$50,000 policy limit
Provides reimbursement for the cost of treatment associated with a medical emergency incurred while traveling.
MEDICAL AND DENTAL COVERAGE
We will pay this benefit, up to the amount on the Schedule, for the following covered expenses incurred by you, subject to the following:
1. Covered expenses will only be payable at the Usual and Customary level of payment; and
2. Benefits will be payable only for covered expenses resulting from a Sickness that first manifests itself or an Injury that occurs while on a Trip; and
3. Benefits payable as a result of incurred covered expenses will only be paid after benefits have been paid under any Other Valid and Collectible Health Insurance in effect for you. This coverage is in excess to any other health insurance you have available to you at the time of the loss. You must submit your claim to that provider first. Any benefits you receive from your primary or supplementary insurance providers will be deducted from your claim with us.
1. Expenses for the following Physician-ordered medical services: services of legally qualified Physicians and graduate nurses, charges for Hospital confinement and services, local ambulance services, prescription drugs and medicines, and therapeutic services, incurred by you within one year from the date of your Sickness or Injury during a Trip; and
2. Expenses for emergency dental treatment incurred by you during a Trip up to the amount in the Schedule.
Your duties in the event of a Medical or Dental Expense:
1. You must provide us with all bills and reports for medical and/or dental expenses claimed.
2. You must provide any requested information related to the claimed expense(s), including but not limited to, an explanation of benefits from any other applicable insurance.
3. You must sign a patient authorization to release any information required by us, to investigate your claim.
Please refer to the Definitions, for an explanation of Pre-Existing Conditions, which are excluded under the Medical or Dental Expense Benefits.
Coordination of Benefits
If you reside in CT, ID, IL, and excess coverage for Medical and Dental Expense Benefits is not permitted, then coordination of benefit provisions in accordance with the laws and regulations in your state will apply in lieu of the excess coverage provisions.
Coordination of Benefits
A. This Coordination of Benefits (“COB”) provision applies to This Policy when you or your covered dependent has health care coverage under more than one Policy. “Policy” and “This Policy” are defined below.
B. If this COB provision applies, the order of benefit determination rules should be looked at first. Those rules determine whether the benefits of This Policy are determined before or after those of another policy. The benefits of This Policy:
i) Will not be reduced when, under the order of benefit determination rules, This Policy determines its benefits before another Policy; but
ii) May be reduced when, under the order of benefits determination rules, another policy determines its benefits first.
A. “Policy” is any of these which provides benefits or services for, or because of, medical or dental care or treatment:
i) Policy will include:
1. group insurance and group subscriber contracts;
2. uninsured arrangements of group or group type coverage;
3. group or group type coverage through HMOs and other prepayment, group practice and individual practice policies;
4. group type contracts. Group type contracts are contracts which are not available to the general public and can be obtained and maintained only because of membership in or connection with a particular organization or group. Individually underwritten and issued guaranteed renewable policies would not be considered group type even though purchased through payroll deductions at the premium savings to the Insured since the Insured would have the right to maintain or renew the Policy independently of continued employment with the Policyholder;
5. the medical benefits coverage in group automobile no-fault contracts, and in traditional automobile fault type contracts to the extent that such contracts are Primary Policies; and
6. Medicare or other governmental benefits, except as provided in subsection (ii)(7) below. That part of the definition of Policy may be limited to the hospital, medical and surgical benefits of the governmental program.
ii) Policy will not include:
1. individual or family insurance contracts;
2. individual or family subscriber contracts;
3. individual or family coverage through Health Maintenance Organizations (HMOs):
4. individual or family coverage under other prepayment, group practice and individual practice policies;
5. group or group type hospital indemnity benefits of $100.00 per day or less;
6. school Accident type coverages; these contracts cover grammar, high school and college student for Accidents only, including athletic injuries, either on a 24 hour basis or on a to and from school basis; and
7. state policy under Medicaid, and will not include a law or policy when, by law, its benefits are in excess of those of any private insurance policy or other non-government policy. Each contract or other arrangement for coverage under (i) or (ii) is a separate policy. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate policy.
B. “This Policy” is this Policy.
C. “Primary Policy/Secondary Policy” – The order of benefit determination rules state whether This Policy is a Primary Policy or a Secondary Policy as to another policy covering the person.When This Policy is a Primary Policy, its benefits are determined before those of the other policy and without considering the other policy’s benefits. When This Policy is a Secondary Policy, its benefits are determined after those of the other policy and may be reduced because of the other policy’s benefit.When there are more than two policies covering the person, This Policy may be a Primary Policy as to one or more other policies, and may be a Secondary Policy as to a different policy or policies.
D. “Allowable Expense” means a necessary, reasonable and customary item of expense for health care; when the item of expense is covered at least in part by one or more policies covering the person for whom the claim is made. When a policy provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an Allowable Expense and a benefit paid.
The following are examples of expenses or services that are not allowable expenses:
i) If an Insured Person is confined in a private hospital room, the difference between the cost of a semi-private room in the hospital and the private room (unless the patient’s stay in a private room is medically necessary in terms of generally accepted medical practice, or one of the policies routinely provides coverage for hospital private rooms) is not an allowable expense.
ii) If a person is covered by two or more plans that compute his/her benefit payments on the basis of usual and customary fees, any amount in excess of the highest of the usual and customary fees for a specific benefit is not an allowable expense.
iii) If a person is covered by two or more plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable expense.
iv) If a person is covered by one plan that calculates its benefits or services on the basis of usual and customary fees and another plan that provides its benefits or services on the basis of negotiated fees, the primary policy’s payment arrangements will be the allowable expense for all policies.
v) The amount a benefit is reduced by the primary policy because an Insured Person does not comply with the policy provisions. Examples of these provisions are second surgical opinions, pre-certification of admissions or services and preferred provider arrangements.
E. “Claim Determination Period” means a calendar year. However, it does not include any part of a year during which a person has no coverage under This Policy, or any part of a year before the date this COB provision or a similar provision takes effect.
3. Order of Benefit Determination Rules
A. General – When there is a basis for a claim under This Policy and another policy, This Policy is a Secondary Policy which has its benefits determined after those of the other policy, unless:
i) The other policy has rules coordinating its benefits with those of This Policy; and
ii) Both those rules and This Policy rules, in Sub-section B below, require that This Policy’s benefits be determined before those of the other policy.
B. Rules – This Policy determines its order of benefits using the first of the following rules which applies.
i) Non-Dependent – the benefits of the policy which covers the person as a subscriber (that is, other than as a dependent) are determined before those of the policy which covers the person as a dependent.
ii) Dependent Child/Parents not Separated or Divorced – except as stated in paragraph B(iii) below, when This Policy and another policy cover the same child as a dependent of different persons, called “parents”:
1. The benefits of the policy of the parent whose birthday falls earlier in a year are determined before those of the policy of the parent whose birthday falls later in that year, but
2. If both parents have the same birthday, the benefits of the policy which covered one parent longer are determined before those of the policy which covered the other parent for a shorter period of time. However, if the other policy does not have the rule described in (1) immediately above, but instead has a rule based upon the gender of the parent, and if, as a result, the policies do not agree on the order of benefits, the rule in the other policy will determine the order of benefits.
iii) Dependent Child/Separated or Divorced Parents – If two or more policies cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order:
1. First, the policy of the parent with custody of the child;
2. Then, the policy of the spouse of the parent with the custody of the child; and
3. Finally, the policy of the parent not having custody of the child. However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Policy of that parent has actual knowledge of those terms, the benefits of that Policy are determined first. The Policy of the other parent will be the Secondary Policy. This paragraph does not apply with respect to any Claim Determination Period or Policy Year during which any benefits are actually paid or provided before the entity has that actual knowledge.
iv) Joint Custody – If the specific terms of a court decree state that the parents will share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the policies covering the child will follow the order of benefit determination rules outlined in paragraph B(ii).
v) Active/Inactive Member – The benefits of a policy which covers a person as an employee who is neither laid off nor retired are determined before those of a policy which covers that person as a laid off Member. The same applies if a person is a dependent of a person covered as a Member. If the other policy does not have this rule, and if, as a result, the policies do not agree on the order of benefits, this Rule (v) is ignored.
vi) Continuation Coverage – If a person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another policy, the following will be the order of benefit determination:
1. First, the benefits of a policy covering the person as a Member or subscriber (or as that person’s dependent);
2. Second, the benefits under the continuation coverage. If the other policy does not have the rule described above, and if, as a result, the policies do not agree on the order of benefits, this rule is ignored.
vii) Longer/Shorter Length of Coverage – If none of the above rules determines the order of benefits, the benefits of the policy which covered a Member or subscriber longer are determined before those of the Policy which covered that person for the shorter term.
4. Effect on the Benefits of This Policy
A. When this Section Applies – this Section 4 applies when, in accordance with Section 3, “Order of Benefit Determination Rules”, This Policy is a Secondary Policy as to one or more other policies. In that event, the benefits of This Policy may be reduced under this section. Such other policy or policies are referred to as “the other policies” in 4(b) immediately below.
B. Reduction in This Policy’s Benefits – The benefits of This Policy will be reduced when the sum of:
i) The benefits that would be payable for the Allowable Expenses under This Policy in the absence of this COB provision; and
ii) The benefits that would be payable for the Allowable Expenses under the other policies, in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made; exceeds those Allowable Expenses in a Claim Determination Period. In that case, the benefits of This Policy will be reduced so that they and the benefits payable under the other policies do not total more than those Allowable Expenses. When the benefits of This Policy are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of This Policy.
“you”, “your” and “yours” refer to the Insured. “we”, “us” and “our” refer to the company providing this coverage. In addition, certain words and phrases are defined as follows:
ACCIDENT means a sudden, unexpected, unintended and external event, which causes Injury.
ACCOMMODATION means any establishment used for the purpose of temporary overnight lodging for which a fee is paid and reservations are required.
ACTUAL CASH VALUE means purchase price less depreciation.
ADOPTION PROCEEDING means any mandatory meeting as a condition of law requiring the attendance of the prospective adoptive parent(s) with the intent to create a legal parent-child relationship.
AIR FLIGHT ACCIDENT means an Accident that occurs while a passenger in or on, boarding or alighting from an aircraft of a regularly scheduled airline or an air charter company that is licensed to carry passengers for hire.
BAGGAGE means luggage, personal possessions and travel documents taken by you on your Trip.
BUSINESS EQUIPMENT means physical property owned by you used in trade, business, or for the production of income, taken by you for use on your Trip, excluding software, data, and any items defined as Baggage within this Policy.
COMMON CARRIER means any land, water or air conveyance, with scheduled and published departure and arrival times, operated under a license for the transportation of passengers for hire, not including taxicabs or rented, leased or privately owned motor vehicles.
DOMESTIC PARTNER means a person who is at least eighteen years of age and you can show: (1) evidence of financial interdependence, such as joint bank accounts or credit cards, jointly owned property, and mutual life insurance or pension beneficiary designations; (2) evidence of cohabitation for at least the previous 6 months; and (3) an affidavit of domestic partnership if recognized by the jurisdiction within which you reside.
ELECTIVE TREATMENT AND PROCEDURES means any medical treatment or surgical procedure that is not medically necessary including any service, treatment, or supplies that are deemed by the federal, or a state or local government authority, or by us to be research or experimental or that is not recognized as a generally accepted medical practice.
FAMILY MEMBER means
• Traveling Companion(s)
• Insured’s or Traveling Companion’s Spouse
• Insured’s, Traveling Companion’s or Spouse’s:
• grandparent, great-grandparent, grandchild or greatgrandchild;
• step-parent, step-child or step-sibling;
• son-in-law or daughter-in-law;
• brother-in-law or sister-in-law;
• aunt or uncle;
• niece or nephew;
• legal guardian;
• foster child or legal ward.
FINANCIAL INSOLVENCY means the total cessation or complete suspension of operations due to insolvency, with or without the filing of a bankruptcy petition, whether voluntary or involuntary, by a tour operator, cruise line, airline, rental car company, hotel, condominium, railroad, motor coach company, or other supplier of travel services which is duly licensed in the jurisdiction of operation other than the entity or the person, organization, agency or firm from whom you directly purchased or paid for your Trip, provided the Financial Insolvency occurs more than 14 days following your effective date for the Trip Cancellation Benefits. There is no coverage for the total cessation or complete suspension of operations for losses caused by fraud or negligent misrepresentation by the supplier of travel services.
HOME means your primary or secondary residence.
HOSPITAL means an institution that meets all of the following requirements: (1) it must be operated according to law; (2) it must give 24-hour medical care, diagnosis and treatment to the sick or injured on an inpatient basis; (3) it must provide diagnostic and surgical facilities supervised by Physicians; (4) registered nurses must be on 24-hour call or duty; and (5) the care must be given either on the hospital’s premises or in facilities available to the hospital on a prearranged basis. A Hospital is not: a rest, convalescent, extended care, rehabilitation or other nursing facility; a facility which primarily treats mental illness, alcoholism, or drug addiction (or any ward, wing or other section of the hospital used for such purposes); or a facility which provides hospice care (or wing, ward or other section of a hospital used for such purposes).
HOST means the person with whom you are scheduled to share pre-arranged overnight accommodations in his/her principal place of residence.
INJURY means bodily harm caused by an Accident which requires the in-person examination and treatment by a Physician. The Injury must be the direct cause of loss and must be independent of all other causes and must not be caused by, or result from, Sickness.
INSURED means the person named on the application form, for whom the required premium payment is received and a Trip is scheduled.
INSURER means Generali US Branch. Generali US Branch operates under the following names: In California: Generali Assicurazioni Generali S.p.A. (U.S. Branch) In Virginia: The General Insurance Company of Trieste and Venice – U.S. Branch
OTHER VALID AND COLLECTIBLE HEALTH INSURANCE means any policy or contract which provides for payment of medical expenses incurred because of Physician, nurse, dental or Hospital care or treatment; or the performance of surgery or administration of anesthesia. The policy or contract providing such benefits includes, but is not limited to, group or blanket insurance policies; service plan contracts; employee benefit plans; or any plan arranged through an employer, labor union, employee benefit association or trustee; or any group plan created or administered by the federal or a state or local government or its agencies. In the event any other group plan provides for benefits in the form of services in lieu of monetary payment, the usual and customary value of each service rendered will be considered a covered expense.
PAYMENTS means the cash, check, credit card amounts paid for your Trip, including but not limited to reservation costs, timeshare exchange fees, ownership dues (not including the cost of your vacation ownership) and maintenance fees. Payments also include the units of currency purchased from a travel or vacation club to be used as valuation in payment for arrangements and to access travel arrangements (including but not limited to points, credits or other values). Such currency units must be used in accordance with travel or vacation club rules and must be for travel under a membership or for a deeded real estate product. In the case of currency units, we reserve the right to replace, restore or replenish your currency units in lieu of reimbursement.
PHYSICIAN means a person licensed as a medical doctor by the jurisdiction in which he/she is resident to practice the healing arts. He/she must be practicing within the scope of his/her license for the service or treatment given and may not be you, a Traveling Companion, or a Family Member of yours.
PORT OF CALL means a city or town on a waterway with facilities for loading and unloading cargo where a ship is scheduled to dock, not including the ports of embarkation and disembarkation.
PRE-EXISTING CONDITION means a Sickness or Injury during the 180-day period immediately prior to your effective date for which you or your Traveling Companion: (1) received, or received a recommendation for, a diagnostic test, examination, or medical treatment; or (2) took or received a prescription for drugs or medicine. Item 2 of this definition does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription throughout the 180-day period before coverage is effective under this Policy.
PROGRAM ADMINISTRATOR means CSA Travel Protection
QUARANTINE means the enforced isolation of you or your Traveling Companion, for the purpose of preventing the spread of illness, disease or pests.
SCHEDULED DEPARTURE DATE means the date on which you are originally scheduled to leave on your Trip.
SCHEDULED RETURN DATE means the date on which you are originally scheduled to return to the point where the Trip started or to a different final destination.
SCHEDULED TRIP DEPARTURE CITY means the city where the scheduled Trip on which you are to participate originates.
SERVICE ANIMAL means any guide dog, signal dog, or other animal individually trained to work or perform tasks for the benefit of an individual with a disability, including, but not limited to, guiding persons with impaired vision, alerting persons with impaired hearing to intruders or sounds, providing animal protection or rescue work, pulling a wheelchair, or fetching dropped items.
SICKNESS means an illness or disease of the body that requires in-person examination and treatment by a Physician.
SPOUSE means your legally wed husband/wife or Domestic Partner as defined by this Policy.
TERRORIST ACT means an act of violence, other than civil disorder or riot, (that is not an act of war, declared or undeclared) that results in loss of life or major damage to property, by any person acting on behalf of or in connection with any organization which is generally recognized as having the intent to overthrow or influence the control of any government.
TRAVELING COMPANION means a person who, during the Trip, will accompany you in the same accommodations.
TRIP means: A period of round-trip travel at least 100 miles away from Home to your designated vacation destination associated with the purchase of this insurance, excluding regular commuting and local travel; the purpose of the Trip is business or pleasure and is not to obtain health care or treatment of any kind; the Trip has defined departure and return dates specified when you purchase the coverage; the Trip does not exceed 365 days in length; or A period of one-way travel that starts in the U.S. or Canada (except U.S. citizens may begin their Trip outside the U.S., if returning to the U.S.); the purpose of the Trip is business or pleasure and is not to obtain health care or treatment of any kind; the Trip has defined departure and arrival dates and defined departure and arrival places specified when you apply; and the Trip does not exceed 31 days in length.
UNINHABITABLE means the dwelling is not suitable for human occupancy in accordance with local public safety guidelines.
USUAL AND CUSTOMARY CHARGE means those charges: (1) for necessary treatment and services that are reasonable for the treatment of cases of comparable severity and nature; (2) that do not exceed the usual level of charges for similar treatment, supplies or medical services in the locality where the expense is incurred; and (3) does not include charges that would not have been made if no insurance existed. In no event will Usual and Customary Charges exceed the actual amount charged.
1. We will not pay for any loss under this Policy, caused by, or resulting from:
a) your or your Traveling Companion’s suicide, attempted suicide, or intentionally self-inflicted injury;
b) mental, nervous, or psychological disorders of you or your Traveling Companion;
c) you or your Traveling Companion being under the influence of drugs or intoxicants, unless prescribed by a Physician;
d) normal pregnancy or resulting childbirth, elective abortion or fertility treatment of you or your Traveling Companion;
e) your or your Traveling Companion’s participation as a professional in athletics;
f) your or your Traveling Companion’s participation in organized amateur and interscholastic athletic or sports competition or events;
g) you or your Traveling Companion riding or driving in any motor competition;
h) you or your Traveling Companion operating or learning to operate any aircraft, as pilot or crew;
i) you or your Traveling Companion mountain climbing, bungee cord jumping, skydiving, parachuting, hang gliding, parasailing, caving, extreme skiing, heli-skiing, skiing outside marked trails, boxing, full contact martial arts, scuba diving below 120 feet (40 meters) or without a dive master, or travel on any air-supported device, other than on a regularly scheduled airline or air charter company;
j) your or your Traveling Companion’s Elective Treatment and Procedures;
k) your or your Traveling Companion’s medical treatment during or arising from a Trip undertaken for the purpose or intent of securing medical treatment;
l) declared or undeclared war, or any act of war;
m) nuclear reaction, radiation or radioactive contamination;
n) any unlawful acts, committed by you or your Traveling Companion;
o) any amount paid or payable under any Worker’s Compensation, disability benefit or similar law;
p) a loss or damage caused by detention, confiscation or destruction by customs or any governmental authority, regulation or prohibition;
q) travel restrictions imposed for a certain area by governmental authority;
r) Financial Insolvency of the person, organization or firm from whom you directly purchased or paid for your Trip, Financial Insolvency which occurred, or for which a petition for bankruptcy was filed by a travel supplier, before your effective date for the Trip Cancellation Benefits, or Financial Insolvency which occurs within 14 days following your effective date for the Trip Cancellation Benefits;
s) a loss that results from an illness, disease, or other condition, event or circumstance which occurs at a time when coverage is not in effect for you;
t) any issue or event that could have been reasonably foreseen or expected when you purchased the coverage.
The following exclusion applies to the Medical and Dental Coverage and Emergency Assistance and Transportation coverages:
We will not pay for loss caused by or resulting from service in the armed forces of any country.
The following exclusion applies to the Medical and Dental, Trip Cancellation, Trip Interruption, and Travel Delay coverages:
We will not pay for loss or expense caused by or incurred resulting from a Pre-Existing Condition, as defined in the Definitions section, including death that results there from.
The following exclusion applies to the Emergency Assistance and Transportation, Medical and Dental, Trip Cancellation, Trip Interruption, and Rental Car Damage coverages:
a) civil disorder
The following exclusion applies to the Emergency Assistance and Transportation, Medical and Dental, Trip Cancellation, Trip Interruption, Missed Connection, Travel Delay, and Rental Car Damage coverages:
a) failure of any tour operator, Common Carrier, or other travel supplier, person or agency to provide the bargained-for travel arrangements other than Financial Insolvency.