$50,000 per person
Provides reimbursement for the cost of treatment associated with a medical emergency incurred while traveling.
Subject to the Limits set forth in the Schedule of Benefits and Limits, and subject to the Conditions and Restrictions contained in this provision, Underwriters will pay the following expenses incurred while this insurance is in effect.
Conditions and Restrictions:
1. The Member must be in compliance with all conditions and provisions of the insurance; and
2. Underwriters will provide benefits only when the Illness or Injury giving rise to the expense are covered under this Insurance; and
3. Any eligible travel arrangements, excluding Emergency Local Ambulance, must be approved in advance and coordinated by Underwriters; for which the Member understands that the timeliness of arrangements can be affected by circumstances which are not within the control of Underwriters such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other Acts of God. The Member agrees to hold Underwriters harmless and Underwriters shall not be held liable for any delays that are not within their direct and immediate control; and
4. As specified below.
ELIGIBLE MEDICAL EXPENSES
1. Charges made by a Hospital for:
a. Daily room and board and nursing services not to exceed the average semi-private room rate; and
b Daily room and board and nursing services in Intensive Care Unit; and
c. Use of operating, treatment or recovery room; and
d. Services and supplies which are routinely provided by the Hospital to persons for use while Inpatients; and
e. Emergency treatment of an Injury, even if Hospital confinement is not required; and
f. Emergency treatment of an Illness; subject to emergency room co-pay as outlined in the Schedule of Benefits and Limits. ER co-payment is waived when the Member is directly admitted to the Hospital as Inpatient for further treatment of that Illness.
2. For Surgery at an Outpatient surgical facility, including services and supplies.
3. For charges made by a Physician for professional services, including Surgery. Charges for an assistant surgeon are covered up to 20% of the Usual, Reasonable and Customary charge of the primary surgeon, but standby availability will not be deemed to be a professional service and therefore is not covered hereunder.
4. For dressings, sutures, casts or other supplies which are Medically Necessary and administered by or under the
supervision of a Physician, but excluding nebulizers, oxygen tanks, diabetic supplies, other supplies for use or application at home, and all devices or supplies for repeat use at home, except Durable Medical Equipment as herein defined.
5. For diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included).
6. For artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof.
7. For reconstructive Surgery when the Surgery is directly related to Surgery which is covered hereunder.
8. For hemodialysis and the charges by the Hospital for processing and administration of blood or blood components but not the cost of the actual blood or blood components.
9. For oxygen and other gasses and their administration by or under the supervision of a Physician.
10. For anesthetics and their administration by a Physician.
11. For drugs which require prescription by a Physician for treatment of a covered Injury or Illness, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of 60 days per prescription.
12. For care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital.
13. Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from an acute care Hospital and only in lieu of Medically Necessary Inpatient hospitalization.
14. Emergency Local Ambulance transport necessarily incurred in connection with Injury or Illness resulting in Inpatient hospitalization.
15. Emergency Dental Treatment and Dental Surgery necessary to restore or replace sound natural teeth lost or damaged in an Accident which was covered under this insurance.
16. Emergency Dental Treatment necessary to resolve Acute On set of Pain, provided treatment is obtained within 24 hours of the Acute Onset of Pain.
17. Medically Necessary rental of Durable Medical Equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.
18. Physical Therapy if prescribed by a Physician who is not affiliated with the Physical Therapy practice, necessarily incurred to continue recovery from a covered Injury or Illness.
19. Injury or Illness resulting from participation in sports or athletic activities not otherwise excluded under this insurance.