Plan Administrator: Trawick International | AM Best Rating: A "Excellent" | Underwriter: GBG Insurance Limited
PART A: ACCIDENT BENEFITS
ACCIDENTAL DEATHAND DISMEMBERMENT BENEFITS 24-Hour (Other than Air Flight)
| Class 1 Principal Sum: | $10,000 |
|---|---|
| Time Period for Loss: | 90 days |
| Loss of: | Benefit: (Percentage of Principal Sum) |
| Loss of Life | 100% |
| Loss of Both Hands or Feet, or Loss of Entire Sight of Both Eyes | 100% |
| Loss of One Hand and One Foot | 100% |
| Loss of One Hand or Foot and Entire Sight of One Eye | 100% |
| Loss of One Hand or Foot | 75% |
| Loss of Sight of One Eye | 75% |
ACCIDENT & SICKNESS MEDICAL EXPENSE BENEFITS
Benefits will be provided only for the Coverages listed below and will be paid only up to the amounts shown.
| Plan Term Maximum for all Medical | $150,000 per Injury or Sickness, to an overall $300,000 Maximum (all Injury or Sickness combined) |
|---|---|
| Deductible Per Plan Participant per Injury or Sickness | Network/ Non-Network Provider: $250 |
| Deductible at Student Health Center: | $35 |
| Out-of-Pocket Maximum | In-Network and Out-of-Network (combined): Once benefits have been paid up to $50,000 per Illness/Injury, the Plan will pay additional covered medical expenses at 100% of the Preferred Allowance or UCR (if Out-ofNetwork Providers in the U.S. are used) |
| Per Plan Term: | |
| Coinsurance: |
In-Network: 100% of the Preferred Allowance Out-of-Network: 75% of Usual, Reasonable & Customary (URC) Charges |
| Pre-Existing Conditions (Covered after 6 months) | $20,000 Lifetime Limit |
| In-Network Office Visit Co-Payment and Out-of-Network | |
| Emergency Room Deductible: | $300 per Occurrence |
| Terms of Payment | Full Excess |
| Lifetime Maximum | Unlimited |
Any Deductibles, Coinsurance, Co-payments, Benefit Periods, and Benefit Maximums apply on a per Plan Participant basis.
After the Deductible has been satisfied, benefits will be paid as listed for the Provider selected.
|
BENEFIT/COVERAGE |
BENEFIT AMOUNT |
|
|
In-Network Provider Benefit |
Out-of-Network Provider Benefit |
|
|
Hospital Room & Board Benefit • Up to 30 days per Admission |
100% of the Preferred Allowance up to $1,000 per day |
75% of the Semi-Private Room Rate |
|
Intensive Care/Cardiac Care Unit Benefit • Up to 30 days per Admission |
100% of the Preferred Allowance up to $1,525 per day |
75% of URC |
|
Hospital Miscellaneous Expense Benefit • Up to $500 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Extended Care/ Inpatient Rehabilitation • Up to 45 days |
100% of the Preferred Allowance |
75% of URC |
|
Surgeon (In or Outpatient) Benefits • Up to $4,000 Maximum Benefit • Outpatient Day Surgery $2,000 Maximum Benefit |
100% of the Preferred Allowance |
70% of URC |
|
Pre-Admission Testing Benefit Up to $900 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Anesthesia Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Day Surgery Miscellaneous Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Diagnostic X-Ray and Lab Benefit • Up to $500 Maximum Benefit, MRI, PET, and CT Scans up to $850 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Ambulance Benefit • Up to $400 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Physician Visit Benefit (Inpatient) |
100% of the Preferred Allowance, limited to 1 visit per day up to a maximum of 30 visits |
75% of URC, limited to 1 visit per day up to a maximum of 30 visits |
|
Physician Visit Benefit (Outpatient) Up to $50 Maximum Benefit per visit |
100% of the Preferred Allowance, limited to 1 visit per day up to a maximum of 30 visits |
75% of URC, limited to 1 visit per day up to a maximum of 30 visits |
|
Consultant Physician Benefit Up to $400 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Emergency Room Benefit |
100% of the Preferred Allowance subject to a $300 deductible per visit, waived if admitted |
75% of URC subject to a $300 deductible per visit, waived if admitted |
|
Extension of Home Country Sickness Medical Benefit |
$500 Maximum Benefit |
$500 Maximum Benefit |
|
Maternity and Pre-Natal Care Expense Benefit • Conception must occur while covered under the Policy • Up to $5,000 Maximum Benefit for normal delivery, $7,500 Maximum Benefit for C-Section |
100% of the Preferred Allowance |
100% of the Preferred Allowance |
|
Elective/ Therapeutic Termination of Pregnancy Benefit • Up to $500 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
MENTAL & NERVOUS CONDITIONS EXPENSE BENEFIT |
||
|
• In-Patient Expense • Up to 30 days |
75% of the Preferred Allowance, up to $5,000 Maximum Benefit |
75% of URC, up to $5,000 Maximum Benefit |
|
Out-Patient Expense • Up to 40 visits |
75% of the Preferred Allowance, up to $500 Maximum Benefit |
75% of URC, up to $500 Maximum Benefit |
|
ALCOHOL & DRUG ABUSE EXPENSE BENEFIT |
||
|
In-Patient Expense |
100% of the Preferred Allowance |
75% of URC |
|
• Out-Patient Expense |
100% of the Preferred Allowance |
75% of URC |
|
Emergency Dental Expense Benefit • Up to $250 per tooth to a $500 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Physiotherapy Expense Benefit – In-patient |
100% of the Preferred Allowance |
75% of URC |
|
Physiotherapy Expense Benefit – Out-patient • Up to $35 Maximum Benefit per visit • Maximum of 12 visits per Injury/Sickness |
100% of the Preferred Allowance |
75% of URC |
|
Motor Vehicle Accident • Up to $10,000 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Durable Medical Equipment Expense Benefit • Up to $1,000 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Sports Activities • Injuries arising from interscholastic, intramural, leisure, and club sports • Up to $3,000 Maximum Benefit |
100% of the Preferred Allowance |
75% of URC |
|
Emergency Medical Evacuation Expense Benefit |
100% of actual expense up to $60,000 Maximum Benefit |
100% of actual expense up to $60,000 Maximum Benefit |
|
Emergency Medical Repatriation Expense Benefi |
100% of actual expense up to $60,000 Maximum Benefit |
100% of actual expense up to $60,000 Maximum Benefit |
|
Return of Mortal Remains |
100% of actual expense up to $50,000 Maximum Benefit |
100% of actual expense up to $50,000 Maximum Benefit |
|
PRESCRIPTION DRUG EXPENSE BENEFIT |
In-Network Provider Benefit |
Out-of-Network Provider Benefit |
|
Covered Percentage: • Up to $100 Maximum Benefit per event • Up to $40 per month for Oral Contraceptives |
100% of the Preferred Allowance based on a 30-day supply per prescription) |
75% based on a 30-day supply per prescription |
NOTES:
DESCRIPTION OF BENEFITS
PART A: ACCIDENT BENEFITS
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS 24-Hour (Other than Air Flight) ACCIDENTAL DEATH AND DISMEMBERMENT
If, within one year from the date of an Accident or Injury covered by the Plan that occurs during the Plan Participant’s Trip, the Plan Participant suffers from a Covered Loss listed below, We will pay the percentage of the Principal Sum set opposite the loss in the table below other than while covered for Air Flight Only Benefits. If the Plan Participant sustains more than one such Loss as the result of one Accident, We will pay only one amount, the largest to which he is entitled. This amount will not exceed the Principal Sum which applies for the Plan Participant. The Principal Sum is the Maximum Benefit Amount shown in Schedule of Benefit.
Benefits are payable if such Injury:
1) Occurs during the course of time the Plan Participant is covered under the Plan;
Loss of: Benefit: (Percentage of Principal Sum)
Loss of Life 100%
Loss of Both Hands or Feet,
or Loss of Entire Sight of Both Eyes 100%
Loss of One Hand and One Foot 100%
Loss of One Hand or Foot and Entire Sight of One Eye 100%
Loss of One Hand or Foot 75%
Loss of Sight of One Eye 75%
Loss of a hand or foot means complete Severance through or above the wrist or ankle joint.
Severance means the complete separation and dismemberment of the part from the body.
Loss of sight means total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means.
EXPOSURE TO THE ELEMENTS OR DISAPPEARANCE
Subject to all other terms and conditions of the Plan, We will:
1) Pay the applicable benefit under BENEFITS FOR ACCIDENTAL DEATH AND DISMEMBERMENT for a Plan Participant's loss specified therein, which results from unavoidable exposure to the elements or disappearance due to:
a) The forced landing; stranding; sinking; or wrecking of a vehicle in which a Plan Participant was traveling; and
b) Such Occurrence occurs from an Accident for which the Plan provides coverage; or
2) Presume that a Plan Participant has died if:
a) A vehicle in which he is traveling disappears; sinks; is stranded; or is wrecked; as a result of an Accident for which the Plan provides coverage; and
b) His body is not found within one year of the Occurrence of (2)(a) above. These benefits will not duplicate any other benefits payable under the Plan Participant’s Evidence of Coverage or any coverage(s) attached to the Plan Participant’s Evidence of Coverage.
ACCIDENT AND SICKNESS MEDICAL EXPENSE BENEFITS
We will pay Accident and Sickness Medical Expense Benefits for Eligible Expenses. These benefits are subject to the Deductibles, Co-Payment, Coinsurance Factors, Benefit Periods, Benefit Maximums and other terms or limits shown below and in the Schedule of Benefits.
Accident and Sickness Medical Expense Benefits are only payable:
1) for Usual, Reasonable and Customary Charges incurred after the Deductible has been met;
2) for those Medically Necessary Eligible Expenses incurred by or on behalf of the Plan Participant; No benefits will be paid for any expenses incurred that are in excess of Usual, Reasonable and Customary Charges.
Eligible Medical Expenses include:
1) Hospital Admission Expenses: Charges for each hospital admission.
2) Outpatient Pre-Surgical Testing benefit – charges for Pre-surgical testing. A scheduled surgical procedure must occur within 7 days of the testing.
3) Nursing Services – Outpatient Charges for nursing services by a Registered Nurse or Licensed Professional
4) Skilled Nursing Facility - charges for services as described in the schedule of benefits. The benefit 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 SNF 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. A SNF confinement must take place within 14 days from a hospital discharge and must represent care for the same condition which required hospitalization that lasted a minimum of three days. Care may not be custodial in nature (e.g., care which could be performed at home). The facility may not be primarily a place which provides general care for the aged.
5) Hospice Care Benefit as follows:
a) nursing care by a Registered Nurse; or a licensed practical Registered Nurse, a vocational Registered Nurse, or a public health Registered Nurse who is under the direct supervision of a Registered Nurse;
b) physical therapy and speech therapy when rendered by a licensed therapist;
c) medical supplies, including drugs and the use of medical appliances;
d) physician’s services; and
e) services, supplies, and treatments deemed Medically Necessary and ordered by a licensed Physician
6) Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or Surgeon.
7) Charges made for artificial limbs, eyes, larynx, and orthotic appliances, but not for replacement of such items.
ADDITIONAL BENEFITS
HOSPITAL ROOM & BOARD BENEFIT
We will pay charges for the most common semi-private daily room rate for each day of the Hospital Stay, up to the Maximum Daily Benefit Amount shown in the schedule. In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge. Hospital Room and Board expenses will include floor nursing while confined in a ward or semi-private room of a Hospital and other Hospital services inclusive of charges for professional service and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the Hospital’s average charge for semiprivate room and board accommodation
INTENSIVE CARE/CARDIAC CARE UNIT BENEFIT
We will pay charges for each day of Intensive Care/Cardiac Care Unit confinement, up to the Daily Maximum Benefit shown in the schedule per day. This payment is in lieu of payment for the Hospital Room and Board charges for those days and includes nursing services
HOSPITAL MISCELLANEOUS EXPENSE BENEFIT
We will pay for services, supplies and charges during a Hospital Stay, up to the Maximum Daily Benefit Amount shown in the schedule per day. Miscellaneous services include services and supplies such as: the cost of the operating room; laboratory tests; X-ray examinations; anesthesia; drugs (excluding take-home drugs) or medicines; therapeutic services; and supplies; and blood and blood transfusions. Miscellaneous services do not include charges for telephone, radio or television, extra beds or cots, meals for guests, take home items, or other convenience items.
EXTENDED CARE FACILITY SERVICES, SKILLED NURSING AND INPATIENT REHABILITATION
Benefits are provided for an Inpatient confinement and services provided in an approved extended care facility following, or in lieu of, an Admission to a Hospital as a result of a covered Illness, disability or Injury. Care provided must be at a skilled level and is payable in accordance with the current Schedule of Benefits. Intermediate, custodial, rest and homelike care services will not be considered skilled and are not covered. Coverage for confinement is subject to Insurer approval. Covered services include the following:
• Skilled nursing and related services on an inpatient basis for patients who require medical or nursing care for a covered Illness. A confinement includes all approved extended care facility Admissions not separated by at least 180 days.
• Rehabilitation for patients who require such care because of a covered Illness, disability or Injury.
SURGEON (IN OR OUTPATIENT) BENEFITS
We will pay charges for:
1) A Physician, for primary performance of a surgical procedure, up to the Maximum Benefit Amount shown in the Schedule of Benefits per procedure. Two or more surgical procedures through the same incision will be considered as one procedure. If an Injury or Sickness requires multiple surgical procedures through the same incision, We will pay only one benefit, the largest of the procedures performed. If multiple surgical procedures are performed during the same operative session, but through different incisions, We will pay for the most expensive procedure and 50% of Eligible Expenses for the additional surgeries.
2) A Physician, for assistant surgeon duties up to the Maximum Benefitshown in the Schedule of Benefits.
PRE-ADMISSION TESTING BENEFIT
We will pay benefits for charges for Pre-admission testing (inpatient confinement must occur within 3 days of the testing).
ANESTHESIA BENEFIT
We will pay benefits for Anesthesia for pre-operative screening and administration of anesthesia during a surgical procedure whether on an inpatient or outpatient basis
DAY SURGERY MISCELLANEOUS BENEFIT
We will pay Day Surgery Miscellaneous benefits for services and supplies such as: the cost of the operating room; laboratory tests; X-ray examinations; anesthesia; drugs or medicine; therapeutic services; and supplies, on an outpatient basis.
DIAGNOSTIC X-RAY AND LABORATORY BENEFIT
We will pay the benefit if the Plan Participant requires diagnostic x -ray and/or laboratory examinations and services due to a Covered Loss, up to the Maximum Benefit per Covered Accident or Sickness indicated in the Schedule of Benefits. Outpatient x-ray services and laboratory tests are limited to the amount shown in the Schedule of Benefits.
AMBULANCE BENEFIT
When, by reason of Injury or Sickness, a Plan Participant requires the use of a community or Hospital Ambulance in a Medical Emergency, We will pay a Benefit Amount up to a Maximum shown in the schedule, within the metropolitan area in which the Plan Participant is located at that time the service is used. Ambulance Service is transportation by a vehicle designed, equipped and used only to transport the sick and injured from home, the scene of the Accident or Medical Emergency to a Hospital or between Hospitals. Surface trips must be to the closest local facility that can provide the covered service appropriate to the condition. If there is no such facility available, coverage is for trips to the closest facility outside the local area
Air transportation is covered when Medically Necessary because of a life-threatening Injury or Sickness or if the Plan Participant is in a rural area, then air ambulance transportation to the nearest metropolitan area will be considered an Eligible Expense. Air Ambulance is air transportation by a vehicle designed, equipped and used only to transport the sick and injured to and from a Hospital for inpatient care.
PHYSICIAN VISIT BENEFIT (INPATIENT)
We will pay charges by a Physician for other than pre- or post-operative care for in-Hospital visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Physician’s Visit – In-Hospital
PHYSICIAN VISIT BENEFIT (OUTPATIENT)
We will pay charges by a Physician for office visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Physician’s Office Visits. Total visits per Injury will not exceed the combined Maximum shown in the Schedule of Benefits for All In-Hospital and Office Physician’s Visits.
CONSULTANT PHYSICIAN BENEFIT
If, by reason of Injury or Sickness, a Plan Participant requires the services of a Consultant or Specialist when they are deemed necessary and ordered by an attending Physician for the purpose of confirming or determining a diagnosis, We will pay the Covered Percentage of the Covered Expenses incurred.
EMERGENCY ROOM BENEFIT
We will pay this benefit if the Plan Participant requires Emergency Room treatment due to a Covered Loss resulting directly and independently of all other causes from a Covered Accident or Sickness.
Emergency Room means a trauma center or special area in a Hospital that is equipped and staffed to give people emergency treatment on an outpatient basis. An Emergency Room is not a clinic or
Physician’s office. Services including physician charges and related x-ray/laboratory interpretations will be paid under this benefit.
EXTENSION OF HOME COUNTRY SICKNESS MEDICAL BENEFIT
We will pay up to a maximum of $1,000 for Eligible Expenses incurred in your Home Country related to an Injury or Sickness which occurred, was diagnosed and treated outside your Home Country during your period of coverage.
MATERNITY AND PRE-NATAL CARE BENEFIT When a covered Maternity is incurred by a Plan Participant the Company will pay the Usual, Reasonable and Customary medical expenses in excess of the Deductible and Coinsurance as stated in the Schedule of Benefits, Maternity. In no event will the Company’s maximum liability exceed the maximum stated in the Schedule of Benefits Maternity, as to Eligible Expenses during any one period of individual coverage. Benefits will be payable for Eligible Expenses a Plan Participant incurs before, during, and after delivery of a Child, including Physician, Hospital, laboratory, and ultrasound services. Coverage for the Inpatient postpartum stay for the Plan Participant and her newborn Child in a Hospital, will, at a minimum, be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their guidelines for Perinatal Care. Coverage for a length of stay shorter than the minimum period mentioned above may be permitted if the Plan Participant Person’s attending Physician determines further Inpatient postpartum care in not necessary for the Plan Participant or her newborn Child provided the following are met: 1) In the opinion of the Plan Participant Person’s attending Physician, the newborn Child meets the criteria for medical stability in the guidelines for Perinatal Care prepared by the Academy of Pediatrics and the American College of Obstetricians and Gynecologists that determine the appropriate length of stay based upon the evaluation of: a) The antepartum, intrapartum, postpartum course of the mother and infant; b) The gestational stage, birth weight, and clinical condition of the infant; c) The demonstrated ability of the mother to care for the infant after discharge; and d) The availability of post discharge follow-up to verify the condition of the infant after discharge; and 2. One (1) at-home post-delivery care visit is provided to the Plan Participant at her residence by a Physician or Registered Nurse performed no later than forty-eight (48) hours following discharge of the Plan Participant and her newborn Child from the Hospital. Coverage for this visit includes, but is not limited to: a) Parent education; b) Assistance in training in breast or bottle feeding; and c) Performance of any maternal or neonatal tests routinely performed during the usual course of Inpatient care for the Plan Participant or newborn Child, including the collection of an adequate sample for the hereditary and metabolic newborn screening. (At the Plan Participant Person’s discretion, this visit may occur at the Physician’s office.)
ELECTIVE/THERAPEUTIC TERMINATION OF PREGNANCY BENEFIT
We will pay benefits as described in the Schedule of Benefits for expenses incurred for the intentional termination of pregnancy before the fetus can live independently.
MENTAL AND NERVOUS CONDITIONS EXPENSE BENEFIT
If a Plan Participant requires treatment for a Mental or Nervous Condition, We will pay for such treatment as follows:
BENEFITS FOR INPATIENT HOSPITAL CONFINEMENT
When a Plan Participant requires Hospital Confinement for treatment of a Mental or Nervous Condition, We will pay the Covered Percentage of the Eligible Expenses incurred for such Hospital Confinement.
Such confinement must be in a licensed or certified facility, including Hospitals.
BENEFITS FOR OUTPATIENT SERVICES
We will pay the Covered Percentage of the Eligible Expenses incurred for the outpatient treatment of Mental and Nervous Conditions as defined up to one visit per day.
The Mental and Nervous Condition must, in the professional judgment of healthcare providers, be treatable, and the treatment must be Medically Necessary.
Outpatient treatment and Physician services include charges made by an outpatient treatment department of a Hospital, or community mental health facility, or charges for services rendered in a Physician's office. Treatment may be provided by any properly licensed Physician, psychologist or other provider as required by law.
Biologically Based Mental Sickness means a mental, nervous, or emotional disorder caused by a biological disorder of the brain which results in a clinically significant, psychological syndrome or pattern that substantially limits the functioning of the person with the Sickness.
We will pay the Covered Percentage of the Eligible Expenses incurred for treatment of biologically based mental Sickness, including:
a) Schizophrenia;
b) Schizoaffective disorder;
c) bipolar affective disorder;
d) major depressive disorder;
e) specific obsessive-compulsive disorder;
f) delusional disorders;
g) obsessive compulsive disorders;
h) anorexia and bulimia; and
i) panic disorder.
ALCOHOL AND DRUG ABUSE EXPENSE BENEFIT
If a Plan Participant requires treatment on account of alcoholism, Alcohol Abuse, Drug Abuse or drug dependency, We will pay for such treatment as follows:
BENEFITS FOR INPATIENT HOSPITAL CONFINEMENT
When a Plan Participant is confined as an inpatient in: (i) a Hospital; or (ii) a Detoxification Facility for the treatment of alcoholism, Alcohol Abuse, Drug Abuse or drug dependency, We will pay the Covered Percentage of the Eligible Expenses incurred for such Hospital Confinement.
Such Confinement must be in a licensed or certified facility, including Hospitals
BENEFITS FOR OUTPATIENT SERVICES
We will pay the Covered Percentage of the Eligible Expenses incurred for the treatment of alcoholism, Alcohol Abuse, Drug Abuse, or drug dependency.
Outpatient Treatment and Physician services include charges for services rendered in a Physician's office or by an outpatient treatment department of a Hospital, community mental health facility or alcoholism treatment facility, so long as the Hospital, community mental health facility or alcoholism treatment facility is approved by the Joint Commission on the Accreditation of Hospitals or certified by the Department of Health. The services must be legally performed by or under the clinical supervision of a licensed Physician or a licensed psychologist who certifies that a Plan Participant needs to continue such treatment.
Alcohol Abuse means a condition that is characterized by a pattern of pathological use of alcohol with repeated attempts to control its use, and with significant negative consequences in at least one of the following areas of life: medical, legal, financial, or psycho-social.
Drug Abuse means a condition that is characterized by a pattern of pathological use of a drug with repeated attempts to control its use, and with significant negative consequences in at least one of the following areas of life: medical, legal, financial, or psycho-social.
Detoxification Facility means a facility that provides direct or indirect services to an acutely intoxicated individual to fulfill the physical, social and emotional needs of the individual by:
a) monitoring the amount of alcohol and other toxic agents in the body of the individual;
b) managing withdrawal symptoms; and
c) motivating the individual to participate in the appropriate addiction treatment programs for Alcohol and Drug Abuse
EMERGENCY DENTAL EXPENSE BENEFIT
We will pay benefits as described in the Schedule of Benefits for expenses for emergency dental treatment due to Injury to natural teeth.
PHYSIOTHERAPY EXPENSE BENEFIT
We will pay benefits as described in the Schedule of Benefits for eligible Physiotherapy expenses incurred by the Plan Participant. We will pay Usual, Reasonable and Customary expenses in excess of the Deductible as stated in the Schedule of Benefits. In no event will the Company’s maximum liability exceed the maximum stated in the Schedule of Benefits, as to Eligible Expenses during any one period of individual coverage.
For the purpose of this section, Physiotherapy means charges for physiotherapy if recommended by a Physician for the treatment of a specific Disablement and administered by a licensed physiotherapist as an inpatient or outpatient, up to up to the maximum amount shown in the Schedule of Benefits per day for the Outpatient Physiotherapy benefit. Charges include treatment and office visits connected with such treatment when prescribed by a Physician, including diathermy, ultrasonic, whirlpool, heat treatments, microtherm, chiropractic, adjustments, manipulation, acupuncture, occupational therapy, homeopathy, vocational and speech therapy, or any form of physical therapy.
AIDS/HIV
Benefits are provided for Medically Necessary, non-experimental services, supplies and medications for the treatment of Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV +), AIDS Related Complex (ARC), sexually transmitted diseases and all related conditions.
MOTOR VEHICLE ACCIDENT
We will pay benefits as described in the Schedule of Benefits for injuries sustained in a motor vehicle Accident.
DURABLE MEDICAL EQUIPMENT EXPENSE BENEFIT
If, by reason of Injury or Sickness, a Plan Participant requires the use of Durable Medical Equipment, We will pay the Covered Percentage of the Eligible Expenses incurred by a Plan Participant for such Durable Medical Equipment. We pay the Covered Percentage of the Eligible Expensesincurred by a Plan Participant for the purchase or rental of such item. In no event shall we pay rental charges in excess of the purchase price. Any rental charges paid will be applied toward the cost of the purchase price if the equipment is purchased at a later date. If Durable Medical Equipment is purchased, it is Our property and is to be returned to Us, at Our expense, upon completion of a Plan Participant's need, if so requested by Us.
We do not pay for the replacement of Durable Medical Equipment.
Durable Medical Equipment means medical equipment that:
1) is prescribed by the Physician who documents the necessity for the item including the expected duration of its use;
2) can withstand long-term repeated use without replacement;
3) is not useful in the absence of an Injury or Sickness and
4) can be used in the home without medical supervision
EMERGENCY MEDICAL EVACUATION, MEDICAL REPATRIATION AND RETURN OF REMAINS
When You suffer loss of life for any reason or incur a Sickness or Injury during the course of Your Trip, the following benefits are payable, up to the Maximum Benefit Amount shown in the Schedule of Benefits.
1) Emergency Medical Evacuation: If the local attending Legally Qualified Physician and the Program Medical Advisor determine that transportation to a Hospital or medical facility is Medically Necessary to treat an unforeseen Sickness or Injury which is acute or life threatening and adequate Medical Treatment is not available in the immediate area, the Transportation Expense incurred will be paid for the Usual and Customary Charges for transportation to the closest Hospital or medical facility capable of providing that treatment.
2) Medical Repatriation: If the local attending Legally Qualified Physician and the Program Medical Advisor determine that it is Medically Necessary for You to return to Your primary place of residence because of an unforeseen Sickness or Injury which is acute or life-threatening, the Transportation Expense incurred within 30 days from the date of the Covered Loss, will be paid for Your return to Your primary place of residence or to a Hospital or medical facility closest to Your primary place of place of residence capable of providing continued treatment via one of the following methods of transportation, as approved, in writing, by the Program Medical Advisor:
a) one-way Economy Transportation;
b) commercial air upgrade (to Business or First Class), based on Your condition as recommended by the local attending Legally Qualified Physician and verified in writing and considered necessary by the program Medical Advisor; or
c) other covered land or air transportation including, but not limited to, commercial stretcher, medical escort, or the Usual and Customary Charges for air ambulance, provided such transportation has been pre-approved and arranged by the Program Medical Advisor. Transportation must be via the most direct and economical route.
3) Return of Remains: In the event of Your death during a Trip, the expense incurred within 30 days from the date of the Covered Loss will be paid for minimally necessary casket or air tray, preparation and transportation of Your remains to Your Home Country or to the place of burial.
OUT-PATIENT PRESCRIPTION DRUG BENEFIT
We will pay the Eligible Expenses, subject to the Deductible Amount, co-payment, and Coinsurance Percentage shown in the Schedule of Benefits, if any; for a Prescription Drug or medication when prescribed by a Physician on an outpatient basis.
Prescription Drug means a drug which:
1) Under Federal law may only be dispensed by written prescription; and
3) Is utilized for the specific purpose approved for general use by the Food and Drug Administration.
The Prescription Drug must be dispensed for the outpatient use by the Plan Participant:
1) On or after the Plan Participant's Effective Date; and
2) By a licensed pharmacy provider. Benefits are payable up to the Maximum Benefit Amount shown on the Schedule of Benefits.