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.
Accident or Accidental shall mean an event, independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.
Administrator shall mean Seven Corners, Inc.
Airworthiness Certificate or Airworthy Certificate shall mean the “Standard” Airworthiness Certificate issued by the Federal Aviation Agency of the United States or its foreign equivalent issued by the government authority having jurisdiction over civil aviation in the country of its registry.
Benefit Period shall mean the one hundred and eighty (180) days following the onset of an Eligible Accident, Injury or Illness in which to receive Medically Necessary Covered Expenses. If Your plan terminates during Your Benefit Period, You will still be eligible to receive Treatment so long as the Treatment is within Your Benefit Period and outside Your Home Country (except as provided under the Home Country Coverage).
Coinsurance shall mean the percentage amount of Covered Expenses, after the Deductible, which is Your responsibility to pay.
Common Carrier shall mean any land, sea, and/or air conveyance operating under a valid license for the transportation of passengers for hire.
Congenital shall mean a physical abnormality or condition that is present at birth, whether inherited or caused by the environment.
Covered Expense shall mean “Eligible Benefit”.
Deductible shall mean the amount of Covered Expenses which is Your responsibility to pay before benefits under the plan are payable.
Disablement (as used with respect to medical expenses) shall mean an Illness or an Accidental bodily Injury necessitating medical Treatment by a Physician.
Eligible Benefit(s) shall mean benefits payable by the Underwriter to reimburse 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 this program and which do not exceed the maximum benefit.
Eligible Dependent Child shall mean Your unmarried children over fourteen (14) days and under nineteen (19) years of age.
Eligible Spouse shall mean Your legal spouse.
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 device 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 devises, or is safer or less costly. The Underwriter will make the final determination as to whether a service or supply is Experimental/Investigational.
Home Country shall mean the country where You have Your true, fixed and permanent home and principal establishment.
Hospital shall mean a place that 1) Is legally operated for the purpose of providing medical care and Treatment(s) to Sick or Injured persons for which a charge is made that the Insured Person(s) is legally obligated to pay in the absence of insurance; 2) Provides such care and Treatment(s) 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 sta ff of one or more Physician(s). 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: (1) A Convalescent, nursing, or rest home or facility, or a home for the aged; (2) A place mainly providing Custodial, Educational, or Rehabilitative Care; or (3) A facility mainly used for the Treatment(s) of drug addicts or alcoholics.
Host Country shall mean any country other than the country where an Insured Person has his or her true, fixed and permanent home and principal establishment.
Illness shall mean sickness or disease of any kind contracted and commencing while this plan is in force as to the Insured Person whose Illness is the basis of claim. Any complication or any condition arising out of an Illness for which the Insured Person is being treated or has received Treatment will be considered as part of the original Illness.
Injury shall mean Accidental bodily Injury or injuries caused by an Accident which occurs after the Effective Date of this policy. The Injury must be the direct cause of the loss, independent of disease or bodily infirmity.
Inpatient shall mean if You are confined in an institution and are charged for room and board.
Insured or Insured Person shall mean a person eligible for benefits under the Policy who has applied for coverage and is named on the application and for whom the Underwriter has accepted premium.
Intensive Care shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Medically Necessary shall mean services and supplies received while insured that are determined by the Underwriter to be: 1) appropriate and necessary for the symptoms, diagnosis, or direct care and Treatment of the Insured Person’s medical conditions; 2) within the standards the organized medical community deems good medical practice for the Insured Person’s condition; 3) not primarily for the convenience of the Insured Person, the Insured Person’s 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 the Insured Person is receiving or the severity of the Insured Person’s 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 this Policy.
Mountaineering shall mean 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.
Outpatient shall mean if 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.
Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.
Period of Coverage or Policy Period shall mean the Period of Coverage issued by the Underwriter to the Insured Person, typically beginning with the Effective Date and ending with the Expiration Date or the date coverage is renewed by the Underwriter.
Physician(s) or Surgeon shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery(ies) in accordance with the laws of the jurisdiction where such professional services are performed.
Pre-existing Conditions shall mean any Injury or Illness which meets the following criteria (unless covered under the Unexpected Recurrence of a Pre-existing Condition benefit): 1) a condition that would have caused a person to seek medical advice, diagnosis, care or Treatment during the thirty-six (36)* months prior to the Effective Date of coverage under this policy; 2) a condition for which medical advice, diagnosis, care or Treatment was recommended or received during the thirty-six (36)* months prior to the Effective Date of coverage under this policy. *For U.S. and Canadian citizens traveling outside the United States, the Pre-existing Condition period is twelve (12) months instead of thirty-six (36) months. Reasonable and Customary shall mean the maximum amount that the plan determines is Reasonable and Customary for Covered Expenses You receive, up to but not to exceed charges actually billed. The determination considers:1) Amounts charged by other Service Providers for the same or similar service in the locality where 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 included but not limited to, a resource based relative value scale.
Relative shall mean 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 of the Insured Person.
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, nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Underwriter approves.
Sound Natural Tooth is a tooth that is whole or properly restored; is without impairment, periodontal or other conditions; is not more susceptible to Injury than a virgin tooth, and is not in need of the Treatment provided for any reason other than Accidental Injury. A tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or Treated by endodontics is not a Sound Natural Tooth.
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.
Traveling Companion shall mean spouse, parent, sibling, child, grandparent, grandchild, step-parent, step-child, step-sibling, in-laws (parent son, daughter, brother, or sister), aunt, uncle, niece, nephew, legal guardian, ward, or business partner of the Insured Person.
Treatment means a specific in-office or Hospital physical examination of or care rendered to You, consultation, diagnostic procedures and services, Surgery, medical services and supplies including medication prescribed or provided by a Service Provider.
Underwriter shall mean Certain Underwriters at Lloyds, London.
You or Your shall mean the Primary Insured Person and the Primary Insured’s Spouse or Dependent.
No Benefit shall be payable for Accident Medical, Sickness Medical, In-Hospital Indemnity, Unexpected Recurrence of a Pre-existing Condition, Dental, Emergency Medical Evacuation/Repatriation,Return of Mortal Remains, Return of Minor Child(ren), Emergency Medical Reunion, as the result of:
1. Pre-existing Conditions which are excluded under this policy. This means that any claims for Pre-existing Conditions will not be covered for the duration of this policy. This exclusion does not apply to Emergency Evacuation/Repatriation or Return of Mortal Remains. Note: If You are a U.S. or Canadian citizen this exclusion is waived up to the maximum stated in the Schedule of Benefits for Eligible Medical Expenses incurred while traveling outside the United States, if resulting from a sudden, unexpected recurrence of a Pre-existing Condition. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the Effective Date of coverage and is subject to the chosen Deductible and Coinsurance. Any exclusion specifically listed below in 2 through 43 will not receive benefits from this waiver.
2. Injury or Illness which is not presented to the Underwriter for payment within ninety (90) days of receiving Treatment;
3. Charges for Treatment which is not Medically Necessary;
4. Charges provided at no cost to You;
5. Charges for Treatment which exceeds Reasonable and Customary charges;
6. Charges incurred for Surgery or Treatments which are, Experimental/Investigational, or for research purposes;
7. Services, supplies or Treatment, including any period of Hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
8. Suicide, or any attempt thereof, while sane or self-destruction or any attempt thereof, while sane;
9. War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the Insured Person or the country in, or over, which the act occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the Insured Person whether war be declared with that state or not, Terrorist activity. For the purpose of this Exclusion:
i) Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).
ii) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals.
iii) Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals.
iv) Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals.
v) Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, cause d by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;
10. Injury sustained while participating in professional athletics, including but not limited to the event, games, practice, conditioning and any other activity related to professional athletics.
11. Injury sustained while participating in amateur or interscholastic athletics, including but not limited to the event, games, practice, conditioning and any other activity related to amateur or interscholastic athletics; this exclusion does not apply to non-competitive, recreational or intramural activities. Note: A sponsored and/or organized Amateur or Interscholastic Athletic event includes training camps, team sports, or any formal grouping of people participating in one or multiple events that may/may not require a fee for participation.
12. Routine physicals, immunizations or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a Disablement established by a prior call or attendance of a Physician;
13. Treatment of the temporomandibular joint;
14. Vocational, speech, recreational or music therapy;
15. Services or supplies performed or provided by a Relative of Yours, or anyone who lives with You;
16. Cosmetic or plastic Surgery, except as the result of a covered Accident; for the purposes of this plan, treatment of a deviated nasal septum shall be considered a cosmetic condition;
17. Elective Surgery which can be postponed until You return to Your Home Country, where the objective of the trip is to seek medical advice, Treatment or Surgery;
18. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids;
19. Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eyeglasses or for the fitting thereof, unless caused by Accidental bodily Injury incurred while covered hereunder;
20. Treatment in connection with alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency or use of any drug or narcotic agent;
21. Injury sustained or Disablement due wholly or partly to the Insured being intoxicated as defined and determined by the laws of the state where the Injury occurred; or to the Insured being under the influence of any narcotic, unless administered on the advice of a Physician;
22. Any Mental and Nervous disorders or rest cures;
23. Congenital abnormalities and conditions arising out of or resulting there from;
24. Expenses which are non-medical in nature;
25. Expenses as a result of or in connection with intentionally self-inflicted Injury or Illness;
26. Expenses as a result of or in connection with the commission of a felony offense;
27. Injury sustained while taking part in mountaineering, hang gliding, parachuting, bungee jumping, racing by any animal or motor vehicle or motorcycle,snowmobiling, motorcycle/motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snowboarding (except for recreational downhill and/or cross country snow skiing or snowboarding. No cover provided while skiing/boarding in any violation of applicable laws, rules or regulations, away from prepared and market in-bound territories; and/or against the advice of the local ski school or local authoritative body); and any sport or athletic activity which is undertaken for thrill seeking and exposes the insured to abnormal or extreme risk of injury;
28. Treatment paid for or furnished under any other individual or group policy or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government plan or facility set up for Treatment without any cost to You;
29. Treatment and or diagnosis of venereal disease;
30. Dental care, except as the result of Injury to natural teeth caused by Accident, unless otherwise covered under this plan;
31. Routine Dental Treatment;
32. Pregnancy or Illness resulting from Pregnancy, childbirth, or miscarriage;
33. Miscarriage resulting from Accident;
34. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof;
35. Treatment for human organ tissue transplants and their related treatment;
36. Expenses incurred while in Your Home Country, except as provided under the Home Country Coverage;
37. Expenses incurred during a Hospital emergency visit which is not of an emergency nature;
38. Covered Expenses incurred for which the Trip to the Host Country was undertaken to seek medical treatment for a condition;
39. Covered Expenses incurred during a Trip after Your Physician has limited or restricted travel;
40. This plan does not insure against loss or damage (including death or Injury) and any associated cost or expense resulting directly 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.
41. Sex change operations, or for treatment of sexual dysfunction or sexual inadequacy;
42. Weight reduction programs or the surgical treatment of obesity;
43. Expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), Aids-Related Complex (ARC) or the Human Immunodeficiency Virus (HIV).
No Benefit shall be payable for Accidental Death and Dismemberment as the result of:
1. Suicide or attempt thereof while sane or self-destruction or any attempt thereof while insane;
2. Disease of any kind; Bacterial infections except pyogenic infection which shall occur through an Accidental cut or wound;
3. Hernia of any kind;
4. Injury sustained while You are riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting from, any type of aircraft;
5. Injury sustained while You are riding as a passenger in any aircraft (a) not having a current and valid Airworthy Certificate and (b) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft;
6. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with: (a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war; (b) mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power; © any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence; (d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the “Occurrences”). Any consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed to be consequences for which the Underwriter shall not be liable under this Policy except to the extent that the Insured Person shall prove that such consequence happened independently of the existence of such abnormal conditions;
7. Service in the military, naval or air service of any country;
8. Flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing or endurance tests;
9. Flying in any rocket-propelled aircraft;
10. Flying in any aircraft being used for or in connection with crop dusting or seeding or spraying, firefighting, exploration, pipe or power line inspection, any form of hunting or herding, aerial photography, banner towing or any experimental purpose;
11. Flying in any aircraft which is engaged in any flight which requires a special permit or waiver from the authority having jurisdiction over civil aviation, even though granted;
12. Sickness of any kind;
13. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified Physician or Surgeon;
14. Injury occasioned or occurring while You are committing or attempting to commit a felony or to which a contributing cause was You being engaged in an illegal occupation;
15. While riding or driving in any kind of competition;
16. Pregnancy, childbirth, miscarriage or abortion;
17. This plan does not insure against loss or damage (including death or Injury) and any associated cost or expense resulting directly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act.
For Interruption of Trip, this insurance does not cover: war or any act of war, whether declared or not; participation in a felony, riot or insurrection; participation in contests of speed; a Pre-existing Condition existing prior to the Insured’s departure from their Home Country that has the likelihood of causing death; the Insured Person or Traveling Companion or Traveling Companion’s family making changes to personal plans; having business or contractual obligations; being unable to obtain necessary travel documents (passports, visas, etc.); being detained or having property confiscated by customs authorities; carrier caused delays (including bad weather); prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which the Insured Person purchased their trip arrangements.
For Loss of Checked Baggage, this insurance does not cover: animals; automobiles or automobile equipment; boats; motors; motorcycles; other conveyances or their appurtenances (except bicycles while checked as baggage with a Common Carrier); household furniture; eye-glasses or contact lenses; artificial teeth or dental bridges; hearing aids; prosthetic limbs; musical instruments; money or securities; tickets or documents; or sporting equipment if loss or damage results from the use thereof.