not include any charge: 1) By a hospital in excess of the approved amount as determined by Medicare; 2) By a Physician or other provider, in excess of the lesser of the actual billed charges or a Reasonable and Customary Charge; or a. For providers who accept Medicare assignment, the approved amount as determined by Medicare; or b. For providers who do not accept Medicare assignment, the limiting charge as determined by Medicare.
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 “Host Country” shall mean any country other than the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.
The term “Illness” wherever used in this Policy shall mean sickness or disease of any kind.
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” shall mean any condition or disease listed in the most recent edition of the International Classification of Diseases as a mental disorder, which clinically significant behavioral or psychological disorder marked by a pronounced deviation from a normal healthy state and associated with a present painful symptom or impairment in one or more important areas of functioning. This disease must not be merely an expectable response to a particular stimulus. Mental Illness does not mean learning disabilities, attitudinal disorders or disciplinary problems.
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 not confined and is not charged for room and board.
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.
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” as used in this Policy shall mean Any Injury or Illness which meets the following criteria: a) condition(s), including any related conditions, associated complications or consequences, which manifested during the thirty-six (36) months prior to the Effective Date of coverage under this policy; (b) condition(s) including any related conditions, associated complications or consequences, that should 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; © condition(s) including any related conditions, associated complications or consequences, for which 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; (d) the symptoms which occurred thirty-six (36) months prior to the Effective Date of coverage under this policy would have allowed a person trained in medicine to make a diagnosis of the condition, including any associated complications or consequences, producing the symptoms.
The term “Primary Health Plan” is a Group Health Benefit Plan, an individual health benefit plan, or a governmental health plan designed to be the first payor of claims (such as Medicare*.) for an Insured Person in effect prior to the effective date of this Policy and continuing as long as this Policy is in effect. Such plans must have coverage limits in excess of $50,000 per incident or per year to be considered a Primary Plan. *In order for Medicare to be considered as a Primary Health Plan, the policyholder must have parts A, B, and C. Medicare is not considered a Primary Health Plan for the following: 1. Insured Persons who are receiving treatment for end-stage renal disease. 2.) Insured Persons who are entitled to Medicare benefits as disabled persons. 3. Insured Persons who are less than 65 years and are entitled to Medicare for any other reason.
A “Group Health Benefit Plan” means a group, blanket, or franchise insurance policy, a certificate issued under a group policy, a group hospital service contract, or a group subscriber contract or evidence of coverage issued by a health maintenance organization that provides benefits for health care services. The term does not include: 1. accident-only, credit or disability insurance coverages; 2. specified disease coverage or other limited benefit policies; 3. long-term care, dental care, or vision care coverages; 4. coverage provided by a single service health maintenance organization; 5. insurance coverage issued as a supplement to liability insurance; 6. insurance coverage arising out of a workers’ compensation system or similar statutory system; 7. automobile medical payment insurance coverage; 8. jointly managed trusts authorized under 29 U.S.C. Section 141 et seq. that contain a plan of benefits for employees that is negotiated in a collective bargaining agreement governing wages, hours, and working conditions of the employees that is authorized under 29 U.S.C. Section 157; 9.hospital confinement indemnity coverage; or 10. reinsurance contracts issued on a stop-loss, quota share, or similar basis.
PLEASE NOTE: Your Primary Health Plan must be effective at the time of claim. Medicaid and V.A. health plans do not constitute primary health insurance because they are not defined as the first payor of medical claims.
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 “Rest Cures” shall mean a treatment, as for nervous disorders, consisting of complete rest, often with special diet, massage, etc., especially at a spa or sanitorium.
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 “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.
For Medical benefits, this Insurance does not cover:
1.Any Injury or Illness which meets the following criteria: a) condition(s), including any related conditions, associated complications or consequences, which manifested during the thirty-six (36) months prior to the Effective Date of coverage under this policy; b) condition(s) including any related conditions, associated complications or consequences, that should 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; c) condition(s) including any related conditions, associated complications or consequences, for which 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; d) the symptoms which occurred thirty-six (36) months prior to the Effective Date of coverage under this policy would have allowed a person trained in medicine to make a diagnosis of the condition, including any associated complications or consequences, producing the symptoms.
If you are traveling outside the United States and Canada, the period is twelve (12) months instead of thirty-six (36) months.
If you are a United States citizen and the United States is your Home Country, this exclusion is waived for Eligible Benefits incurred outside the United States and Canada as defined below:
a) For persons less than age 65 with a Primary Health Plan as defined in the policy, Pre-Existing Conditions are waived up to the medical maximum selected.
b) For persons less than age 65 without a Primary Health Plan as defined in the policy, Pre-Existing Conditions are waived up to the first $20,000.
c) For persons age 65 and over, Pre-Existing Conditions are waived up to the first $2,500 regardless of whether there is a Primary Health Plan.
This waiver does not include coverage for known, scheduled, required, required or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program.
If you are a non-United States citizen and suffer a Myocardial Infarction or Stroke and are admitted to a Hospital, this exclusion is waived only in order to pay a $200 per night benefit for each night spent in the Hospital, up to a maximum benefit of $3,000. The term “Myocardial Infarction” shall require an acute and emergent onset of the condition. The term “Stroke” shall require an acute and emergent onset of the condition.
2. Charges for Treatment(s) of the following Illness(es) or Surgery(ies), which Manifest(ed) themselves or are recommended, or symptoms occur during the first one hundred and eighty (180) days of Coverage hereunder beginning on the initial Effective Date: any condition of the breast; any treatment of all forms of cancer/neoplasm; any condition of the prostate; disorders of the reproductive system; hysterectomy; gall stones or urologic stones (kidney, ureteral, bladder or urethral stones) and any associated complications; any acne diagnosis or acne related condition; asthma; allergies; tonsillectomy; back conditions; adenoidectomy; hemorrhoids; hemorrhoidectomy; hernia, or any Surgery(ies) that is(are) not Emergency in nature, as Emergency is defined hereunder. (Does not apply to United States citizens traveling outside of the United States and Canada)
3. Claims not received by Seven Corners within ninety (90) days of the date of service;
4. 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 nonmedical in nature;
5. Expenses for Vocational, Speech, Recreational or Music Therapy;
6. Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
7. Suicide or any attempt thereof; self-destruction or any attempt thereof; intentionally self-inflicted Injury or Illness;
8. Expenses as a result of or in connection with the commission of a felony or any other criminal or illegal activity as defined by the local governing body;
9. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war;
10. Injury sustained while participating in professional, sponsored and/or organized Amateur or Interscholastic Athletics;
11. Routine physicals, innoculations, or other examinations including but not limited to laboratory, diagnostic, or x-ray examinations where there are no objective indications or impairment in normal health;
12. Treatment of the Temporomandibular joint;
13. Services or supplies performed or provided by a Relative of the Insured Person, or anyone who lives with the Insured Person;
14. 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;
15. Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent; injury sustained while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor or drugs or narcotic agent,unless administered under the advice of a Physician and said narcotic agent was taken in accordance with the proper dosing as directed by the physician;
16. Any Mental and Nervous disorders or Rest Cures;
17. Congenital abnormalities and conditions arising out of or resulting therefrom;
18. Weight reduction programs or the surgical treatment of obesity;
19. Expenses incurred during a hospital emergency room visit which is not of an emergency nature;
20. Injury sustained while taking part in mountaineering, hang gliding, parachuting, bungee jumping, zip lining, racing by any animal or motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding (whether as passenger or driver), scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snow boarding, luge, motocross, Moto X, skateboarding, and any other sport or athletic activity which is undertaken for thrill seeking and exposes the insured to abnormal or extreme risk of injury and/or is in violation of applicable laws, rules, or regulations. Mountaineering shall mean the sport, hobby or profession of walking, hiking, and climbing either: 1) utilizing harnesses, ropes, crampons, or ice axes; or 2) ascending 4,500 meters or above. Parachuting shall mean an activity involving the breaking of a free fall using a parachute. (UNLESS HAZARDOUS SPORTS RIDER IS PURCHASED, SEE PROVISION BELOW, AS THIS EXCLUSION IS REPLACED);
21. Treatment paid for or furnished under any other individual, government, or group policy or charges provided at no cost to the Insured Person;
22. Treatment of venereal or sexually transmitted disease;
23. Sex change operations, or for treatment of sexual dysfunction or sexual inadequacy;
24. Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), Aids-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV).
25. Pregnancy expenses or Illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an Accident;
26. 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;
27. Expenses incurred while the Insured Person is in their Home Country (except after approved Emergency Medical Evacuation / Repatriation or if treatment is a follow-up to a covered disablement during coverage (see Home Country Coverage Benefit) or if the expenses pertain to the Home Country Coverage Benefit);
28. 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.
29. Expenses incurred as a result of the Insured’s failure to accept or follow a Physician’s advice, treatment, or recommended treatment.
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 proximately or remotely occasioned by, or traceable to, or arising in connection with the following, which shall hereinafter for the purposes of this Exclusion be called the “Incidents”: 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. Any consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether proximately or remotely occasioned by, traceable to, or arising in connection with, any of the said Incidents shall be deemed to be consequences for which the Company shall not be liable under this plan 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 (3) 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 Loss 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.
Hazardous Sport Coverage (when applicable): To cover motorcycle/motor scooter riding (whether as a passenger or a driver), hang gliding, parachuting, bungee jumping, water skiing, snow skiing, snowmobiling, snowboarding, and spelunking. (covered if the required premium has been paid)
Pre Notification / Referral – Seven Corners Assist must be contacted prior to: (1) any medical treatment being received in the United States; or (2) hospital admissions worldwide; or (3) inpatient or outpatient surgeries worldwide. Additionally, the Company’s appointed network provider must be utilized for medical expenses incurred inside the United States (when available – contact Seven Corners Assist with questions). A listing of network facilities can be found at www.sevencorners.com/findproviders on the worldwide web. Pre Notification does not guarantee that benefits will be paid. Failure to follow Pre Notification / Referral will result in a 20% reduction of Eligible Benefits. (For Emergency admissions and situations, Seven Corners Assist must be contacted within 48 hours, or as soon as reasonably possible.) Please be awarethat this is not a general health insurance policy, but an interim travel medical program intended for use while away from your Home Country or Country of Residence.
This Policy does not guarantee payment to a facility or individual for medical expenses until the Company determines that it is an eligible expense.
Please be aware that this is not a general health insurance policy, but an interim travel medical program intended for use while away from your Home Country or Country of Residence. This Policy does not guarantee payment to a facility or individual for medical expenses until the Company determines that it is an eligible expense.