Surgery

If $50,000 option for Emergency Medical is selected, plan includes a scheduled benefit of up to $2,500 per injury/sickness

If $100,000 option for Emergency Medical is selected, plan includes scheduled benefit of up to $4,250 per injury/sickness

If $250,000 option for Emergency Medical is selected, plan includes scheduled benefit of up to $4,900 per injury/sickness

For travelers age 70 and over, plan includes scheduled benefit of up to $2,100 per injury/sickness

MEDICAL EXPENSE BENEFITS – INJURY AND SICKNESS

When a covered Injury or Sickness requires treatment by a Physician, this program will provide benefits for the Usual and Customary Charges for Medically Necessary Covered Medical Expenses which exceed the deductible per person for each Injury or Sickness and which are incurred within 26 weeks following the Injury or Sickness. Payment for any Covered Medical Expense will be no more than the Benefit Limit shown for it in the Schedule of Benefits. The total payable for all Covered Medical Expenses will be no more than the Maximum Benefit Limit per Sickness or Injury. Benefits are subject to the Excess Benefits Provision.

If a benefit is designated in the Schedule of Benefits, Covered Medical Expenses include:

• Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional services and (with the exception of personal services of a non-medical nature; charges made for an operating room.
• Hospital Miscellaneous Expenses: 1) while Hospital Confined; or 2) for pre-admission expenses for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.
• Charges made for diagnosis, treatment and Surgery by a Physician for inpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this inpatient surgery benefit; or under the outpatient surgery benefit, but not for both.
• Charges made for the cost and administration of anesthetics: in connection with inpatient surgery.
• Charges made for diagnosis, treatment and Surgery by a Physician for outpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this outpatient surgery benefit; or under the inpatient surgery benefit, but not both.
• Day Surgery Miscellaneous (Outpatient Surgical Facility): in connection with outpatient day surgery; excluding non-scheduled surgery, and surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and x-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies.
• Anesthetist (Outpatient): in connection with outpatient surgery.

When you incur a covered Injury or Illness, the program will pay Usual, Reasonable and Customary medical charges for Covered Expenses, excess of the chosen Deductible and Coinsurance, up to the selected Policy Maximum. Only such expenses, incurred as the result of a disablement, which are specifically enumerated in the following list of charges, are incurred within six months from the onset of an Injury or Illness, and which are not excluded in the Exclusions, shall be considered as Covered Expenses:

• Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service and (with the exception of personal services of a non-medical nature); charges made for an operating room.
• Charges made for diagnosis, treatment and Surgery by a Physician; charges made for the cost and administration of anesthetics.
• Charges made for Outpatient treatment, same as any other treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion consultations.

  HOSPITAL INDEMNITY
  
  Should the Insured Person be hospitalized while traveling outside the United States or Canada, and the hospitalization is considered a Covered Expense, the Company will indemnify the Insured $100 for each night spent in the hospital.

If the $50,000 option for Emergency Medical is selected, plan includes a scheduled benefit of $4,000, per injury/sickness

If the $100,000 option for Emergency Medical is selected, plan includes a scheduled benefit of $6,600, per injury/sickness

For travelers age 70 and over, the $50,000 plan includes $3,200, per injury/sickness

MEDICAL EXPENSE BENEFITS – INJURY AND SICKNESS

When a covered Injury or Sickness requires treatment by a Physician, the policy will provide benefits for the Usual and Customary Charges for Medically Necessary Covered Medical Expenses which exceed the deductible per person for each Injury or Sickness. Payment for any Covered Medical Expense will be no more than the Benefit Limit shown for it. The total payable for all Covered Medical Expenses will be no more than the Maximum Benefit Limit per Sickness or Injury. Benefits are subject to the Excess Provision.

Covered Medical Expenses will be paid under the Schedule of Benefits for loss:

• Surgery: Physician’s fees for inpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this inpatient surgery benefit; or under the outpatient surgery benefit, but not for both.
• Anesthetist Services: in connection with inpatient surgery.

Covered Accident and Sickness Medical Expenses: For the purpose of this section, only such expenses, incurred as the result of a Disablement, which are specifically enumerated in the following list of charges, and which are not excluded in Section III, Exclusions, shall be considered as Covered Expenses:

• Charges made for diagnosis, Treatment and Surgery by a Physician.
• Charges made for an operating room.

An Insured Person must follow the Pre-Certification Program in order to receive full benefits under the Policy. If the Insured Person does not properly follow the Pre-Certification Program, their benefits under the Policy will be reduced, as described below. The Insured Person is responsible for obtaining any required Pre-Certification for all Hospital admissions or transplants worldwide, or for any Outpatient Surgery or Covered Expenses. The Insured Person or someone on his behalf, must notify the Company prior to Treatment, by telephoning the Company’s Assistance Company. The telephone number of the Assistance Company is shown on the Insured Person’s Identification Card.

The Pre-Certification Program requires that the Insured Person obtain Pre-Certification (unless otherwise noted herein) for the following: For Scheduled Hospital Admissions, Outpatient Treatments or Covered Expenses, and transplants: The Pre-Certification Program requires that the Insured Person, or someone on their behalf, contact the Assistance Company as soon as possible, but not less than 48 hours, prior to the date of admission for any Scheduled Hospital Confinement or Scheduled Treatment , to obtain the following:
If additional days of Hospital confinement are necessary beyond the initial number of Pre-Certified days, the attending Physician or an official representative of the facility where the Insured Person is confined, must contact the Company (no later than the last day originally Pre- Certified) to obtain Pre-Certification for any additional days of Hospital confinement. The Company will review with the attending Physician the request for the additional days of Hospital confinement.
A list with the name(s) and address(es) of the United States Hospitals that are members of the Participating Provider Network, to which the Insured Person will have access as an Insured Person under the Policy. The Insured Person must use a Hospital which is a member of the Participating Provider Network in order to receive full benefits under the Policy, as described below
. For Emergency Hospital confinements: The Pre-Certification Program requires that the Insured Person, or someone on their behalf, contact the Company as soon as possible, but no later than 48 hours after the date of admission to a Hospital in case of Emergency. For Transplants Worldwide: The Insured Person, or someone on their behalf, must contact the Company immediately, but not later than 48 hours after the Insured Person is identified by the attending Physician, as a candidate for a bone marrow, cornea, heart, heart and lung, single lung, pancreas and kidney, or liver transplant, and at least 2 days prior to any scheduled admission to a Hospital.

PRE-CERTIFICATION. PROGRAM EFFECT ON BENEFITS: Subject to all provisions of the Policy, when the requirements of the Pre-Certification Program are properly followed and the Hospital admission or transplant Treatment is Pre-Certified, benefits for Covered Expenses will be payable as described in Your Schedule of Coverage and Service and in any amendments of endorsements to the Policy.

If an Insured Person does not properly follow the Pre- Certification Program and if the required Pre-Certification is not obtained, the benefit percentage payable for Covered Expenses incurred for all Treatment, services, and supplies related to the Disablement will be reduced to and payable at 60% (whether or not the Coinsurance has been met), after any Deductible amount which may apply. The reduction in the benefit percentage payable will not apply where there is no Participating Provider Network Hospital in the city or immediate vicinity where the Insured Person is to be Hospitalized, provided the Insured Person complied with the Pre-Certification requirements.

The additional amounts an Insured Person is required to pay as a result of the lower percentage payable due to not following this Pre-Certification Program will not be used to satisfy any Deductible amount or the Coinsurance in the Policy.

PRE-CERTIFICATION DOES NOT GUARANTEE BENEFITS: Benefits payable under the Policy are still subject to eligibility at the time charges are actually incurred, and to all other terms, limitations, and exclusions of the Policy. Pre- Certification does not guarantee or confirm benefits under the Policy.

Medical Coverage

1. Inpatient and Outpatient charges made by a Hospital.
2. Charges made by a Physician, surgeon, radiologist, anesthesiologist, and any other medical specialist to whom the Physician has referred the case.

When a covered Injury or Illness is incurred by the Insured Person, the Company will pay 100% of Reasonable and Customary medical charges for Covered Expenses, excess of the Per Occurrence deductible, up to the Per Occurrence Maximum of USD 60,000. In no event shall the Company's maximum liability exceed the maximum as stated on the ID Card. The Deductible and Coinsurance amount consists of Covered Expenses which would otherwise be payable under this Policy. These expenses must be borne by each Insured Person. A maximum of 3 Policy Period deductibles per family under the same application will apply.

Only such expenses, incurred as the result of and within twenty-six (26) weeks from a Disablement, which are specifically enumerated in the following list of charges, and which are not excluded in PART IV - EXCLUSIONS, shall be considered as Covered Expenses:

• Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service and (with the exception of personal services of a non-medical nature); charges made for an operating room.
• Charges made for diagnosis, treatment and Surgery by a Physician; charges made for the cost and administration of anesthetics..
• Charges made for Outpatient treatment, same as any other treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion consultations..

When a covered Injury or Illness is incurred by the Insured Person, the Company will pay 100% of Reasonable and Customary medical charges for Covered Expenses, excess of the Per Occurrence deductible, up to the Per Occurrence Maximum of USD 60,000. In no event shall the Company's maximum liability exceed the maximum as stated on the ID Card. The Deductible and Coinsurance amount consists of Covered Expenses which would otherwise be payable under this Policy. These expenses must be borne by each Insured Person. A maximum of 3 Policy Period deductibles per family under the same application will apply.

Only such expenses, incurred as the result of and within twenty-six (26) weeks from a Disablement, which are specifically enumerated in the following list of charges, and which are not excluded in PART IV - EXCLUSIONS, shall be considered as Covered Expenses:

• Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service and (with the exception of personal services of a non-medical nature); charges made for an operating room.
• Charges made for diagnosis, treatment and Surgery by a Physician; charges made for the cost and administration of anesthetics..
• Charges made for Outpatient treatment, same as any other treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion consultations..

When a covered Injury or Illness is incurred by the Insured Person, the Company will pay 100% of Reasonable and Customary medical charges for Covered Expenses, excess of the Per Occurrence deductible, up to the Per Occurrence Maximum of USD 60,000. In no event shall the Company's maximum liability exceed the maximum as stated on the ID Card. The Deductible and Coinsurance amount consists of Covered Expenses which would otherwise be payable under this Policy. These expenses must be borne by each Insured Person. A maximum of 3 Policy Period deductibles per family under the same application will apply.

Only such expenses, incurred as the result of and within twenty-six (26) weeks from a Disablement, which are specifically enumerated in the following list of charges, and which are not excluded in PART IV - EXCLUSIONS, shall be considered as Covered Expenses:

• Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service and (with the exception of personal services of a non-medical nature); charges made for an operating room.
• Charges made for diagnosis, treatment and Surgery by a Physician; charges made for the cost and administration of anesthetics..
• Charges made for Outpatient treatment, same as any other treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion consultations..

Before this Plan pays for any benefits, the Insured Person must satisfy his/her Period of Insurance Deductible. After the Insured Person satisfies the Deductible, the Insurer will begin paying for Covered Services as described in this section.

The benefits described in this section will be paid for Covered Expenses incurred on the date the Insured Person receives the service or supply for which the charge is made. These benefits are subject to all terms, conditions, exclusions, and limitations of this Plan. All services are paid at percentages and amounts indicated below or in the Benefit Overview Matrix, and subject to limits outlined in Section IV, How the Plan Works. Following is a general description of the supplies and services for which the Insured Person’s Plan will pay benefits, if such supplies and services are Medically Necessary:

Services and Supplies Provided by a Hospital For any eligible condition other than for Mental, Emotional or Functional Nervous Conditions or Disorders, Alcoholism or Drug Abuse, the Insurer will pay indicated benefits on Covered Expenses for:

1. Inpatient services and supplies provided by the Hospital except private room charges above the prevailing two-bed room rate of the facility.
2. Outpatient services and supplies including those in connection with outpatient surgery performed at an Ambulatory Surgical Center.

1. Services must be those which are regularly provided and billed by the Hospital.
2. Services are provided only for the number of days required to treat the Insured Person’s Illness or Injury
   
   Note: No benefits will be provided for personal items, such as TV, radio, guest trays, etc.

Before this Plan pays for any benefits, the Insured Person must satisfy his/her Period of Insurance Deductible. After the Insured Person satisfies the Deductible, the Insurer will begin paying for Covered Services as described in this section.

The benefits described in this section will be paid for Covered Expenses incurred on the date the Insured Person receives the service or supply for which the charge is made. These benefits are subject to all terms, conditions, exclusions, and limitations of this Plan. All services are paid at percentages and amounts indicated below or in the Benefit Overview Matrix, and subject to limits outlined in Section IV, How the Plan Works. Following is a general description of the supplies and services for which the Insured Person’s Plan will pay benefits, if such supplies and services are Medically Necessary:

Services and Supplies Provided by a Hospital For any eligible condition other than for Mental, Emotional or Functional Nervous Conditions or Disorders, Alcoholism or Drug Abuse, the Insurer will pay indicated benefits on Covered Expenses for:

1. Inpatient services and supplies provided by the Hospital except private room charges above the prevailing two-bed room rate of the facility.
2. Outpatient services and supplies including those in connection with outpatient surgery performed at an Ambulatory Surgical Center.

1. Services must be those which are regularly provided and billed by the Hospital.
2. Services are provided only for the number of days required to treat the Insured Person’s Illness or Injury
   
   Note: No benefits will be provided for personal items, such as TV, radio, guest trays, etc.

Covered Expenses

Only such expenses incurred as the result of and within 52 weeks from a Disablement, which shall mean an illness or an accidental bodily Injury necessitating medical treatment, and which are specifically enumerated in the following list of charges:

• Charges made for diagnosis, treatment and surgery by a Physician;
• Charges made for the cost and administration of anesthetics;
• Charges for medication, x-ray services, laboratory tests and services, the use of radium and radio-active isotopes, oxygen, blood transfusions, iron lungs, and medical treatment;

Following is a general description of the supplies and services for which the Insured Person’s Plan will pay benefits, if such supplies and services are Medically Necessary:
Services and Supplies Provided by a Hospital For any eligible condition other than for Mental, Emotional or Functional Nervous Conditions or Disorders, Alcoholism or Drug Abuse, the Insurer will pay indicated benefits on Covered Expenses for:

1. Inpatient services and supplies provided by the Hospital except private room charges above the prevailing two-bed room rate of the facility.
2. Outpatient services and supplies including those in connection with outpatient surgery performed at an Ambulatory Surgical Center.

1. Services must be those which are regularly provided and billed by the Hospital.
2. Services are provided only for the number of days required to treat the Insured Person’s Illness or Injury
   
   Note: No benefits will be provided for personal items, such as TV, radio, guest trays, etc.

   Hospitals, Physicians, and Other Providers.
   
   The amount that will be treated as a Covered Expense for services provided by a Provider will not exceed the lesser of actual billed charges or a Reasonable Charge as determined by the Insurer. Exception: If Medicare is the primary payer, Covered Expense does not include any charge:

   1. By a Hospital in excess of the approved amount as determined by Medicare; or
   2. By a Physician or other provider, in excess of the lesser of the maximum Covered Expense stated above; 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 Insured Person will always be responsible for any expense incurred which is not covered under this Plan.