Plan Administrator: WorldTrips | AM Best Rating: A "Excellent" | Underwriter: Lloyd's
Eligibility
U.S. Citizens and Non-U.S. Citizens who are at least 14 days of age are eligible for coverage outside of their home countries, except as provided under home country coverage. U.S. Citizens and residents are not eligible for coverage within the U.S, except as provided under home country coverage or an eligible benefit period. Individuals age 70 to 79 as of the certificate effective date are subject to a $250,000 overall maximum limit or less. Individuals age 80 and over as of the certificate effective date are subject to a $10,000 overall maximum limit.
Certificate Effective Date
Insurance hereunder is effective on the later of:
a. The moment we receive an application and correct premium if the application and payment is made online or by fax; or
b. 12:01am U.S. Eastern Time on the date we receive an application and correct premium if the application and payment is made by mail;
c. The moment you depart from your home country; or
d. 12:01am U.S. Eastern Time on the date requested on the application
Certificate Termination Date
Insurance hereunder terminates on the earlier of:
1. 11:59pm U.S. Eastern Time on the last day of the period for which premium has been paid;
2. 11:59pm U.S. Eastern Time on the date requested on the application; or
3. The moment of arrival upon your return to your home country (unless you have started a benefit period or are eligible for home country coverage).
Benefit Period
While the certificate is in effect, the benefit period does not apply. Upon termination of the certificate, in accordance with this provision, we will pay eligible medical expenses for up to 90 days beginning on the first day of diagnosis or treatment of a covered injury or illness while you are outside your home country. The benefit period applies only to eligible medical expenses related to the injury or illness that began while the certificate was in effect.
In the event you begin a benefit period while the certificate is in effect, and the certificate terminates because you return to your home country, we will pay eligible medical expenses which are incurred in your home country during the benefit period. Home country coverage applies only to eligible medical expenses related to the injury or illness that began while the certificate was in effect.
Incidental Home Country Coverage
U.S. home country: For every three-month period during which you are covered, eligible medical expenses incurred in the U.S. are covered up to a maximum of 15 days.
Non-U.S. home country: For every three-month period during which you are covered, eligible medical expenses incurred in your home country are covered up to a maximum of 30 days.
Any benefit accrued under a single three-month period does not accumulate to another period. Failure to continue your international trip or your return to your home country for the sole purpose of obtaining treatment for an illness or injury that began while traveling shall void any home country coverage provided under the terms of this agreement.
Except for a benefit period, coverage provided under this Master Policy is for a maximum duration of 365 days for non-U.S. citizens or residents whose travel does not include the U.S. or U.S. Territories, and for all other members, the maximum certificate period is 364 days. Any extension is based upon the eligibility rules in force and is solely at our discretion.
Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole option, elect to cancel all members of the same sex, age, class or geographic location, provided we give no less than 30 days advance written notice by mail to your last known address.
Accident means a sudden, unintentional and unexpected occurrence caused by external, visible means and resulting in physical injury to you. The cause or one of the causes of such accident is external to your own body and occurs beyond your control.
Assured means the The Atlas/International Citizen Group Insurance Trust, Hamilton, Bermuda.
Certificate means the document issued to you that provides evidence of benefits payable under the Master Policy and that will confirm the plan type, period of cover, home country, certificate number, special terms and/or conditions, deductible, chosen benefit list, and geographical area of cover.
Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date. The maximum certificate period is 364 days.
Coinsurance means your payment of eligible expenses at the percentage specified in the Schedule of Benefits and Limits.
Custodial Care means that type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist you in performing the activities of daily living. Custodial care also includes non-acute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients.
Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.
Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.
Durable Medical Equipment means a standard basic hospital bed and/or a standard basic wheelchair.
Educational or Rehabilitative Care means care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an illness or injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy.
Emergency means 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.
Extended Care Facility means an institution, or a distinct part of an institution, which is licensed as a hospital, extended care facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a physician and the direct supervision of a registered nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a physician; and provides each patient with active treatment of an illness or injury. Extended care facility does not include a facility primarily for rest, the aged, substance abuse treatment, custodial care, nursing care or for care of mental health disorders or the mentally incompetent.
Home Country means the country where you principally reside and receive regular mail. U.S. Citizens are not eligible for coverage within the U.S., except as provided under home country coverage, regardless of the location of your principal residence.
Home Health Care Agency means a public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing home nursing care under the supervision of a registered nurse, and maintains a daily record on each patient, and provides each patient with a planned program of observation and treatment by a physician.
Home Nursing Care means services provided by a home health care agency and supervised by a registered nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of medically necessary inpatient care in a hospital.
Hospital means an institution which operates as a hospital pursuant to law, and is licensed by the state or country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as inpatients; and provides 24-hour nursing service by registered nurses on duty or call; and has a staff of one or more physicians available at all times; and provides organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, long-term care facility, extended care facility, nursing, rest, custodial care or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment
Illness means a sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. For purposes of this insurance, illness includes Complications of Pregnancy during the first 26 weeks of pregnancy. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.
Injury means an unexpected and unforeseen harm to the body caused by an accident that requires medical treatment.
Inpatient means a patient who occupies a hospital bed for more than 24 hours for medical treatment and whose admission was recommended by a physician, or a patient held for observation in a hospital for at least 12 hours.
Intensive Care Unit means a cardiac care unit or other unit or area of a hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Investigational, Experimental or for Research Purposes means procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current medical practice.
Medically Necessary means a service or supply which is necessary and appropriate for the diagnosis or treatment of an illness or injury based on generally accepted current medical practice as determined by us. A service or supply will not be considered medically necessary if is provided only as a convenience to you or the provider, and/or is not appropriate for your diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment of an illness or injury.
Member means an individual who is covered under this insurance.
Mental Health Disorder means a mental or emotional disease or disorder which generally denotes a disease of the brain with predominant behavioral symptoms; or a disease of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. Mental health disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, and those psychiatric illnesses listed in the current edition of the diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.
Outpatient means a member who receives medically necessary treatment by a physician for injury or illness that does not require overnight stay in a hospital.
Physician means a Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DDM), Doctor of Podiatry (DPM), Doctor of Osteopathy (DO), a licensed Physical Therapist or Physiotherapist, and a Doctor of Psychiatry (Psy.D) and a Doctor of Psychology (Ph.D.). Physician also includes a Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), Nurse Midwife or a Physician Assistant (PA) under the direction of a medical doctor. A physician must be currently licensed by the jurisdiction in which the services are provided, and the services must be within the scope of that license and covered under this Master Policy.
Relative means biological or step parent; biological or step child; current spouse; biological or stepsiblings; or parent, children, or sibling in law.
Routine Physical Exam means and examination of the physical body by a physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition.
Sexually Transmitted Diseases means diseases including but not limited to syphilis, gonorrhea, chlamydiosis, trichomoniasis, genital herpes, and Human Papillomavirus (HPV).
Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency.
Surgery or Surgical Procedure means 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.
Urgent Care Center means a U.S. medical facility separate from a hospital emergency department where ambulatory patients can be treated on a walk-in basis without an appointment and receive immediate, non-routine urgent care for an injury or illness presented on an episodic basis.
Usual, Reasonable and Customary means the lesser of the following:
1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or
2. Most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; such other factors we, in the reasonable exercise of discretion, determine are appropriate.
You/Your means each insured person named in the certificate.
We/Us/Our means Tokio Marine HCC - Medical Insurance Services Group.
Certain Underwriters at Lloyds, London (“Underwriters”) promise to provide the benefits described in this Master Policy. Underwriters makes this promise in consideration of the assured’s application, each member’s application, and the payment of premium.
Tokio Marine HCC – MIS Group is hereby recognized by Underwriters as the plan administrator. All communications, notices and payments shall be transmitted through us. Receipt by us shall be considered receipt by Underwriters.
Underwriters’s agreement is subject to all terms, conditions, provisions and exclusions of this Master Policy, including any exhibits, schedules, endorsements, or riders attached hereto.
Tokio Marine HCC- Medical Insurance Services Group (“MIS Group”)
A subsidiary of Tokio Marine HCC, HCC Lloyd’s Syndicate 4141 is managed by HCC Underwriting Agency Ltd which is authorized by the Prudential Regulation Authority (PRA) and regulated by the Financial Conduct Authority (FCA) and thePRA. Registered in England and Wales No. 04632146. Registered office: 1 Aldgate, London EC3N 1RE, United Kingdom. Lloyd’s is authorised as an insurer in Spain by the Spanish insurance regulatory authority (Dirección General de Seguros y Fondos de Pensiones) under reference L0017.
These details can be checked on the Financial Services Register by visiting: www.fca.org.uk or contacting the Financial Conduct Authority on 0800 111 6768.
This insurance is not subject to, and does not provide certain insurance benefits required by the United States’ Patient Protection and Affordable Care Act (“PPACA”). PPACA requires certain U.S. citizens or US residents to obtain PPACA compliant health insurance, or “minimum essential coverage.” PPACA also requires certain employers to offer PPACA compliant insurance coverage to their employees. Tax penalties may be imposed on U.S. residents or citizens who do not maintain minimum essential coverage, and on certain employers who do not offer PPACA compliant insurance coverage to their employees. In some cases, certain individuals may be deemed to have minimum essential coverage under PPACA even if their insurance coverage does not provide all of the benefits required by PPACA. You should consult your attorney or tax professional to determine whether this policy meets any obligations you may have under PPACA.
This Master Policy is effective as of April 1, 2019 and shall remain in effect until March 31, 2020. Thereafter, this Master Policy may be renewed for successive 12-month periods. This Master Policy can be terminated at any time by either Underwriters or us giving at least 30 days advance written notice to the other party. Such termination of the Master Policy will have no effect on certificates issued to members prior to the date of termination or on payments made or to be made by or to Underwriters under such certificates. No certificates will be issued after the date the Master Policy is terminated.
Entire Agreement
The Master Policy, including any exhibits, schedules, endorsements and/or riders attached hereto, constitutes the entire agreement between Underwriters and us. The certificate issued to the member, including the member’s application and any exhibits, schedules, endorsements and/or riders attached thereto, is an outline of the insurance provided by this Master Policy. The certificate does not extend or change the insurance provided by the Master Policy. The insurance described in the certificate is subject to all terms, conditions, provisions and exclusions of the Master Policy, including any exhibits, schedules, endorsements and/or riders attached hereto.
Insolvency
The insolvency, bankruptcy, financial impairment, receivership, voluntary plan of arrangement with creditors or dissolution of us or any member shall not impose upon Underwriters any liability other than that specifically included in this insurance.
Currency
The monetary limits and premiums stated in the Master Policy and any certificate issued hereunder are in U.S. dollars.
Notice
Any notice to you shall be placed in the United States mail, postage prepaid, and addressed to your mailing address on file as of the date the notice is mailed. You are required to promptly notify us of any change in mailing address.
Data Protection
We respect individual privacy and value your confidence. We restrict access to personal information to employees/partners who need to know that information in order to perform their jobs. Any employee that we determine is in violation of this policy will be subject to disciplinary action, up to and including termination and criminal prosecution.
We will not disclose your personal information to third parties outside Tokio Marine HCC and our partners unless ordered to do so to comply with the law of the countries in which we do business or when complying with the legal process.
Rights of Third Parties
You may assign benefits under this insurance to a hospital, physician or other provider. Any assignment shall not confer upon such hospital, physician or other provider, any right or privilege granted to you under this insurance except for the right to receive benefits, if any, which are determined to be due and payable hereunder. No hospital, physician or other provider shall have any direct or indirect claim or right of action against us.
Law and Jurisdiction
No action of law or equity may be brought to recover benefits under this insurance until 60 days after written proof of claim has been provided to us. No such action may be brought after the end of three (3) years after the time written proof of claim is required to be furnished. The validity, interpretation, and performance of this agreement shall be governed by and construed in accordance with the laws of Bermuda.