Plan Administrator: Seven Corners | AM Best Rating: A "Excellent" | Underwriter: Lloyd's
SCHEDULE OF BENEFITS
All benefits listed in this Schedule of Benefits are in United States Dollar amounts. All Medical and Dental benefits are subject to the Deductible. All benefits are per person, per Injury or Illness, unless otherwise noted. No Coinsurance applies.
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Plan Name |
Inbound® USA-Basic |
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Plan type |
Scheduled |
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Length of Coverage |
5 days to 364 days |
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Ages |
14 days to age 99 |
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Benefit Period |
180 Days |
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Medical Treatment & Services |
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Medical Maximum Options (Per person, per Injury or Illness) |
Ages 14 days to 69 years: $50,000; $75,000; $100,000; $125,000;$150,000 Ages 70 to 99 years: $50,000; $75,000; $100,000 |
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Deductible Options (Per person, per Injury or Illness) |
Ages 14 days to 69 years: $0; $50; $100 Ages 70 to 99 years: $100; $200 |
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Hospital Room & Board, including Laboratory Tests, X-Rays, Prescription Medication, Extended Care Facility and other Hospital Miscellaneous Expenses |
Up to $1,000/day, 30 day maximum |
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Hospital Intensive Care Unit |
Additional $500/day, 8 day maximum |
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Surgery (Inpatient & Outpatient) |
Up to $3,000 |
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Anesthetist (Inpatient & Outpatient) |
Up to $500 |
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Assistant Surgeon (Inpatient & Outpatient) |
Up to $500 |
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Physician Non-Surgical Visits, including Urgent Care (Inpatient & Outpatient) |
Up to $50/visit, 1/day, 30 visits maximum |
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Consulting Physician when requested by attending Physician |
Up to $250 |
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Private Duty Nursing |
Up to $500 |
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Pre-Admission Tests within 7 days of Hospital admission |
Up to $750 |
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Diagnostic Basic (X-ray & Laboratory Tests) |
Up to $500 |
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Diagnostic Comprehensive (PET, CAT, MRI) |
Up to $750 |
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Hospital Emergency Room |
Up to $250 |
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Prescription Drugs |
Up to $150 Per Period of Coverage |
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Outpatient Surgical Facility Day surgery miscellaneous, related to Outpatient scheduled Surgery performed at a Hospital or licensed Outpatient Surgery center; including the cost of the operating room, anesthesia, drugs and medicines and medical supplies. |
Up to $750
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Other Treatment & Services |
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Ambulance Services |
Up to $250 |
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Initial Orthopedic Prosthesis/Brace |
Up to $1,000 |
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Durable Medical Equipment |
Up to $1,200 |
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Chemotherapy and/or Radiation Therapy |
Up to $1,500 |
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Dental Emergency - Accident Coverage |
Up to $500 |
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Dental Emergency - Sudden Relief of Pain* |
Up to $500 |
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Mental & Nervous Disorder & Substance Abuse |
Same as any Illness |
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Physiotherapy (Inpatient & Outpatient) |
Up to $30/visit, 1/day, 12 visits maximum |
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Emergency Medical Evacuation |
$100,000 |
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Return of Mortal Remains |
$20,000 |
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Local Cremation / Burial |
$5,000 |
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Terrorism |
$25,000 |
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Incidental trips to Home Country* |
$25,000 |
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Common Carrier AD&D |
$25,000 per Insured Person (aggregate limit of $125,000 per any one Accident) |
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International Travel Coverage* |
Up to Medical Maximum |
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Acute Onset of Pre-Existing Conditions |
Ages 14 days to 69 years: Up to $50,000 Ages 70 to 79 years: Up to $25,000 Age 80 and older: N/A |
MEDICAL
Deductibles: Subject to Section 1.4, the Deductible is per person and per Injury or Illness. It is applied to Covered Expenses and must be paid by You prior to receiving payment or reimbursement of benefits under this Certificate. In no event will the Company's maximum liability exceed the amount set forth in the Schedule of Benefits.
Deductible
The Deductible is set forth in the Schedule of Benefits.
Medical Covered Expenses. Subject to the terms of the Certificate, the Company will reimburse You for Covered Expenses up to the amount shown in the Schedule of Benefits for the following medical Expenses that are incurred as the result of and within the Benefit Period. Payment for any Covered Expense will be no more than the amount shown in the Schedule of Benefits. The total payable for all Covered Expenses will be no more than the Medical Maximum per Illness or Injury. If a benefit is designated in the Schedule of Benefits, Covered Medical Expenses include:
(a) Hospital Room and Board:
(i) Daily semi-private room rate when Hospital confined;
(ii) General nursing care provided and charged for by the Hospital;
(iii) Hospital Miscellaneous Expenses: 1) While Hospital confined; or 2) for pre-admission expenses for being Hospital confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.
(b) Intensive Care: Intensive Care is defined in Section 8.
(c) Surgery: Physician’s fees for Inpatient or Outpatient Surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits.
(d) Anesthetist Services: In connection with Inpatient or Outpatient Surgery.
(e) Assistant Surgeon: In connection with Inpatient or Outpatient Surgery.
(f) Physician’s Visits:
(i) When Hospital confined: Benefits are limited to one (1) Physician’s visit per day. Benefits do not apply when related to Surgery. Covered medical Expenses will be paid under the Inpatient benefit or under the Outpatient benefit for Physician’s visits, but not both.
(ii) Outpatient: Benefits are limited to one (1) Physician’s visit per day. Includes injections administered during visit. Benefits do not apply when related to Surgery or Physiotherapy. Covered medical Expenses will be paid under the Outpatient benefit or under the Inpatient benefit for Physician’s visits, but not both.
(g) Consultant Physician fees: When requested and approved by the attending Physician.
(h) Private Duty Nursing Services:
(i) Private duty nursing care only; and
(ii) While Hospital confined; and
(iii) Ordered by a licensed Physician; and
(iv) Medically Necessary.
General nursing care provided by the Hospital is not covered under this benefit.
(i) Pre-Admission Testing: Limited to routine tests such as complete blood count, urinalysis, and chest x-ray. If otherwise payable under the Certificate, major diagnostic procedures such as CAT scans, NMR’s, and blood chemistries will be paid as “Hospital Miscellaneous Expenses” under the “Hospital Room and Board” benefit.
(j) Diagnostic Basic: X-rays and laboratory tests (Outpatient)
(k) Diagnostic Comprehensive: PET, CAT, and MRI scans (Outpatient)
(l) Hospital Emergency Room (Outpatient): Only in connection with a Medical Emergency as defined in Section 8. Benefits will be paid for the use of the emergency room and supplies.
(m) Prescription Drugs (Outpatient)
(n) Outpatient Surgical Facility Day Surgery Miscellaneous: In connection with Outpatient day Surgery; excluding non-scheduled Surgery, and Surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic. Benefits will be paid for services and supplies such as the cost of the operating room, laboratory tests and x-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies.
(o) Initial Orthopedic Prosthesis/Braces:
(i) When prescribed by a Physician; and
(ii) a written prescription accompanies the claim when submitted.
(p) Durable Medical Equipment: Durable Medical Equipment is defined in Section 8.
(q) Chemotherapy and/or Radiation Therapy.
(r) Mental and Nervous Disorder including Substance Abuse (Inpatient or Outpatient): The benefits and the maximum amounts are specified in the Schedule of Benefits. Benefits are limited to one (1) Physician’s visit per day.
(s) Physiotherapy (Inpatient & Outpatient).
The exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 3.2.
Ambulance Services. The Company will reimburse You up to the amount set forth in the Schedule of Benefits for the Period of Coverage for local ambulance service from within the metropolitan area to the nearest Hospital having facilities required for Medically Necessary Treatment. Other than in an emergency, a licensed air ambulance transportation may be substituted for a ground ambulance if You are in a rural area and unreachable by ground ambulance. The exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 3.3.
Pre-Certification Requirements. Pre-certification is required in the United States only and for the following:
(a) Outpatient surgeries or procedures;
(b) Inpatient surgeries, procedures, or stays including those for rehabilitation;
(c) Diagnostic procedures including MRI, MRA, CT, and PET Scans;
(d) Chemotherapy;
(e) Radiation therapy;
(f) Physiotherapy (must include Physician’s recommendation and treatment plan); and
(g) Extended Care Facility.
To obtain pre-certification, You must:
(a) Contact Seven Corners Assist as soon as possible before the Expense is incurred;
(b) Comply with Seven Corners Assist’s instructions and submit any required information or documents; and
(c) Notify all Physicians, Surgeons, Hospitals, and other providers that this Insurance contains pre-certification requirements and request that they fully cooperate with Seven Corners Assist.
If You do not comply with the pre-certification requirements:
(a) Covered Expenses will be reduced by $500; and
(b) The Deductible will be subtracted from the remaining benefit amount.
Pre-certification does not guarantee coverage, payment, or reimbursement. Eligibility, coverage, and payment or reimbursement remains subject to all the terms, conditions, provisions, and exclusions herein.
For Inpatient stays of any kind in the United States, the Administrator initially will pre-certify a limited number of days of confinement. Notify all Physicians, Surgeons, Hospitals, and other providers that this Insurance requires them to receive prior approval for additional days of confinement following the pre-certification requirements.
Incidental Trips to Home Country. If the Period of Coverage is greater than thirty (30) days, the Company will reimburse You for Covered Expenses up to the amount set forth in the Schedule of Benefits for a new covered Injury or Illness that begins while You are on an incidental trip to Your Home Country. You must first depart Your Home Country before utilizing this benefit, and it does not apply to the final trip to Your Home Country. You may be required to provide proof of your travel intentions.
Additionally, this coverage will not apply:
(i) if the Illness began or Injury occurred while You were outside Your Home Country; or
(ii) for Pre-Existing Conditions.
Under this Section 3.5, You will receive five (5) days of medical coverage per month up to sixty (60) days for every three hundred sixty-four (364) days purchased in a policy. This coverage will apply separately for each three hundred sixty-four (364) day period, which means that any unused days of coverage from the prior three hundred sixty-four (364) day period(s) will not carry over to the any subsequent three-hundred sixty-four (364) day period, but, instead, you will start earning days of coverage over again. The exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 3.5.
The limit for this coverage is that amount shown on the Schedule of Benefits under “Incidental Trips to Home Country,” not that amount shown for “Medical Maximum Options.” The Deductible options set forth in Section 3.1 apply to this coverage and will be Your responsibility.
Acute Onset of Pre-Existing Condition(s). If you are a non-United States Resident, the exclusion set forth in Section 7(a) is waived for the eligible medical Expenses for the first Acute Onset of a Pre-Existing Condition(s) during the Period of Coverage up to the amount set forth in the Schedule of Benefits for eligible medical Expenses incurred in the United States. This waiver is subject to Your payment of your selected Deductible. This waiver does not include coverage for known, scheduled, required, or expected medical care, drugs, or Treatments existent or necessary prior to arrival in the United States and prior to the Effective Date of Coverage; coverage for Treatment for which You have traveled; or coverage for conditions for which travel was undertaken after Your Physician has limited or restricted travel.
Coverage ceases on the earliest of:
(i) the condition no longer being considered acute; or
(ii) your discharge from the Hospital.
Acute Onset of Pre-Existing Condition(s) is defined in Section 8. See the Schedule of Benefits for additional details.
DENTAL
Dental Emergency - Sudden Relief of Pain. If the Certificate has a Period of Coverage thirty (30) days or more, the Company will reimburse You up to the amount set forth in the Schedule of Benefits for Covered Expenses exceeding the Deductible for emergency Treatment for the relief of pain to Sound Natural Teeth. The exclusions set forth in Section 7 apply to the coverage provided by this Certificate under this Section 4.1.
Dental Emergency - Accident Coverage. The Company will reimburse You up to the amount set forth in the Schedule of Benefits for Covered Expenses exceeding the Deductible for emergency Treatment to repair or replace Sound Natural Teeth damaged as the result of an Accidental Injury caused by external contact with a foreign object. Coverage does not apply if You break a Sound Natural Tooth while eating or biting into a foreign object. Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 4.2.
EMERGENCY SERVICES AND ASSISTANCE
Emergency Medical Evacuation. The Company will pay transportation and related medical Expenses incurred during such transportation up to the amount set forth in the Schedule of Benefits if any covered Injury or Illness commences while You are outside Your Home Country during the Period of Coverage and results in Your Medically Necessary Emergency Medical Evacuation. All transportation arrangements must be by the most direct and economical route. The Emergency Medical Evacuation must be arranged by Seven Corners Assist in consultation with Your local attending Physician. Failure to utilize Seven Corners Assist will result in the denial of benefits. Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 5.1.
Return of Mortal Remains. Provided that You have not elected the benefit provided under Section 5.3, the Company will pay up to the amount set forth in the Schedule of Benefits for the reasonable expenses incurred for embalming, a minimally-necessary container appropriate for transportation, shipping costs, and the necessary government authorizations to return Your remains to Your Home Country if You die while outside Your Home Country during the Period of Coverage from an Illness or Injury covered under this Insurance. This benefit applies regardless of whether the death is related to a Pre-Existing Condition. The return of mortal remains must be arranged by Seven Corners Assist. Failure to utilize Seven Corners Assist will result in the denial of benefits. Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 5.2.
Local Burial or Cremation. Provided that You have not elected the benefit provided under Section 5.2, the Company will pay up to the amount set forth in the Schedule of Benefits for the reasonable expenses incurred for preparation and either Your local burial or Your cremation if You die while outside Your Home Country during the Period of Coverage from an Illness or Injury covered under this Insurance. This benefit applies regardless of whether the death is related to a Pre-Existing Condition. This Insurance does not include the expenses for the religious practitioners performing the service, flowers, music, food, or beverages. The local burial and cremation must be arranged by Seven Corners Assist. Failure to utilize Seven Corners Assist will result in the denial of benefits. Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 5.3.
Terrorist Activity. The Company will reimburse You up to the amount set forth in the Schedule of Benefits for Your Covered Expenses incurred resulting from Terrorist Activity provided:
(i) You have no direct or indirect involvement in the Terrorist Activity;
(ii) the Terrorist Activity is not in a country or location where the United States government has issued a Level 3 Terrorism, Level 3 Civil Unrest, or any Level 4 Travel Advisory or the appropriate authorities of either Your Host Country or Your Home Country have issued similar warnings, any of which have been in effect within the six (6) months prior to Your date of arrival; and
(iii) You departed the country or location following the date a warning to leave that country or location is issued by the United States government or the appropriate authorities of either Your Host Country or Your Home Country.
OTHER COVERAGES AND SERVICES
Travel Assistance Services. Upon enrollment, You are eligible to use any of the assistance services provided by Seven Corners Assist. These services are available 24 hours per day, 365 days per year. Multilingual personnel, Physicians, and nurses are on staff and can assist with, among other things, emergency situations and locating local facilities.
Common Carrier Accidental Death and Dismemberment. The Company will pay an indemnity up to the amount set forth in the Schedule of Benefits if You die as the result of an Injury suffered from an Accident while You were traveling on a Common Carrier. Death must occur during the Period of Coverage and while You are riding as a passenger on a Common Carrier and not as a pilot, operator, or member of the crew. The benefit will be paid to the person determined by application of the relevant provisions of Section 6.2.
The total amount payable under this Section 6.2 when there are multiple Insured Persons covered by the Certificate is the Aggregate Limit as set forth in the Schedule of Benefits. If the total of such indemnity exceeds the Aggregate Limit, the Company will not be liable to any Insured for a greater proportion of such Insured’s indemnity afforded by the Common Carrier Accidental Death and Dismemberment Benefit than their proportionate share.
Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 6.2.
International Travel Coverage. An insured person may travel to additional countries, other than the United States, up to a maximum of fourteen (14) days. You must purchase a minimum of thirty (30) days of coverage to be eligible for this benefit. International travel coverage does not include travel back to the Insured Person’s Home Country, and it does not extend after your current Expiration Date of Coverage. International travel must be utilized during your current Period of Coverage. The Trip must originate in the United States.