Collegiate Care Enhanced

Plan Detail

Plan Administrator: Trawick International | AM Best Rating: A "Excellent" | Underwriter: GBG Insurance Limited

Description


ELIGIBILITY FOR INSURANCE

We retain the right to investigate eligibility status and attendance records to verify eligibility requirements are met. If We discover the eligibility requirements are not met, Our only obligation is to refund any premium paid for that person.

The Plan Participant must actively attend classes for at least the first 31 days after the date for which coverage is purchased. Home study, correspondence, and television (TV) courses do not fulfill the eligibility requirements that the Plan Participant actively attend classes. The Plan Participant must attend a minimum of 6 hours to be eligible. We maintain the right to investigate student status and attendance records to verify that the Plan eligibility requirements have been met. If and whenever we discover that the Plan eligibility requirements have not been met, our only obligation is refund of premium.

 A Plan Participant Person’s Dependent(s), as applicable, are eligible on the latest of the date:

1) the Plan Participant is eligible, if the Plan Participant has Dependents on that date; or

2) the date the person becomes a Dependent; or

If the Plan Participant is in a Class of Eligible Persons and is also eligible as a Dependent, He or She may be Covered only once under the Plan. In no event will a Dependent be eligible if the Plan Participant is not eligible.

 This insurance is not subject to and will not be administered as a PPACA (Patient Protection and Affordable Care Act) insurance plan. PPACA requires certain U.S. residents and citizens obtain PPACA compliant insurance coverage. This plan is not designed to cover U.S. residents and citizens. This Plan is not subject to guaranteed issuance or renewal.

EFFECTIVE DATES OF INSURANCE

Plan Effective Date. The Plan begins on the Plan Effective Date shown in the Schedule of Benefits at 12:01 A.M. at and will continue in force until either a) the Plan Expiration Date stated in the Schedule; or b) the Plan is cancelled pursuant to the terms of the Master Policy.

Plan Participant’s Effective Date for all other Coverages:

A Person will become a Plan Participant under the Plan, provided proper premium payment is made, on the latest of:

1) The Effective Date of the Plan; or

2) The date the Company receives a completed application or enrollment form; or

3) The day He becomes eligible, subject to any required waiting period, according to the referenced date requested and shown in the Application/Enrollment Form, Schedule of Benefits; or

4) The Date the Company approves the Application.

Newborn Children Coverage: Coverage for a newborn Child will begin from the moment of birth. You must give Us notice within 31 days of the birth of the Child. If notice is not given within 31days, coverage for the newborn Child will terminate upon the expiration of the initial 31-day period.

Newborn Adopted Children Coverage: In the case of adoption of a newborn Child, coverage will be on the same basis as a newborn Child if a written agreement to adopt such Child has been entered into by You prior to the birth of the Child, whether or not such agreement is enforceable. Newborn Child Exception: This section does not apply to a newborn Child at that Child’s birth if the Child is born to You while You are a Plan Participant as a Dependent under the Plan. Benefits for Newborn Children apply only to a Child born to a Plan Participant or their Spouse

Adopted Children Coverage: Coverage for an adopted Child, other than a newborn, will begin from the date of placement in Your home for the purpose of adoption or the date of an entry of an interim court order granting You temporary custody of the child, whichever comes first. A notice of placement for adoption must be submitted to Us. If notice is not given within 31 days, coverage for the adopted Child will terminate upon the expiration of the initial31, day period. Coverage for an adopted child is not guaranteed, and subject to a health statement. If approved, any applicable pre-existing condition limitation will apply.

TERMINATION DATE OF INSURANCE

Plan Termination Date

 Termination takes effect at 11:59 P.M. on the date of termination. Termination by the Plan Participant or by the Company will be without prejudice to any claims originating prior to the date of termination.

 The Plan terminates automatically on the earlier of:

1) The Plan Expiration Date shown in the Plan; or

2) The premium due date if premiums are not paid when due, subject to any grace period.

Failure by the Plan Participant to pay all required premiums due by the last day of the grace period shall be deemed notice by the Plan Participant to the Company to terminate the Plan on the last day of the period for which premiums have been paid.

The Plan may be terminated by the Plan Participant or the Company as of any premium due date by giving written notice to the other and the Participating Organization at least 31 days prior to such date.

The Plan Participant and the Company may terminate the Plan at any time by written mutual consent.

 If premiums have been paid beyond the termination date, the Company will refund the excess; or if premiums have been paid short of the termination date, the Plan Participant will owe the Company the difference.

Plan Participant’s Termination Date for all other Coverages:

Insurance for a Plan Participant will end on the earliest of:

1) The date He is no longer in an Eligible Class; or

2) The date the Plan Participant returns to his or her Home Country unless otherwise covered under the Plan; or;

3) The date shown on the Evidence of Coverage issued by the Company or

4) The date the Plan Participant becomes a permanent resident of the United States or;

5) The date He reports for full-time active duty in any Armed Forces, according to the referenced date shown in the Application. We will refund, upon receipt of proof of service, any premium paid, calculated from the date active duty begins until the earlier of:

a) The date the premium is fully earned; or

b) The Expiration Date of the Plan. This does not include Reserve or National Guard duty for training; Elite TCC-004 TCC-005 Elite TCC-004 TCC-005

 6) The end of the period for which the last premium contribution is made; or

7) The date the Plan is terminated; or

8) The date the Plan Participant requests, in writing, that his/her coverage be terminated; or

9) The date the Plan Participant’s participation in the Program terminates; or

10) The date the Plan Participant’s Trip is completed.

PREMIUM PROVISIONS

Grace Period:

A grace period of 31 days is granted for each premium due after the first premium due date. Coverage will stay in force during this period provided the Plan Participant pays all the premiums due by the last day of the grace period, unless notice has been sent, in accordance with the TERMINATION provision, of the intent to terminate coverage under the Plan. Coverage will end if the premium is not paid by the end of the grace period.

 Changes in Premium Rate

The Company may change the premium rates from time to time with at least 31days advanced written or authorized electronic notice. Notice will be sent to the Plan Participant’s most recent address in Our records.

 However, the Company reserves the right to change rates at any time if any of the following events occur:

1) A change in the terms of the Plan.

2) A subsidiary, division, affiliated organization or eligible class is added or deleted to the Plan.

3) A change in the factors bearing on the risk assumed.

4) A misrepresentation in the information relied on in establishing the rate for the Plan.

If an increase or decrease in rates takes place on a date that is not a Premium Due Date, a prorated adjustment will apply from the date of the change to the next Premium Due Date.

Reinstatement

The Plan may be reinstated within 31 days of lapse if it is lapsed for nonpayment of premium, if the Plan Participant submits written application to the Company, the Company accepts the application and the Plan Participant makes payment of all overdue premiums.

SCOPE OF COVERAGE

Benefits are payable under the Plan for Eligible Expenses incurred by a Plan Participant for the items stated in the, Schedule of Benefits. Benefits will be payable to either the Plan Participant or the Service Provider for Eligible Expenses incurred Worldwide, outside the Plan Participant’s Home Country.

The charges enumerated herein will in no event include any amount of such charges which are in excess of Usual, Reasonable and Customary charges. If the charge incurred is in excess of such average charge such excess amount will not be recognized as an Eligible Expense. All charges will be deemed to be incurred on the date such services or supplies, which give rise to the expense or charge, are rendered or obtained.

 We will provide the benefits described in the Plan to all Plan Participants who suffer a Covered Loss which:

1) Is within the scope of the DESCRIPTION OF BENEFITS PROVISIONS; and

2) Occurs while the person is a Plan Participant under the Plan.

Terms of Payment for Benefits:

Full Excess Medical Expense:

If an Injury or Sickness to the Plan Participant results in his incurring Eligible Expenses for any of the services in the SCHEDULE OF BENEFITS, We will pay the Eligible Expenses incurred, subject to any applicable Deductible Amount, Benefit Period, Co-Payment, and Coinsurance Percentage, that are in excess of Expenses payable by any other Health Care Plan, regardless of any Coordination of Benefits provision contained in such Health Care Plan.

The Plan Participant must be under the care of a Physician when the Eligible Expenses are incurred. The Expense must be incurred solely for the treatment of a covered Injury or Sickness:

1) While the person is a Plan Participant under the Plan; or

2) During the Benefit Period stated on the SCHEDULE OF BENEFITS.

The first Expense must be incurred within the time frame shown on the SCHEDULE OF BENEFITS.

The total of all medical benefits payable under the Plan is shown on the SCHEDULE OF BENEFITS and is subject to the specific maximums shown on the SCHEDULE OF BENEFITS.

Failure by a Plan Participant to follow the terms and conditions and/ or failure to utilize the network providers and facilities of His primary coverage will result in a benefit reduction of Eligible Expense to 40% of the amount otherwise xpayable under the Plan. This limitation will not apply to emergency treatment required within 24 hours after an Accident when the Accident occurs outside the geographic area served by Your primary plan’s HMO, PPO or other similar arrangement for provision of benefits or services, if applicable.

DEFINITIONS

The male pronoun includes the female whenever used.

 For the purposes of the Plan the capitalized terms used herein are defined as follows:

Additional terms may be defined within the provision to which they apply. Accident means an unforeseeable event which:

1) Causes Injury to one or more Plan Participants; and

2) Occurs while coverage is in effect for the Plan Participant.

AIDS means Acquired Immune Deficiency Syndrome, as that term is defined by the United States Centers for Disease Control.

Air Carrier means any air conveyance operating under a valid license for the transportation of passengers for hire.

Benefit Period means the period of time from the date of the Accident causing the Injury for which benefits are payable, as shown in the Schedule of Benefits, and the date after which no further benefits will be paid.

Caregiver means an individual employed for the purpose of providing assistance with activities of daily living to the Plan Participant or to the Plan Participant’s Immediate Family Member who has a physical or mental impairment. The Caregiver must be employed by the Plan Participant or the Plan Participant’s Immediate Family Member. A Caregiver is not a babysitter; childcare service, facility or provider; or persons employed by any service, provider or facility to supply assisted living or skilled nursing personnel.

Child means the Plan Participant’s natural Child, adopted Child (or Child placed in the Plan Participant’s home for purposes of adoption), foster Child, stepchild, or other Child for whom the Plan Participant has legal guardianship (proof will be required). A Child must reside with the Plan Participant in a parent-Child relationship. NOTE: In the event the Plan Participant shares physical custody of the Child with another parent, the requirement that the Child reside with the Plan Participant will be waived.

Child Caregiver means an individual providing basic childcare service needs for the Plan Participant minor children under the age of 18 while the Plan Participant is on the Trip without the minor children. The arrangement of being the Child Caregiver while the Plan Participant is on the Trip must be made 30 or more days prior to the Scheduled Departure Date

Civil Union Partner means a party to a civil union who is entitled to the same legal obligations, responsibilities, protections and benefits that are afforded a spouse. Throughout the Plan, a party to a civil union shall be included in any definition or use of the terms such as spouse, Immediate Family, dependent, next of kin, and other terms descriptive of spousal relationships. This includes the terms 'marriage' or 'married' or variations thereon. The term spouse or dependent includes civil union couples whenever used

Class means a group of people defined by a common characteristic, including but not limited to demographic group and geographic region.

Common Carrier means any motorized land, sea, and/or air conveyance operating under a valid license for the transportation of passenger for hire.

Coinsurance means the percentage of Eligible Expenses for which the Company is responsible for a specified covered service after the Deductible, if any, has been met.

Company means GBG Insurance Limited. Also, hereinafter referred to as We, Us and Our.

Complications of Pregnancy means a condition which:

• When pregnancy is not terminated, requires medical treatment and whose diagnosis is distinct from pregnancy but is adversely affected by or are caused by pregnancy, such as: (a) acute nephritis; (b) nephrosis; (c) cardiac decompensation; (d) missed abortion; (e) eclampsia; (f) puerperal infection; (g) R.H. Factor problems; (h) severe loss of blood requiring transfusion; and (i) other similar medical and surgical conditions of comparable severity related to pregnancy.

• When pregnancy is terminated: (a) non-elective cesarean section; (b) ectopic pregnancy that is terminated; and (c) spontaneous termination of pregnancy during a period of gestation in which a viable birth is not possible; Complications of Pregnancy will not include:

• False Labor;

• Occasional spotting;

• Physician prescribed rest during the period of pregnancy;

• Morning Sickness; and

• Similar conditions associated with the management of a difficult pregnancy, but which are not a separate Complication of Pregnancy. Delivery by cesarean section is considered a complication of pregnancy if the cesarean section is non-elective. A cesarean section will be considered non-elective if the fetus or mother is determined to be in distress and is in immediate danger of death, Sickness or Injury if a cesarean section is not performed. A cesarean section beyond one performed in any previous pregnancy will also be considered non-elective if vaginal delivery is medically inappropriate, or a vaginal delivery is attempted but discontinued due to immediate danger of death, Sickness or Injury to the Child or mother.

Co-Payment means a specified charge that the Plan Participant is required to pay when a medical service is rendered.

Cosmetic Surgery means the surgical alteration of tissue primarily for the improvement of appearance rather than to improve or restore bodily functions.

Covered Accident means an Accident that occurs while coverage is in force for a Plan Participant and results in a Covered Loss for which benefits are payable.

Covered Loss or Covered Losses means an accidental death, dismemberment or other Injury covered under the Plan and indicated on the Schedule of Benefits.

Custodial Care means that type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist a Plan Participant, whether or not totally disabled, in the activities of daily living.

Deductible means the dollar amount of Eligible Expenses which must be incurred and paid by the Plan Participant before benefits are payable under the Plan. It applies separately to each Plan Participant.

Dentist means 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 means a Plan Participant’s:

 1) lawful spouse, if not legally separated or divorced, or Domestic Partner or Civil Union Partner.

2) unmarried Children under age 19.

The age limitations will not apply to a Plan Participant’s unmarried Child who is dependent on the Plan Participant or other care providers for lifetime care and supervision, and incapable of self-sustaining employment by reason of mental or physical handicap that occurred before age 19. Proof of such dependence and incapacity must be furnished to the Company immediately upon enrollment or within 31 days of the Child reaching the age limitation. Thereafter proof will be required whenever reasonably necessary, but not more often than once a year after the 2-year period following the age limitation.

Domestic Partner means an opposite or same sex partner who, for at least 12 consecutive months, has resided with the Plan Participant and shared financial assets/obligations with the Plan Participant. Both the Plan Participant and the Domestic Partner must: (1) intend to be life partners; (2) be at least the age of consent in the state in which they reside; and (3) be mentally competent to contract. Neither the Plan Participant nor the Domestic Partner can be related by blood to a degree of closeness that would prohibit a legal marriage, be married to anyone else, or have any other Domestic Partner. The Company requires proof of the Domestic Partner relationship in the form of a signed and completed Affidavit of Domestic Partnership.

Economy Transportation means the lowest published available transportation rate for a ticket on a Common Carrier matching the original class of transportation that the Plan Participant purchased for the Plan Participant’s Trip.

Eligible Expenses means the Usual, Reasonable and Customary charges for services or supplies which are incurred by the Plan Participant for the Medically Necessary treatment of an Injury. Eligible Expenses must be incurred while the Plan is in force.

Emergency means a Sickness or Injury for which the Plan Participant seeks immediate medical treatment at the nearest available facility. The condition must be one which manifests itself by acute symptoms which are sufficiently severe (including severe pain) that without immediate medical care a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would cause:

• His life or health would be in serious jeopardy, or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn Child;

• His bodily functions would be seriously impaired; or

• A body organ or part would be seriously damaged.

Experimental/Investigational means that a drug, device or medical care or treatment will be considered experimental/investigational if:

• The drug or device cannot be lawfully marketed without approval of the Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;

• The informed consent document utilized with the drug, device, medical care or treatment states or indicates that the drug, device, medical care or treatment is part of a clinical trial, experimental phase or investigational phase or if such a consent document is required by law;

• The drug, device, medical care or treatment or the patient informed consent document utilized with the drug, device or medical care or treatment was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal or state law requires such review and approval;

• Reliable Evidence show that the drug, device or medical care or treatment is the subject of ongoing Phase I or Phase II clinical trials, is the research, experimental study or investigational arm of ongoing Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis; or

 • Reliable Evidence show that the prevailing opinion among experts regarding the drug, device or medical care or treatment is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis.

Reliable evidence means only: published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility studying substantially the same drug, device or medical care or treatment or the written informed consent used by the treating facility or other facility studying substantially the same drug, device or medical care or treatment. Eligible Expenses will be considered in accordance with the drug, device or medical care at the time the expense isincurred.

Management staff in Our Claims Department or a Claims Payor acting on Our behalf will make the determination if the drug, device or medical care is Experimental/Investigational based on the above criteria.

Extended Care Facility means an institution operating pursuant to applicable laws that is engaged in providing, for a fee, inpatient skilled nursing care and related services under the supervision of a Physician and Registered Nurses. It must have facilities for 10 or more inpatients and maintain medical records of all its patients.

He, His and Him includes "she", "her" and "hers."

Health Care Plan means any contract, Plan or other arrangement for benefits or services for medical or dental care or treatment under:

1) Group or blanket insurance, whether on an insured or self-funded basis;

2) Hospital or medical service organizations on a group basis;

3) Health Maintenance Organizations on a group basis.

4) Group labor management plans;

5) Employee benefit organization plan;

6) Professional association plans on a group basis; or

7) Any other group employee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974 as amended.

Home Country means the country where a Plan Participant has his or her true, fixed and permanent home and principal establishment and holds current and valid passport

Home Health Care means nursing care, treatment and Daily Living Services provided in the Plan Participant’s home as part of an overall extended treatment plan. To qualify for Home Health Care Benefits:

1) the Home Health Care plan must be established and approved by the attending Physician, including certification that confinement in a Hospital or Extended Care Facility would be required if it were not for Home Health Care; and Necessary care and treatment are not available from a Plan Participant's Immediate Family Member or other persons residing with the Plan Participant without causing undue hardship;

2) nursing care and treatment must be provided by a Hospital certified to provide Home Health Care services or by a certified Home Health Care agency and nursing service; and

3) Daily Living Services must be provided by the attending Physician or by the provider of the nursing care service.

“Daily Living Services” are cooking, feeding, bathing, dressing and personal hygiene services that are necessary to a person’s care and health.

 Home Health Care consists of, but shall not be limited to, the following:

• Part time and intermittent skilled nursing services: services given to the Plan Participant at least once every 60 days or as frequently as a few hours per day, several days per week.

• Therapeutic services: physical therapy occupational therapy; speech and hearing therapy; and

• Medical social services, medical supplies, drugs and medicines, related pharmaceutical services and laboratory services to the extent such charges or costs would have been covered under the Evidence of Coverage if the Plan Participant had remained in the Hospital.

Hospital means an institution licensed, accredited or certified by the State that:

1) Operates as a Hospital pursuant to law for the care, treatment and providing in-patient services for sick or injured persons;

2) Is accredited by the Joint Commission on Accreditation of Healthcare Organizations;

3) Provides 24-hour nursing service by registered nurses (R.N.) on duty or call;

4) Has a staff of one or more licensed Physicians available at all times;

5) Provides organized facilities for diagnosis, treatment and surgery, either a) on its premises; or b) in facilities available to it, on a pre-arranged basis;

6) Is not primarily a nursing care facility, rest home, convalescent home or similar establishment, or any separate ward, wing or section of a Hospital used as such; and

7) Is not a place for drug addicts, alcoholics or the aged.

Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities.

We will not deny a claim for services solely because the Hospital lacks major surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is specifically for the treatment of a physical disability, and the Hospital is accredited by any one of the following:

1) the Joint Commission of Accreditation of Hospitals; or

2) the American Osteopathic Association; or

3) the Commission on the Accreditation of Rehabilitative Facilities.

In addition, We will not deny a claim for a Skilled Nursing Facility if it meets the definition of such a facility and is an Eligible Expense under the Plan.

Hospital does not include a place, special ward, floor or other accommodation used for: custodial or educational care; rest, the aged; a nursing home or an institution mainly rendering treatment or services for mental illness or substance abuse, except as specifically stated.

Hospital Stay means a Medically Necessary overnight confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge is made by the Hospital.

Immediate Family means a Plan Participant’s spouse, domestic partner, Civil Union Partner, parent (includes Step-parent), Child(ren) (includes legally adopted or step Child(ren), brother, sister, stepChild(ren), grandchild(ren), or in-laws). A Member of the Immediate Family includes an individual who normally lives in the Plan Participant's household.

Injury means bodily harm which results independently of disease or bodily infirmity, from an Accident after the effective date of a Plan Participant’s coverage under the Plan, while the Plan is in force as to the person whose Injury is the basis of the claim. All injuries to the same Plan Participant sustained in one Accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury.

Incidental Trip means a trip to the Plan Participant’s Home Country for up to30 days per 12 months of coverage.

Inpatient means a Plan Participant who is confined in an institution and is charged for room and board.

Insurance means the coverage that is provided under the Plan.

Intensive Care Unit means 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.

Intoxicated means a blood alcohol level that equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the Plan Participant is located at the time of an incident.

Maximum Benefit means the largest total amount of Eligible Expenses that the Company will pay for the Plan Participant as shown in the Plan Participant’s Schedule of Benefits.

Medically Necessary means a treatment, drug, device, service, procedure or supply that is:

1) Required, necessary and appropriate for the diagnosis or treatment of a Sickness or Injury;

2) Prescribed or ordered by a Physician or furnished by a Hospital;

3) Performed in the least costly setting required by the condition;

4) Consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered.

When specifically applied to Hospital confinement, it means that the diagnosis or treatment of symptoms or a condition cannot be safely provided on an outpatient basis.

The purchasing or renting air conditioners, air purifiers, motorized transportation equipment, escalators or elevators in private homes, swimming pools or supplies for them, and general exercise equipment are not considered Medically Necessary.

A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may consider the cost of the alternative to be the Eligible Expense.

A treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it:

• Is Experimental/Investigational or for research purposes;

• Is provided for education purposes or the convenience of the Plan Participant, the Plan Participant's family, Physician, Hospital or any other provider;

• Exceeds in scope, duration, or intensity that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment and where ongoing treatment is merely for maintenance or preventive care;

• Could have been omitted without adversely affecting the person's condition or the quality of medical care;

• Involves the use of a medical device, drug or substance not formally approved by the United States Food and Drug Administration;

• Involves a service, supply or drug not considered reasonable and necessary by the Healthcare Financing Administration Medicare Coverage Issues Manual; or

• It can be safely provided to the patient on a less cost-effective basis such as out-patient, by a different medical professional, or pursuant to a more conservative form of treatment.

Mental or Nervous Disorder means any condition or disease, regardless of its cause, listed in the most recent edition of the International Classification of Diseases as a Mental Disorder on the date the medical care or treatment is rendered to a Plan Participant.

Natural Teeth means the major portion of the individual tooth which is present, regardless of filings and caps; and is not carious, abscessed, or defective.

Network Provider means a Physician, Hospital and other healthcare providers who have contracted to provide specific medical care at negotiated prices.

Non-Network Provider means a Physician, Hospital and other healthcare providers who have not agreed to any pre-arranged fee schedules. A Plan Participant may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are the Plan Participant’s responsibility.

Occurrence means all losses or damages that are attributable directly or indirectly to one cause or one series of similar causes. All such losses will be added together, and the total amount of such losses will be treated as one Occurrence without regard to the period of time or the area over which such losses occur.

Outpatient means a Plan Participant who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for a Sickness or Injury, but who is not confined and is not charged for room and board.

Outpatient Surgical Facility means a surgical or medical center which has (1) permanent facilities for surgery; (2) organized medical staff of Physicians and registered graduate Registered Nurses; (3) is authorized by law in the jurisdiction in which it is located to perform surgical services and is licensed (if no license is required, officially approved) under law.

Out-of-Pocket Maximum means the maximum dollar amount the Plan Participant is responsible to pay during a Plan Term. After the Plan Participant has reached the Out-of-Pocket Maximum, the Plan pays 100% of Eligible Expenses for the remainder of the Plan Term. The Out-of-Pocket Maximum is met by accumulated Deductible, Coinsurance. Penalties and amounts above the Usual, Reasonable and Customary Expenses do not count toward the Out-of-Pocket Maximum. The Out-of-Pocket Maximum is shown on the Schedule of Benefits.

Physician means a person who is a qualified practitioner of medicine. As such, He or She must be acting within the scope of his/her license under the laws in the state in which He or She practices and providing only those medical services which are within the scope of his/her license or certificate. It does not include a Plan Participant, a Plan Participant’s Spouse, son, daughter, father, mother, brother or sister or other relative      

Physical Therapy means any form of the following administered by a Physician: (1) physical or mechanical therapy; (2) diathermy, (3) ultra-sonic therapy; (4) heat treatment in any form; or (5) manipulation or massage.

Plan Participant means a Person and Dependent eligible for coverage as identified in the Enrollment/Application as a Non-United States Citizen traveling outside their Home Country and has his or her true, fixed and permanent home and principal establishment outside of the United States and holds a current and valid passport for whom proper premium payment has been made when due, and who is therefore a Plan Participant under the Plan.

Plan means this document, the Application of the Plan Participant and any end endorsements, riders or amendments that will attach during the Period of Coverage.

Plan Period means the period of time following the Effective Date, as shown on the Schedule of Benefits.

Preferred Allowance means the amount a Network Provider will accept as payment in full for Eligible Expenses.

Pre-Existing Condition means an Injury, Sickness, disease, or other condition during the 365 day period immediately prior to the date the Plan Participant’s coverage is effective 1) received or received a recommendation for a test, examination, or medical treatment for a condition which first manifested itself, worsened or became acute or had symptoms which would have prompted a reasonable person to seek diagnosis, care or 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 365 day period before coverage is effective under the Plan Participant’s Plan.

Pregnancy means the physical condition of being pregnant, including Complication of Pregnancy.

Prescription Drugs means drugs which may only be dispensed by written prescription under Federal law and approved for general use by the Food and Drug Administration.

Registered Nurse means a licensed registered professional Registered Nurse (R.N.).

Rehabilitation Facility means a non-residential facility that provides therapy and training rehabilitation services at a single location in a coordinated fashion, by or under the supervision of a physician pursuant to the law of the jurisdiction in which treatment is provided. The center may offer occupational therapy, physical therapy, vocational training, and special training such as speech therapy. The facility may be either of the following:

1) A Hospital or a special unit of a Hospital designated as a Rehabilitation Facility; or

2) A free-standing facility.

Scheduled Departure Date means the date on which the Plan Participant is originally scheduled to leave on the Plan Participant’s Trip.

Scheduled Return Date means the date on which the Plan Participant is originally scheduled to return to the point of origin or the original final destination of the Plan Participant’s Trip.

Service Provider means 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 Sickness or disease contracted and causing loss commencing while the Plan is in force as to the Plan Participant whose Sickness is the basis of claim. Any complication or any condition arising out of a Sickness for which the Plan Participant is being treated or has received Treatment will be considered as part of the original Sickness.

Skilled Nursing Facility means a facility that provides skilled nursing 24 hours a day, seven days a week, under the supervision of a Registered Nurse, and/or skilled rehabilitative services at least five days per week. The emphasis is on skilled nursing care, with restorative, physical, occupational, and other therapies available. A Skilled Nursing Facility provides services that cannot be efficiently or effectively rendered at home or in an intermediate care facility. The service provided must be directed towards the patient achieving independence in activities of daily living, improving the patient’s condition, and facilitating discharge.

Spouse means lawful spouse, if not legally separated or divorced, or Domestic Partner or Civil Partner.

Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency.

Surgery or Surgical Procedure means an invasive diagnostic procedure; or the treatment of Sickness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.

Third Party means a person or entity other than the Plan Participant, , or the Company.

Transportation Expense means the cost of Medically Necessary conveyance, personnel, and services or supplies.

Trip means a scheduled trip for which coverage for Travel Arrangements is requested and the premium is paid prior to the Plan Participant’s actual or Scheduled Departure Date of the Plan Participant’s Trip.

Usual, Reasonable and Customary means the most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the area in which the charge is incurred. The most common charge means the lesser of:

• The actual amount charged by the provider;

• The negotiated rate; or

• The charge which would have been made by the provider (Physician, Hospital, etc.) for a comparable service or supply made by other providers in the same Geographic Area, as reasonable determined by Us for the same service or supply.

"Geographic Area" means the three-digit zip code in which the service, treatment, procedure, drugs or supplies are provided; a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.

Usual, Reasonable and Customary Charges, Fees or Expenses as used in the Plan to describe expense will be considered to mean the percentile of the payment system in effect at Plan issue as shown on the Schedule of Benefits.

Utilization of Nuclear, Chemical or Biological weapons of mass destruction shall mean 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, or

• any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins), or

• any solid, liquid or gaseous chemical compound which, when suitably distributed;

• which is capable of causing incapacitating disablement or death amongst people or animals.

We, Our, Us means GBG Insurance Limited.

You, Your, Yours, He or She means the Plan Participant who meets the eligibility requirements of the Plan and whose insurance under the Plan is in force.