In the Certificate, “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:
Accidental Injury means an accidental bodily Injury sustained by an Insured Person which is the direct cause of a loss independent of disease, bodily infirmity, or any other cause.
Age means the Insured Person’s attained age.
Ambulatory Surgical Center is a freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It also must meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.
Certificate of Coverage is the document issued to each Eligible Participant outlining the benefits under the group Policy.
Coinsurance is the percentage of Covered Expenses the Insured Person is responsible for paying (after the applicable Deductible is satisfied. Coinsurance does not include charges for services that are not Covered Services or charges in excess of Covered Expenses. These charges are the Insured Person’s responsibility and are not included in the Coinsurance calculation.
Complications of Pregnancy are conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from the pregnancy, but are adversely affected by the pregnancy, including, but not limited to acute nephritis, nephrosis, cardiac decompression, missed abortion, pre-eclampsia, intrauterine fetal growth retardation, and similar medical and surgical conditions of comparable severity. Complications of Pregnancy also include termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible. Complications of Pregnancy do not include elective abortion, elective cesarean section, false labor, occasional spotting, morning sickness, physician prescribed rest during the period of pregnancy, hyperemesis gravidarium, and similar conditions associated with the management of a difficult pregnancy not constituting a distinct complication of pregnancy.
A Continuing Hospital Confinement means consecutive days of in-hospital service received as an inpatient, or successive confinements for the same diagnosis, when discharge from and readmission to the Hospital occurs within 24 hours.
Cosmetic and Reconstructive Surgery. Cosmetic Surgery is performed to change the appearance of otherwise normal looking characteristics or features of the patient’s body. A physical feature or characteristic is normal looking when the average person would consider that feature or characteristic to be within the range of usual variations of normal human appearance. Reconstructive Surgery is surgery to correct the appearance of abnormal looking features or characteristics of the body caused by birth defects, Injury, tumors, or infection. A feature or characteristic of the body is abnormal looking when an average person would consider it to be outside the range of general variations of normal human appearance. Note: Cosmetic Surgery does not become Reconstructive Surgery because of psychological or psychiatric reasons.
The Coverage Period Maximum Benefit is the maximum amount of benefits available to each Insured Person during the person’s Coverage Period (Period of Insurance and/or Trip Coverage Period). All benefits furnished are subject to these maximum amounts.
Covered Expenses are the expenses incurred for Covered Services. Covered Expenses for Covered Services will not exceed Reasonable Charges. In addition, Covered Expenses may be limited by other specific maximums described in this Plan under section IV, How the Plan Works and section V, Benefits: What the Plan Pays. Covered Expenses are subject to applicable Deductibles, penalties and other benefit limits. An expense is incurred on the date the Insured Person receives the service or supply.
Covered Services are Medically Necessary services or supplies that are listed in the benefit sections of this Plan, and for which the Insured Person is entitled to receive benefits.
Custodial Care is care provided primarily to meet the Insured Person’s personal needs. This includes help in walking, bathing, or dressing. It also includes preparing food or special diets, feeding, administration of medicine that is usually self-administered, or any other care that does not require continuing services of a medical professional.
Deductible means the amount of Covered Expenses the Insured Person must pay for Covered Services before benefits are available to him/her under this Plan. The Period of Insurance Deductible is the amount of Covered Expenses the Eligible Participant must pay for each Insured Person before any benefits are available regardless of provider type.
Dental Prostheses are dentures, crowns, caps, bridges, clasps, habit appliances, and partials.
The Effective Date of the Policy is the date that the Group’s Policy became active with the Insurer.
The Effective Date of Coverage is the date on which coverage under this Plan begins for the Eligible Participant and any other Insured Person.
Eligible Dependent (See ‘Eligibility Rules’ in Section II of this Plan).
Eligible Participant (See ‘Eligibility Rules’ in Section II of this Plan).
Emergency Hospitalization and Emergency Medical Care means hospitalization or medical care that is provided for an Injury or a Sickness condition manifesting itself by acute symptoms of sufficient severity including without limitation sudden and unexpected severe pain for which the absence of immediate medical attention could reasonably result in:
1. Permanently placing the Insured Person’s health in jeopardy, or
2. Causing other serious medical consequences; or
3. Causing serious impairment to bodily functions; or
4. Causing serious and permanent dysfunction of any bodily organ or part.
Previously diagnosed chronic conditions in which subacute symptoms have existed over a period of time shall not be included in this definition of a medical emergency, unless symptoms suddenly become so severe that immediate medical aid is required.
Experimental or Investigative Procedure is treatment, a device or prescription medication which is recommended by a Physician, but is not considered by the medical community as a whole to be safe and effective for the condition for which the treatment, device or prescription medication is being used, including any treatment, procedure, facility, equipment, drugs, drug usage, devices, or supplies not recognized as accepted medical practice; and any of those items requiring federal or other governmental agency approval not received at the time services are rendered. The Insurer will make the final determination as to what is Experimental or Investigative.
Foreign Country is a country other than the Insured Person’s Home Country.
Foreign Country Provider is any institutional or professional provider of medical or psychiatric treatment or care who practices in a country outside the United States of America. A Foreign Country Provider may also be a supplier of medical equipment, drugs, or medications. HTH provides Insured Persons with access to a database of Foreign Country Providers.
A Full Time Student is a student enrolled at an accredited college, university, or trade school participating in the Federally Guaranteed Student Loan Program. The student must be currently attending classes, carrying at least 12 units per term.
Group refers to the business entity to which the Insurer has issued the Policy.
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. coverage of Medicare services under a federal contract;
4. Medicare Supplement and Medicare Select policies regulated in accordance with federal law;
5. long-term care, dental care, or vision care coverages;
6. coverage provided by a single service health maintenance organization;
7. insurance coverage issued as a supplement to liability insurance;
8. insurance coverage arising out of a workers’ compensation system or similar statutory system;
9. automobile medical payment insurance coverage;
10. 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;
11. hospital confinement indemnity coverage; or
12. reinsurance contracts issued on a stop-loss, quota share, or similar basis.
Home Country means the Insured Person’s country of domicile named on the enrollment form or the roster, as applicable. However, the Home Country of an Eligible Dependent who is a child is the same as that of the Eligible Participant.
A Hospital is a facility which provides diagnosis, treatment and care of persons who need acute inpatient hospital care under the supervision of Physicians. It must:
1. be licensed as a hospital and operated pursuant to law; and
2. be primarily engaged in providing or operating (either on its premises or in facilities available to the hospital on a contractual prearranged basis and under the supervision of a staff of one or more duly licensed physicians) medical, diagnostic, and major surgery facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; and
3. provide 24 hour nursing service by or under the supervision of a registered graduate professional nurse (R.N.); and
4. be an institution which maintains and operates a minimum of five beds; and
5. have X-ray and laboratory facilities either on the premises or available on a contractual prearranged basis; and
6. maintain permanent medical history records.
This definition excludes convalescent homes, convalescent facilities, rest facilities, nursing facilities, or homes or facilities primarily for the aged, those primarily affording custodial care or educational care.
HTH means Highway to Health HTH Worldwide). This is the entity that provides the Insured Person with access to online databases of travel, health, and security information and online information about physicians and other medical providers.
HTH International Healthcare Community consists of physicians, dentists, mental health professionals, other allied health professionals, hospitals, health systems and medical practices countries throughout the world, all dedicated to providing high quality medical care to international travelers, employees and students. The providers are accessed through the HTH online database or through the HTH customer services.
An Illness is a sickness, disease, or condition of an Insured Person which first manifests itself after the Insured Person’s Effective Date.
Injury (See Accidental Injury).
Insurance Coverage Area is the primary geographical region in which coverage is provided to the Insured Person.
Insured Dependents are members of the Eligible Participant’s family who are eligible and have been accepted by the Insurer under this Plan.
Insured Participant is the Eligible Participant whose application has been accepted by the Insurer for coverage under this Plan.
Insured Person means both the Insured Participant and all Insured Dependents who are covered under this Plan.
The Insurer means HM Life Insurance Company, a nationally licensed and regulated insurance company. Insurer also includes a third party administrator with which the Insurer has contracted to perform certain of its duties on its behalf. The Group and the Insured Participant will be notified of the use of an administrator.
Investigative Procedures (See Experimental/Investigational).
Medically Necessary services or supplies are those that the Insurer determines to be all of the following:
1. Appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition.
2. Provided for the diagnosis or direct care and treatment of the medical condition.
3. Within standards of good medical practice within the organized community.
4. Not primarily for the patient’s, the Physician’s, or another provider’s convenience.
5. The most appropriate supply or level of service that can safely be provided. For Hospital stays, this means acute care as an inpatient is necessary due to the kind of services the Insured Person is receiving or the severity of the Insured Person’s condition and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting.
The fact that a Physician may prescribe, authorize, or direct a service does not of itself make it Medically Necessary or covered by the Policy.
A Newborn is a recently born infant within 31 days of birth.
Office Visit means a visit by the Insured Person, who is the patient, to the office of a Physician during which one or more of only the following three specific services are provided:
1. History (gathering of information on an Illness or Injury).
3. Medical Decision Making (the Physician’s diagnosis and Plan of treatment).
This does not include other services (e.g. X-rays or lab services) even if performed on the same day.
Other Plan is an insurance plan other than this plan that provides medical, repatriation of remains, and/or medical evacuation benefits for the Insured Person.
Out-of-Pocket Maximum is the amount of Coinsurance each Insured Person incurs for Covered Expenses in a Period of Insurance. The Out-of-Pocket does not include any amounts in excess of Covered Expenses, the Deductible, any penalties, or any amounts in excess of other benefit limits of this Plan.
The Period of Insurance Maximum Benefit is the maximum amount of benefits available to each Insured Person during the person’s Period of Coverage. All benefits furnished are subject to this maximum amount.
Physical and/or Occupational Therapy/Medicine is the therapeutic use of physical agents other than drugs. It comprises the use of physical, chemical and other properties of heat, light, water, electricity, massage, exercise, spinal manipulation and radiation.
A Physician means a physician licensed to practice medicine or any other practitioner who is licensed and recognized as a provider of health care services in the state and/or country the Insured Person resides or is treated; and provides services covered by the Plan that are within the scope of his/her licensure.
Plan is the set of benefits described in the Certificate of Coverage booklet and in the amendments to this booklet (if any). This Plan is subject to the terms and conditions of the Policy the Insurer has issued to the Group. If changes are made to the Policy or Plan, an amendment or revised booklet will be issued to the Group for distribution to each Insured Participant affected by the change.
Policy is the Group Policy the Insurer has issued to the Group.
Pre-existing Condition means a medical condition for which medical advice, diagnosis, care, or treatment was recommended or received during the 6 months immediately preceding the Insured Person’s Effective Date of Coverage.
A Primary Plan is a Group Health Benefit Plan, an individual health benefit plan, or a governmental health plan (including Medicare) designed to be the first payor of claims for an Insured Person prior to the responsibility of this Plan.
A Reasonable Charge, as determined by the Insurer, is the amount the Insurer will consider a Covered Expense with respect to charges made by a Physician, facility or other supplier for Covered Services. In determining whether a charge is Reasonable, the Insurer will consider all of the following factors:
1. The actual charge.
2. Specialty training, work value factors, practice costs, regional geographic factors and inflation factors.
3. The amount charged for the same or comparable services or supplies in the same region or in other parts of the country.
4. Consideration of new procedures, services or supplies in comparison to commonly used procedures, services or supplies.
5. The Average Wholesale Price for Pharmaceuticals.
Reconstructive Surgery (See Cosmetic and Reconstructive Surgery).
Special Care Units are special areas of a Hospital that have highly skilled personnel and special equipment for acute conditions that require constant treatment and observation.
Totally Disabled or Total Disability means:
1. As applied to an Insured Participant, any period of time during the Insured Participant’s lifetime in which he/she is unable to perform substantially all the duties required by his/her usual occupation, provided the disability commences within twelve (12) months from the date the disabling condition occurred;
2. As applied to a Dependent, not being able to perform the normal activities of a like person of the same age and sex.
The patient must be under the care of a Physician.
The Trip Coverage Period Maximum Benefit is the maximum amount of benefits available to each Insured Person during the person’s Trip Coverage Period. All benefits furnished are subject to this maximum amount.
U.S. means the United States of America.
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.
BAGGAGE means luggage, personal possessions and travel documents taken by you on the Covered Trip.
COMMON CARRIER means any land, water or air conveyance operated under a license for the transportation of passengers for hire, not including taxicabs or rented, leased or privately owned motor vehicles.
COVERED TRIP means: 1) A period of round-trip travel away from Home to a destination outside your city of residence; 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 the Insured enrolls; the trip does not exceed 365 days; or 2) 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 the Insured applies; and the trip does not exceed 365 days in length.
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 they 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.
EXOTIC VEHICLE includes Alfa Romeo, Aston Martin, Auburn, Avanti, Bentley, Bertone, BMC/Leyland, BMW M Series, Bradley, Bricklin, Citroen, Clenet, Corvette, Cosworth, DeLorean, Excalibre, Ferrari, Fiat, Iso, Jaguar, Jensen Healy, Lamborghini, Lancia, Lotus, Maserati, Mercedes Benz, MG, Morgan, Pantera, Panther, Pininfarina, Porche, Rolls Royce, Rover, Stutz, Sterling, Triumph, TVR, and Yugo. You must contact CSA Travel Protection at (866) 655-3058 before renting to obtain confirmation that the vehicle is covered.
FAMILY MEMBER includes your or your Traveling Companion’s dependent, spouse, child, spouse’s child, son/daughter-in-law, parent(s), sibling(s), brother/sister, grandparent(s), grandchild, step-brother/sister, stepparent( s), parent(s)-in-law, brother/sister-in-law, aunt, uncle, niece, nephew, guardian, Domestic Partner, foster child, or 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 state(s) of operation other than the entity or the person, organization, agency or firm from whom you directly purchased or paid for your Covered 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 which 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).
INJURY means bodily harm caused by an Accident which: 1) occurs while your coverage is in effect under the plan; and 2) requires 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 an eligible person who arranges a Covered Trip, and pays any required plan payment.
INSURER means Stonebridge Casualty Insurance Company.
OTHER COVERED EVENTS means only the following unforeseeable events or their consequences which occur while coverage is in effect under this Policy:
1. Common Carrier delays resulting from inclement weather, or mechanical breakdown of the aircraft, ship or boat or motor coach on which you are scheduled to travel, or organized labor strikes that affect public transportation;
2. arrangements canceled by an airline, cruise line, motor coach company, or tour operator, resulting from inclement weather, mechanical breakdown of the aircraft, ship or boat or motor coach on which the Insured is scheduled to travel, or organized labor strikes that affect public transportation.
Items 1 and 2 above are subject to the following conditions:
a) the scheduled carrier connecting times must meet airline required legal minimum connect times; and
b) the scheduled time between arrival at the Scheduled Trip Departure City and the scheduled trip departure must be 2 hours or longer.
3. arrangements canceled by a tour operator, cruise line, airline, rental car company, hotel, condominium, railroad, motor coach company, or other supplier of travel services, resulting from Financial Insolvency;
Item 3 above is subject to your plan payment being received prior to/or within 24 hours of final payment for your Covered Trip;
4. a change in plans by you, a Family Member traveling with you, or Traveling Companion resulting from one of the following events which occurs while coverage is in effect under this Policy:
a) being directly involved in a documented traffic accident while en route to departure;
b) being hijacked, quarantined (except as a result of a pandemic or epidemic), required to serve on a jury, or required by a court order to appear as a witness in a legal action, provided you, a Family Member traveling with you or a Traveling Companion is not 1) A party to the legal action, or 2) Appearing as a law enforcement officer;
c) your Home made Uninhabitable by fire, flood, volcano, earthquake, hurricane or other natural disaster;
d) your Accommodation at your destination made Uninhabitable by fire, flood, volcano, earthquake, hurricane or other natural disaster;
e) mandatory evacuation or public official evacuation advisements where there is no mandatory evacuation issued by local government authorities at your destination due to adverse weather or natural disaster. In order to cancel or interrupt your Covered Trip, you must have 4 days or 50% of your total Covered Trip length or less remaining on your Covered Trip at the time the mandatory evacuation ends;
f) being called into active military service to provide aid or relief in the event of a natural disaster;
g) a documented theft of passports or visas;
h) a transfer of employment of 250 miles or more;
i) a Terrorist Act which occurs in your departure city or in a city which is a scheduled destination for your Covered Trip, provided the Terrorist Act occurs within 7 days of the Scheduled Departure Date for your Covered Trip;
j) your involuntary termination of employment or layoff, which occurs more than 15 days after your effective date of coverage and was not under your control. You must have been continuously employed with the same employer for 1 year prior to the termination or layoff. This provision is not applicable to temporary employment, independent contractors or self-employed persons;
k) you or your Traveling Companion is required to work during the Covered Trip. A notarized written statement by a company officer and/or the Human Resources department demonstrating revocation of previously approved time off will be required;
l) you or your Traveling Companion’s place of employment is rendered unsuitable for business due to burglary, fire, flood, volcano, earthquake, hurricane, or other natural disaster and you or your Traveling Companion is required to work as a result;
m) you or your Traveling Companion is directly involved in the merger of his or her employer or the acquisition of his or her employer by another company.
OTHER VALID AND COLLECTIBLE GROUP INSURANCE means any group 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 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.
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.
PRE-EXISTING CONDITION means an illness, disease, or other condition during the 180 day period immediately prior to your effective date for which you or your Traveling Companion or Family Member is scheduled or booked to travel with you:
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.
SCHEDULED DEPARTURE DATE means the date on which you are originally scheduled to leave on your Covered Trip.
SCHEDULED RETURN DATE means the date on which you are originally scheduled to return to the point where the Covered 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.
SICKNESS means an illness or disease of the body which requires examination and treatment by a Physician.
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 whose name(s) appear(s) with you on the same Covered Trip arrangement and who, during the Covered Trip, will accompany you.
UNINHABITABLE means the dwelling is not suitable for human occupancy in accordance with local public safety guidelines.
USUAL AND CUSTOMARY CHARGE means those charges for necessary treatment and services that are reasonable for the treatment of cases of comparable severity and nature. This will be derived from the mean charge based on the experience in a related area of the service delivered and the MDR (MedicalData Research) schedule of fees valued at the 100th percentile and the Anesthesia Relative Value Guide.