Co-Insurance is the percentage of Eligible Expenses, after the deductible, which is the responsibility of the insured.
Plan pays 100% after deductible
Co-Insurance is the percentage of Eligible Expenses, after the deductible, which is the responsibility of the insured.
Plan pays 100% after deductible.
GENERAL DEFINITIONS – Throughout this document, when capitalized, certain words and phrases are defined as follows:
Accident means a sudden, unexpected, unintended, specific event that occurs at an identifiable time and place, but shall also include exposure resulting from a mishap to a conveyance in which You are traveling.
Accidental Injury means Bodily Injury caused by an Accident (of external origin) being the direct and independent cause in the Loss and that 1) requires a physical examination and medical treatment by a Physician and 2) commences while Your coverage is in effect.
Actual Cash Value means the lesser of the replacement cost and the purchase price less depreciation.
Bodily Contact Sports means any sport where the objective is to physically render an opponent unable to continue with the competition such as boxing and full contact karate.
Bodily Injury means identifiable physical injury that is caused by an Accident and is independent of disease or bodily infirmity.
Certificate of Insurance means this document, and any endorsements, riders or amendments that will attach during the period of coverage.
Checked Baggage means a piece of baggage that accompanies You for which a claim check has been issued to You by a Common Carrier.
Common Carrier means any land, sea, and/or air conveyance operating under a valid license for the transportation of passengers for hire. Taxis and limousines are not Common Carriers as defined herein.
Company means Nationwide Mutual Insurance Company.
Confirmation of Benefits means the document that outlines Your benefits and Maximum Benefit amounts.
Covered Expenses means expenses incurred by You that are for Medically Necessary care or treatment; due to Sickness or Bodily Injury; prescribed, performed or ordered by a Physician; Reasonable and Customary Charges incurred while insured under this Certificate; and that do not exceed the Maximum Benefit limits shown in the Confirmation of Benefits, under each stated benefit.
Deductible means the amount of expenses for covered services and supplies that must be incurred by You before specified benefits become payable.
Domestic Partner means a person with whom You reside and can show evidence of cohabitation (including the shared responsibility for basic living expenses) for at least the previous six (6) months and has an affidavit of domestic partnership, if recognized by the jurisdiction within which You reside.
Economy Fare means the lowest published rate for a round trip economy ticket.
Effective Date means 12:01 A.M. local time, at Your location, on the day after the required premium for such coverage is received by the Company or its authorized representative.
Extreme Sports means an athletic pursuit that involves a high degree of danger or risk.
Family Member means Your legal or common law spouse, parent, legal guardian, step-parent, grandparent, parents-in-law, grandchild, natural or adopted child, step-child, children-in-law, brother, sister, step-brother, step-sister, brother-in-law, sister-in-law, aunt, uncle, niece or nephew, Domestic Partner who reside in the United States, Canada or Mexico.
Home Country means the country where You have Your true, fixed and permanent home and principal establishment.
Hospital means a facility that:
a) holds a valid license if it is required by the law;
b) operates primarily for the care and treatment of sick or injured persons as in-patients;
c) has a staff of one or more Physicians available at all times;
d) provides twenty-four (24) hour nursing service and has at least one registered professional nurse on duty or call;
e) has organized diagnostic and surgical facilities, either on the premises or in facilities available to the hospital on a pre-arranged basis; and
f) is not, except incidentally, a clinic, nursing home, rest home, drug or physical rehabilitation facility or convalescent home for the aged, or similar institution.
Insured means the person who enrolled for coverage and whose premium was paid under the Policy.
Land/Sea Arrangements means pre-paid land and/or sea arrangements made by the Travel Supplier.
Loss means Bodily Injury, Sickness or damage sustained by You, while coverage is in effect, in consequence of happening of one or more of the occurrences against which the Company has undertaken to indemnify You.
Maximum Benefit means the largest total amount that the Company will pay under any one benefit for You, as shown on the Confirmation of Benefits.
Medically Necessary means a service or supply that: a) is recommended by the attending Physician; b) is appropriate and consistent with the diagnosis in accord with accepted standards of community practice; c) could not have been omitted without adversely affecting Your condition or quality of medical care; d) is delivered at the most appropriate level of care and not primarily for the sake of convenience; and e) is not considered experimental unless coverage for experimental services or supplies is required by law.
Mountaineering means 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.
Parachuting means an activity involving the breaking of a free fall from an airplane using a parachute.
Physician means a licensed practitioner of medical, surgical or dental services, acting within the scope of his/her license. The treating Physician may not be You, a Traveling Companion or a Family Member.
Policy means the Group Master Policy including the application and any endorsements, riders or amendments that will attach during the period of coverage.
Reasonable and Customary Charges means charges commonly used by Physicians in the locality in which care is furnished.
Scheduled Departure Date means the date on which You are originally scheduled to leave on the Trip.
Scheduled Return Date means the date on which You are originally scheduled to return to the point of origin or to a different final destination.
Sickness means an illness or disease of the body that: 1) requires a physical examination and medical treatment by a Physician and 2) commences while Your coverage is in effect. An illness or disease of the body that begins prior to the Effective Date of coverage is not a Sickness as defined herein and is not covered by this Certificate unless it suddenly worsens or becomes acute after the Effective Date.
Sound Natural Teeth means teeth that are whole or properly restored and are without impairment, periodontal or other conditions and are not in need of the treatment provided for any reason other than an Accidental Injury. For purposes of this Certificate, teeth previously restored with a crown, inlay, onlay, or porcelain restoration or treated by endodontics, except amalgam or composite resin fillings, are not considered Sound Natural Teeth.
Strike means any unannounced labor disagreement that interferes with the normal departure and arrival of a Common Carrier.
Terrorist Incident means an incident deemed a terrorist act by the United States Government that causes property damage and/or loss of life.
Travel Arrangements means: (a) transportation; (b) accommodations; and © other specified services arranged by the Travel Supplier for the Trip.
Travel Supplier means tour operator, Participating Organization, Cruise line, airline, hotel, travel agency, etc. who has made the land, air and/or sea arrangements.
Trip means a trip or class of trips outside Your Home Country as described on the Confirmation of Benefits.
Unforeseen means not anticipated or expected and occurring after the Effective Date of Your coverage.
You or Your refers to the Insured.
LIMITATIONS AND EXCLUSIONS
The following exclusions apply to Accidental Death & Dismemberment, Accident Medical Expense, Sickness Medical Expense and Trip Interruption:
Loss caused by or resulting from:
1. suicide, attempted suicide or any intentionally self-inflicted injury while sane or insane, unless results in the death of a non-traveling Family Member;
2. intentionally self-inflicted injuries;
3. war, invasion, acts of foreign enemies, hostilities between nations (whether declared or not), civil war;
4. participation in any military maneuver or training exercise;
5. piloting or learning to pilot or acting as a member of the crew of any aircraft;
6. participation as a professional in athletics;
7. being under the influence of drugs or intoxicants, unless prescribed and used in accordance with
the instructions provided by a Physician;
8. commission or the attempt to commit a dishonest, fraudulent or criminal act;
9. participating in Bodily Contact Sports; skydiving; hang-gliding; Parachuting; Mountaineering; any race; bungee cord jumping; speed contest (speed contest shall not include any of the regatta races;); spelunking or caving; heliskiing; extreme skiing; Extreme Sports;
10. dental treatment except as a result of an injury to Sound Natural Teeth within twelve (12) months of the injury;
11. pregnancy and childbirth (except for complications of pregnancy);
12. curtailment or delayed return for other than covered reasons;
13. traveling for the purpose of securing medical treatment;
14. services not shown as covered;
15. directly or indirectly, the actual, alleged or threatened discharge, dispersal, seepage, migration, escape, release or exposure to any hazardous biological, chemical, nuclear radioactive material, gas, matter or contamination;
16. care or treatment that is not Medically Necessary;
17. care or treatment for which compensation is payable under Worker’s Compensation Law, any Occupational Disease law; the 4800 Time Benefit plan or similar legislation;
18. care or treatment that is payable under any other Insurance policy;
19. Accidental Injury or Sickness when traveling against the advice of a Physician;
20. cosmetic surgery except for: reconstructive surgery incidental to or following surgery for trauma, or infection or other covered disease of the part of the body reconstructed, or to treat a congenital malformation of a child.
21. canyoning or canyoneering (traveling in canyons using a variety of techniques that may include walking, scrambling,climbing, jumping, abseiling and/or swimming);
22. any expenses incurred in the Home Country.
The following exclusions apply to Baggage/Personal Effects:
The Company will not provide benefits for any Loss or damage to:
2. automobiles and automobile equipment;
3. boats or other vehicles or conveyances;
8. bicycles (except when checked as baggage with a Common Carrier);
9. household effects and furnishing;
10. antiques and collector’s items;;
11. eye glasses, sunglasses or contact lenses;
12. artificial teeth and dental bridges;
13. hearing aids;
14. artificial limbs and other prosthetic devices;
15. prescribed medications;
16. keys, cash, stamps, securities and non-travel documents;
18. credit cards;
19. professional or occupational equipment or property, whether or not electronic business equipment;
20. cell phones, computer hardware or software;
21. sporting equipment if loss or damage results from the use thereof;
22. musical instruments;
23. retainers and orthodontic devices.
Any Loss caused by or resulting from the following is excluded:
1. breakage of brittle or fragile articles;
2. wear and tear or gradual deterioration;
3. insects or vermin;
4. inherent vice or damage while the article is actually being worked upon or processed;
5. confiscation or expropriation by order of any government;
6. war or any act of war whether declared or not;
7. theft or pilferage while left unattended in any vehicle;
8. mysterious disappearance;
9. property illegally acquired, kept, stored or transported;
10. insurrection or rebellion;
11. imprudent action or omission;
12. property shipped as freight or shipped prior to the Scheduled Departure Date.
EMERGENCY MEDICAL EVACUATION & REPATRIATION EXCLUSIONS AND LIMITATIONS:
• You must not be disabled from travel at the time You pay the premium and intend to travel;
• Suicide, attempted suicide, or any intentionally self-inflicted injuries while sane or insane;
• War, invasion, acts of foreign enemies, hostilities between nations (whether declared or not), civil war;
• Participation in any military maneuver or training exercise;
• Piloting or learning to pilot or acting as a member of the crew of any aircraft;
• While or as a result of riding in any device for aerial navigation;;
• Mental or nervous disorders, unless hospitalized;
• Participation as a professional in athletics;
• Semi-professional or inter-scholastic team sports;
• Being under the influence of drugs or intoxicants, unless prescribed by a physician;
• Commission or the attempt to commit a criminal act;
• Participating in bodily contact sports; skydiving; hang gliding; parachuting; mountaineering; any race; bungee jumping; speed contest; (speed contest shall not include any of the regatta races); spelunking or caving; heli-skiing; extreme skiing;
• Pregnancy and childbirth (except for complications of pregnancy);
• Hernia unless resulting from an Accidental Injury that occurs during Your Trip;
• Traveling for the purpose of securing medical treatment;
• Directly or indirectly, the actual, alleged or threatened discharge, dispersal, seepage, migration, escape, release or exposure to any hazardous biological, chemical, nuclear radioactive material, gas, matter or contamination;
• Directly or indirectly 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, regardless of any other cause or event contributing concurrently or in any other sequence thereto;
• Care or treatment which is not medically necessary;
• Accidental Injury or Sickness when traveling against the advice of a Physician;
• Cosmetic surgery except for: reconstructive surgery incidental to or following surgery for trauma, or infection or other covered disease of the part of the body reconstructed, or to treat a congenital malformation of a child;