$250,000 per person
Emergency Medical can reimburse the costs to treat a medical emergency during a trip.
Services and Supplies Provided by a Hospital
For any eligible condition not excluded under this Certificate other than for Mental, Emotional or Functional Nervous Conditions or Disorders, and Substance 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.
Note: When outside the United States, this benefit will provide coverage for private rooms if that is all that is available or if the choice is between a ward or a more than two person room and a private room.
2. Outpatient services and supplies including those in connection with outpatient surgery performed at an Ambulatory Surgical Center.
3. Emergency Hospitalization and Emergency Medical Care provided in a Hospital emergency room, including professional air and ground ambulance services for transport to and from the Hospital for such Emergency Hospitalization and Emergency Medical Care.
Payment of Inpatient Covered Expenses are subject to these conditions:
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 Covered Person’s Illness or Injury
Note: No benefits will be provided for personal items, such as TV, radio, guest trays, etc.
Note: Injuries and Illnesses resulting from Terrorism and pandemics are covered as any other Injury or Illness provided all of the following conditions are met:
1. The Covered Person had no direct or indirect involvement in the Terrorist Activity;
2. The Terrorist Activity or pandemic is not in a country or location where the United States movement has issued a travel warning that has been in effect with the three (3) months prior to the Covered Person’s date of arrival
3. The Covered Person has not unreasonably failed or refused to depart a country or location following the date a warning to leave that country or location is issued by the United State Government.
Professional and Other Services
The Insurer will pay Covered Expenses not excluded under this Certificate for:
1. Services of a Physician.
2. Services of an anesthesiologist or an anesthetist.
3. Outpatient diagnostic radiology and laboratory services.
4. Surgical implants.
5. The first pair of contact lenses or the first pair of eyeglasses when required as a result of a covered eye surgery.
6. Self-Administered injectable drugs.
7. Syringes when dispensed with self-administered injectable drugs (except insulin).
8. Blood transfusions, including blood processing and the cost of un-replaced blood and blood products.
9. Rental or purchase of Durable Medical Equipment and/or supplies that are all of the following:
a) ordered by a Physician;
b) of no further use when medical need ends;
c) usable only by the patient;
d) not primarily for the Covered Person’s comfort or hygiene;
e) not for environmental control;
f) not for exercise; and
g) manufactured specifically for medical use.
Note: Medical equipment and supplies must meet all of the above guidelines in order to be eligible for benefits under this Certificate of Coverage. The fact that a Physician prescribes or orders equipment or supplies does not necessarily qualify the equipment or supply for payment. The Insurer determines whether the item meets these conditions. Rental charges that exceed the reasonable purchase price of the equipment are not covered.
The following ambulance services are covered under this Certificate of Coverage:
1. Base charge, mileage and non-reusable supplies of a licensed ambulance company for ground or air service for transportation to and from a Hospital.
2. Monitoring, electrocardiograms (EKGs or ECGs), cardiac defibrillation, cardiopulmonary resuscitation (CPR) and administration of oxygen and intravenous (IV) solutions in connection with ambulance service. An appropriate licensed person must render the services.
The Insurer pays as stated in the Benefit Overview Matrix.
Complications of Pregnancy
Complications of Pregnancy are covered under this Certificate of Coverage as any other medical condition. Benefits for complications of pregnancy shall be provided for all Covered Persons.
Dental Care for an Accidental Injury
Benefits are payable for dental care for an Accidental Injury to natural teeth that occurs while the Covered Person is covered under this Plan, subject to the following:
1. services must be received during the six months following the date of Injury;
2. no benefits are available to replace or repair existing dental prostheses even if damaged in an eligible Accidental Injury; and
3. damage to natural teeth due to chewing or biting is not considered an Accidental Injury under this Certificate of Coverage.
In addition, the Certificate of Coverage provides benefits for up to three days of Inpatient Hospital services when a Hospital stay is ordered by a Physician and a Dentist for dental treatment required due to an unrelated medical condition. The Insurer determines whether the dental treatment could have been safely provided in another setting. Hospital stays for the purpose of administering general anesthesia are not considered Medically Necessary. The Insurer pays as stated in the Benefit Overview Matrix.
Dental Care for Relief of Pain
Benefits are payable for dental care for Relief of Pain to the teeth that occurs while the Covered Person is covered under this Certificate of Coverage. Services must be received while covered during the Trip Coverage Period. The Insurer pays as stated in the Benefit Overview Matrix.
Physical and/or Occupational Therapy/Medicine, Including spinal manipulations and other specified therapies including acupuncture
Charges incurred for the following rehabilitative therapies, if prescribed by a Physician to restore function loss due to an illness or injury covered under this Certificate of Coverage: physical, occupational, chelation, massage, hearing and cardiac/pulmonary therapy. Additionally, coverage shall also be provided for chiropractic care delivered by a currently licensed chiropractor acting within the scope of his or her practice. The coverage shall include initial diagnosis and clinically appropriate and Medically Necessary services and supplies required to treat the diagnosed disorder, subject to the terms and conditions of the Certificate of Coverage; Acupuncture that treats a covered illness or injury provided by Doctor of Acupuncture.
Therapies excluded under this coverage include, but are not limited to: speech therapy, vocational rehabilitation, behavioral training, gym or swim therapy, dance therapy, marital counseling, legal or financial counseling, biofeedback, neuro-feedback, hypnosis, sleep therapy, employment counseling, back to school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities, developmental delays or intellectual disabilities.
These Covered Expenses are Limited as stated in the Benefit Overview Matrix.
Benefits for Claims resulting from downhill skiing and scuba diving
The Insurer will pay Covered Expenses for claims resulting from downhill (alpine) skiing. It will also pay Covered Expenses resulting from scuba diving provided that the diver is certified by the Professional Association of Diving Instructors (PADI) or the National Association of Underwater Instructors (NAUI), or equivalent governing body, or provided that he/she is diving under the supervision of a certified instructor. These Covered Expenses are Limited as stated in the Benefit Overview Matrix.