“Accident” or “Accidental” shall mean an event, independent of Illness or self inflicted means, which is the direct cause of bodily Injury to You.
“Assistance Company” means the service provider with which the Company has contracted to coordinate and deliver Emergency travel assistance, medical evacuation, and repatriation.
“Benefit Period” means the allowable time period You have from the date of Injury or onset of Illness to receive Treatment for a covered Injury or Illness.
“Child” shall mean Your step-child or a Child under Your legal guardianship, but only if such Child depends on Your support and maintenance and lives with You in a parent-Child relationship. The term Child does not include a foster Child who is eligible for benefits provided by a governmental program or law, unless required by the law of the State.
“Coinsurance” shall mean the percentage amount of eligible Covered Expenses, after the Deductible, which is Your responsibility and must be paid by You. The Coinsurance amount is stated in Your Schedule of Coverage and Service, under each stated benefit.
“Common Carrier” shall mean any land, sea, and/or air conveyance operating under a valid license for the transportation of passenger for hire.
“Cosmetic Surgery” means the surgical alteration of tissue primarily for the improvement of appearance rather than to improve or restore bodily functions.
“Covered Expenses” shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment; due to Illness or Injury; prescribed, performed or ordered by a Physician; Reasonable and Customary charges; incurred while insured under the policy; and which do not exceed the maximum limits shown in Your Schedule of Coverage and Service, under each stated benefit.
“Deductible” shall mean the amount of eligible Covered Expenses which is Your responsibility and must be paid by You before benefits under the policy are payable by the Company. The Deductible amount is stated in Your Schedule of Coverage and Service, under each stated benefit.
“Dentist” shall mean a legally licensed doctor of dental Surgery; dental medicine or dental science. A dental hygienist who works within the scope of his/her license, under the supervision of a Dentist, is a covered practitioner.
“Dependent” shall mean the spouse who is legally married to You; Your unmarried Child from until his/her 19th birthday; or Your unmarried Child who is over 18 years old but not older than 25 years old and is enrolled as a full-time student at an accredited school or college and is not employed on a full-time basis and is dependent on You for his/her support and maintenance. The age limits that apply to Dependent Child(ren) will not apply to Your Child who remains dependent on You for support and maintenance because he or she becomes incapable of working due to a physical handicap or retardation which occurs: before reaching the age limit; and while insured under the policy or any prior plan, provided such Child was insured on the date of termination of the prior plan.
“Disablement” as used with respect to medical expenses shall mean an Illness or an Accidental bodily Injury necessitating medical Treatment by a Physician as defined in the policy.
“Effective Date” shall mean the date Your coverage under the policy begins. The Effective Date Is the later of the following: 1. The Date the Company receives a completed enrollment form and premium for the Individual Coverage Term or 2. The moment You exit Your Home Country airspace.
“Emergency” shall mean a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing Your life or limb in danger if medical attention is not provided within 24 hours.
“Experimental/Investigational” means all services or supplies associated with: 1) Treatment or diagnostic evaluation which is not generally and widely accepted in the practice of medicine in the United States of America or which does not have evidence of effectiveness documented in peer reviewed articles in medical journals published in the United States. For the Treatment or diagnostic evaluation to be considered effective such articles should indicate that it is more effective than others available: or if less effective than other available Treatments or diagnostic evaluations, is safer or less costly; 2) A drug which does not have FDA marketing approval; 3) A medical device which does not have FDA marketing approval; or has FDA approval under 21 CFR 807.81, but does not have evidence of effectiveness for the proposed use documented in peer reviewed articles in medical journals published in the United States. For the devise to be considered effective, such articles should indicate that it is more effective than other available devices for the proposed use; or if less effective than other available devices, or is safer or less costly. The company will make the final determination as to whether a service or supply is Experimental/Investigational.
“Family Member” shall mean Your spouse, parent, sibling or Child.
“Home Country” shall mean the country where You have Your fixed and permanent home and principal establishment.
“Hospital” as used in the policy shall mean except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and Treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision means a place that 1.) is legally operated for the purpose of providing medical care and Treatment to sick or injured persons for which a charge is made that You are legally obligated to pay in the absence of insurance 2.) provides such care and Treatment in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) operates under the supervision of a staff of one or more Doctors. Hospital also means a place that is accredited as a hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Health Care Organizations (JCAHO). Hospital does not mean: a convalescent, nursing, or rest home or facility, or a home for the aged; a place mainly providing custodial, educational, or rehabilitative care; or a facility mainly used for the Treatment of drug addicts or alcoholics.
“Host Country” shall mean any country other than the country where You have Your true, fixed and permanent home and principal establishment.
“Illness” wherever used in the policy shall mean Sickness or disease of any kind and Disablement covered by the policy.
“Incident” or “Occurrence” shall mean all Illnesses that exist simultaneously and which are due to the same or related causes are considered to be one Incident. Further, if an Illness is due to causes which are the same as or related to the causes of a prior Illness, the Illness will be deemed to be a continuation of the prior Illness and not a separate Incident. All Injuries due to the same Accident shall be deemed to be one Incident.
“Individual Coverage Term” means the period of time beginning when You have been enrolled for coverage under the policy and for whom the required premium has been paid and ending on the termination date as described in the Schedule of Coverage and Service.
“Injury” wherever used in the policy means Accidental bodily Injury or injuries caused by an Accident. The Injury must be the direct cause of the Loss, independent of disease, bodily infirmity or other causes. Any Loss due to Injury must begin after the Effective Date of the policy.
“Inpatient” means You are confined in an institution and is charged for room and board.
“Insured Person(s)” shall mean a person who has applied for coverage and is named on the Confirmation of Benefits and for whom the Company has accepted premium. Insured Persons are also referred to as You and Your.
“Land/Sea Arrangements” means land and or sea arrangements made by Travel Supplier
“Loss” in reference to quadriplegia, paraplegia, hemiplegia, and uniplegia, shall mean the complete and irreversible paralysis of such limbs and with regard to hands and feet, actual severance through and above the wrist or ankle joints, and with regard to eyes, entire irrecoverable Loss of sight and with regard to thumb and index finger, actual severance through or above the joint that meets the finger at the palm. Loss in reference to other coverages shall mean injury or damage sustained by You in consequence of happening of one or more of the accidents against which the Company has undertaken to indemnify You.
“Maximum Benefit” means the largest total amount of Covered Expenses that the Company will pay for You.
“Medically Necessary” or “Medical Necessity” shall mean services and supplies received by You that are determined by the Company to be: 1) appropriate and necessary for the symptoms, diagnosis, or direct care and Treatment of Your medical conditions; 2) within the standards the organized medical community deems good medical practice for Your condition; 3) not provided solely for educational purposes or primarily for Your convenience, Your Physician or another Service Provider or person; 4) not Experimental/Investigational or unproven, as recognized by the organized medical community, or which are used for any type of research program or protocol; and 5) not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate Treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services You are receiving or the severity of Your condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe, order, recommend, or approve a service, supply, or level of care does not, of itself, make such Treatment Medically Necessary or make the charge of a Covered Expense under the policy.
“Medicine” or “Medications” shall mean the drugs prescribed or dispensed to You, by a licensed Physician, as a result of a Covered Expense. Medicine or Medication shall mean the generic equivalent of a drug, or if the generic equivalent is not available, the brand name drug.
“Mental and Nervous Disorder” shall mean any condition or disease listed in the most recent edition of the International Classification of Diseases as a mental disorder, which exhibits clinically significant behavioral or psychological disorder marked by a pronounced deviation from a normal healthy state and associated with a present painful symptom or impairment in one or more important areas of functioning. This disease must not be merely an expectable response to a particular stimulus. Mental Illness does not mean learning disabilities, attitudinal disorders or disciplinary problems.
“Outpatient” shall mean You receive care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for an Illness or Injury, but who is confined and is not charged for room and board.
“Permanent Residence” shall mean the country where You have Your fixed and permanent home and principal establishment, and to which You have the intention of returning.
“Physician” as used in the policy shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed, however, such definition will exclude chiropractors and physiotherapists.
“Pre-existing Condition” for the purposes of the policy shall mean 1) a condition that would have caused a person to seek medical advice, diagnosis, care or Treatment during the 180 days prior to the Effective Date of coverage under the policy; 2) a condition for which medical advice, diagnosis, care or Treatment was recommended or received during the 180 days prior to the Effective Date of coverage under the policy. Sicknesses or conditions are not considered pre-existing if the Sickness or condition for which prescribed drugs or medicine is taken remains controlled without any change in the required prescription.
“Prior Plan” shall mean the coverage provided on a group or individual basis by an insurance policy benefit plan or service plan that was terminated on the day before Your Effective Date of coverage under that policy and replaced by this policy.
“Reasonable and Customary” shall mean the maximum amount that the Company determines is Reasonable and Customary for Covered Expenses You receive up to but not to exceed charges actually billed. The Company’s determination considers: 1) amounts charged by other Service Providers for the same or similar service in the locality were received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; 2) any usual medical circumstances requiring additional time, skill or experience; and 3) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale. For a Service Provider who has a reimbursement agreement, the Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company. If a Service Provider accepts as full payment an amount less than the negotiated rate under a reimbursement agreement, the lesser amount will be the maximum Reasonable and Customary charge. The Reasonable and Customary charge is reduced by any penalties for which a Service Provider is responsible as a result of its agreement with the Company.
“Registered Nurse” shall mean a graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other jurisdictional authority, and who is legally entitled to place the letters
“R.N.” after his or her name.
“Relative”shall mean Your spouse, parent, sibling, Child, grandparent, grandchild, step-parent, step-child, step- sibling, in-laws (parent, son, daughter, brother and sister), aunt, uncle,niece, nephew, legal guardian, ward, or cousin.
“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.
“Service Provider” shall mean a Hospital, convalescent/skilled nursing facility, ambulatory surgical center, psychiatric Hospital, community mental health center, residential Treatment facility, psychiatric Treatment facility, alcohol or drug dependency Treatment center, birthing center, Physician, Dentist, chiropractor, licensed medical practitioner, Registered Nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves.
“Sickness” means Illness or disease contracted and causing Loss commencing while coverage under the policy is in force as You whose Sickness is the basis of claim. Any complication or any condition arising out of a Sickness for which You are being treated or has received Treatment will be considered as part of the original Sickness.
“Surgery” shall mean an invasive diagnostic procedure; or the Treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
“Terrorism” is defined as the systematic or planned use of violence, fear, or threat of violence in order to intimidate a population or government, especially as a means of coercion or to obtain a granting of any demand. Terrorism does not include an event in any country or location where the United States government has issued a travel advisory that has been in effect within the 6 months prior to Your date of arrival. Terrorism does not include an event that occurs after a travel advisory has been issued after Your arrival date, and where You unreasonably fail or refuse to depart the location.
“Terrorist Attack” means an incident deemed an act of terrorism by the United States Government.
“Travel Supplier” means tour operator, cruise line, hotel etc. who has made the land and/or sea arrangements.
“Treatment” means a specific in-office or Hospital physical examination of, care rendered to You.
“Trip” means any trip taken during the Individual Coverage Term. Maximum Trip duration is 6 months. Coverage is available for persons under age eighty (80).
“Unexpected” means not anticipated or expected and occurring after the effective date of the Policy.