INF SelectCare

Plan Detail

Plan Administrator: INF Healthcare | AM Best Rating : "A+"(Superior) | Underwriter: Axis Insurance Company.

Description


Please note that certain words used in this Policy have specific meanings. The words defined below and capitalized within the text of this Policy have the meanings set forth below.

Accident or Accidental means a sudden, unexpected, specific and abrupt event that occurs by chance at an identifiable time and place while the Insured Person is covered under this Policy.

Age an Insured Person’s age, means for purposes of initial premium calculations, is His age attained on the later of the first day of the Policy Term and the date coverage becomes effective for Him under this Policy.

Aircraft means a vehicle which:

1. has a valid Airworthiness Certificate; and

2. is being flown by a pilot with a valid license to operate the Aircraft.

Airworthiness Certificate means a “Standard" Airworthiness Certificate issued by the Federal Aviation Agency of the United States of America or its equivalent issued by the governmental authority having jurisdiction over civil aviation in the country of registry.

Calendar Year means January 1st through December 31st of any year

Common Carrier or Public Conveyance means:

1. a Conveyance, including Aircraft, licensed for hire to carry fare-paying passengers; or

2. a transport Aircraft operated by the Air Mobility Command of the United States of America or similar air transport service of another country.

Conveyance means a motorized craft, vehicle or mode of transportation licensed or registered by a governmental authority.

Covered Accident means an Accident that results in a Covered Loss during the Policy Term.

Covered Activity or Covered Activities means any activity that is shown in the Schedule of Benefits and:

1. takes place under one of the Conditions of Coverage specified in the Schedule of Benefits; and

2. is sponsored, organized, scheduled or otherwise provided by the Policyholder

Covered Expenses means expenses actually incurred by or on behalf of an Insured Person for treatment, services and supplies covered by this Policy. A Covered Expense is deemed to be incurred on the date treatment, service or supply that gave rise to the expense or the charge, was rendered or obtained.

Covered Injury means Accidental bodily injury: (1) which is sustained by an Insured Person as a direct result of an unintended, unanticipated Covered Accident that is external to the body and that occurs while the injured person's coverage under the Policy is in force; (2) which results directly and independently from all other causes from a Covered Accident; and (3) which occurs while such person is participating in a Covered Activity. The Covered Injury must be caused through Accidental means. All injuries sustained by an Insured Person in any one Covered Accident, including related conditions and recurrent symptoms of these injuries, are considered a single injury.

Covered Loss means a loss which meets the requisites of one or more benefits, and results from a Covered Accident, Covered Injury or Covered Activity.

Dependent Child means the Insured Person's unmarried child who meets the following requirements.

1. A child from birth to 17 years old.

2. A child who is 17 or more years old but less than 30 years old, enrolled in a school as a full-time student and primarily supported by the Insured Person. Coverage will continue during any period between school terms or school years as long as the Company is provided satisfactory proof that he has enrolled for the next following school term or year.

3. A child who is 17 or more years old, primarily supported by the Insured Person, and incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child’s condition and dependence must be submitted to the Company within 31 days after the date the child ceases to qualify as a Dependent Child for the reasons listed above. During the next two years, the Company may, from time to time, require proof of the continuation of such condition and dependence. After that, the Company may require proof no more than once a year.

A Dependent Child, for purposes of this definition, includes the Insured Person’s:

1. Natural child;

2. Adopted child, beginning with any waiting period pending finalization of the child’s adoption;

3. Stepchild who resides with the Insured Person;

4. Child for whom the Insured Person is legal guardian, as long as the child resides with the Insured Person and depends on him for financial support. Financial support means that the Insured Person is eligible to claim the dependent for purposes of Federal and State income tax returns.

If the Insured Person who is the legal guardian of a child is not a step-parent, grandparent, aunt or uncle, then the child must have resided with him for at least six consecutive months and intends to reside with him for an indefinite period of time.

Eligible Person

means an individual as defined in the Schedule of Benefits.

He, His, Him

refers to any individual, male or female

Home Country

means a country from which the Insured Person holds a passport or where the Insured Person has primary residency. If the Insured Person holds passports fro more than one Country, his or her Home Country will be the country that he has declared to Us in writing as his Home Country.

Hospital

means an institution that meets all of the following:

1. it is licensed as a Hospital pursuant to applicable law;

2. it is primarily and continuously engaged in providing medical care and treatment to sick and injured persons;

3. it is managed under the supervision of a staff of medical doctors;

4. it provides 24-hour nursing services by or under the supervision of a graduate registered Nurse (R.N.);

5. it has medical, diagnostic and treatment facilities, with major surgical facilities on its premises, or available on a prearranged basis; and

6. it charges for its services.

The term Hospital does not include a clinic, facility, or unit of a Hospital for:

1. rehabilitation, convalescent, custodial, educational or nursing care;

2. the aged, drug addicts or alcoholics; or

3. a Veteran’s Administration Hospital or Federal Government Hospital unless the Insured Person incurs an expense.

Hospital Confined, Hospital Stay

means a stay of 24 or more consecutive hours as a confined to a hospital registered resident bed-patient in a Hospital. Separate Hospital Stays due to the same Covered Accident or Emergency Sickness will be treated as one Hospital Stay unless separated by at least 30 days .

Immediate Family Member

means a person who is related to the Insured Person in any of the following ways: Spouse, brother-in-law, sister- in-law, daughter-in-law, son-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild).

Inpatient

means confined overnight as a registered bed patient in a Hospital or other medical facility where at least one day’s room and board is charged. The confinement must be on the advice of a Physician.

Insured Person

means an Eligible Person, as defined in the Schedule of Benefits, for whom required premium has been paid when due and for whom coverage under this Policy remains in force.

Medically Necessary

means medical services that: (1) are essential for diagnosis, treatment or care of the Covered Injury or Emergency Sickness for which it is prescribed or performed; (2) meets generally accepted standards of medical practice; and (3) are ordered by a Physician and performed under His care, supervision or order.

Nurse

means a licensed graduate Registered Nurse (R.N.) or a Licensed Practical Nurse (L.P.N.) who is not:

1. the Insured Person;

2. an Immediate Family Member of either the Insured Person or the Insured Person's Spouse;

3. a person living in the Insured Person's household; or

4. a person employed or retained by the Policyholder.

Outpatient

means an Insured Person who is a patient and is not hospitalized overnight but who visits a Hospital, clinic, or associated facility for diagnosis or treatment.

Physician

means a licensed health care provider practicing within the scope of his license and rendering care and treatment to the Insured Person that is appropriate for the condition and locality, and who is not:

1 the Insured Person;

2. an Immediate Family Member of either the Insured Person or the Insured Person's Spouse;

3. a person living in the Insured Person's household;

4. a person employed or retained by the Policyholder; or

5. a person providing homeopathic, aroma-therapeutic, or herbal therapeutic services.

Policyholder

means the entity, named on this Policy’s face page, to which the Company issues this Policy.

Policy Term

means the time period defined for the Policyholder shown on this Policy’s face page

Pre existing condition

means an illness, disease, injury or other condition of the Insured Person that in the 90 day period before the Insured Person’s coverage became effective under the Policy:

1. Was treated by a Physician or treatment had been recommended by a Physician.

2. Required taking prescribed drugs or medicines, or

3. first manifested itself, worsened, became acute or exhibited symptoms that would have caused an ordinarily prudent person to seek diagnosis.

Private Passenger Automobile

means a validly registered, four wheel private passenger car, including Policyholder-owned cars, campers, motor homes, station wagons, sport utility vehicles, pick-up trucks and van-type cars that are not licensed commercially or being used for commercial purposes. Any vehicle being used as a taxi cab, bus or other Public Conveyance will not be considered a Private Passenger Automobile.

Scheduled Airlines or Aircraft

means any carrier holding a certificate, license or similar authorization for civilian scheduled air transport issued by the country of the Aircraft's registry, and which, in accordance with that authorization flies, maintains and publishes schedules and tariffs for regular passenger service between named cities at regular and specified times, but only if the Aircraft is then used for any regular or chartered flight operated by such carrier.

Spouse

means the Insured Person's lawful spouse.

Usual and Customary Charge

means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided.

We, Us, Our

means AXIS Insurance Company.

CONDITIONS OF COVERAGE

This Section describes the Conditions of Coverage under which benefits provided by this Policy become payable. Any benefits are payable only once, even though more than one Condition of Coverage may apply. Please read these and the Common Exclusions sections in order to understand all of the terms, conditions and limitations of coverage.

24-HOUR ACCIDENT COVERAGE

The Company will pay the benefit amount shown in the Schedule of Benefits,subject to all applicable conditions and exclusions,when the insured persons suffers a covered loss that occurs during one of the covered activites shown in the schedule of benefits

Definitions

For purposes of this condition of coverage:

Personal Deviation means

1. an activity that is not reasonably related to the Insured Person's covered activity;

2. such travel or activities coincide with the Insured person's covered activity; and

3. Personal Deviation is limited to any consecutive 2 day period immediately prior to,during or following such covered activity.

Exclusions

Exclusions that apply to this condition of coverage are in the common exclusions section.

Certain words used in this Rider have specific meanings. The words defined below and capitalized within the text of this Rider have the meanings set forth below. If a capitalized term is not set forth below, it may be defined in the Policy to which this Rider is attached. If a term contained in this Rider is defined in both the Policy and this Rider, the definition in this Rider shall govern.

Benefit Period as used in this Rider means the maximum period that benefits are payable under this Rider.

Complication(s) of Pregnancy mean(s) conditions which require Hospital Stays before the pregnancy ends and whose diagnoses are distinct from but are caused or affected by pregnancy. These conditions are

Acute nephritis or nephrosis; or

Pre eclampsia; or

Eclampsia puerperal infection; or

RH Factor problems; or

Severe loss of blood requiring transfusion; or

Cardia decomposition or missed abortion; or

Similar condition as severe as these above;

Non elective cesarean section; and

Termination of an ectopic pregnancy; and

Spontaneous termination when live birth is not possible (This does not include voluntary or elective abortion)

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 the mother is determined to be in distress and is in immediate danger of death, Sickness or Covered Injury if the 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 vaginal delivery is attempted but discontinued due to immediate danger of death, Sickness or injury to child or mother.

Not included: (a) false labor, occasional spotting or Physician prescribed rest during the period of pregnancy; (b) morning sickness; (c) hyperemesis gravidarum and (d) similar conditions not medically distinct from a difficult pregnancy.

Covered Expenses as used in this Rider means expenses actually incurred by or on behalf of an Insured Person for treatment, services and supplies covered by this Policy. Coverage under the Policyholders’ Policy must remain continually in force from the date of the Covered Accident or Sickness until the date of treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date treatment, service or supply that gave rise to the expense or the charge, was rendered or obtained.

Covered Injury as used in this Rider means bodily Injury; 1) directly and independently caused by specific accident which is unrelated to any pathological, functional, or structural disorder to Injury; 2) treated by a Physician within 30 days after the Covered Accident; and 3) which caused loss during the term of this Rider.

Covered Trip as used in this Rider, means travel by air, land or sea from the Insured Person’s Home Country.

Deductible as used in this Rider means the amount that must be paid for Covered Medical Services by the Insured Person before benefits will become payable under this Rider. A separate deductible shall apply to each Covered Loss.

Home Country as used in this Rider means a country from which the Insured Person holds a passport or where the Insured Person has primary residency. If the Insured Person holds passports from more than one Country, his or her Home Country will be the country that he has declared to Us in writing as his Home Country

Hospital - as used in this Rider, means a facility that:

1. is operated according to law for the care and treatment of injured people;

2. has organized facilities for diagnosis and surgery on its premises or in facilities available to it on a prearranged basis;

3. has 24 hour nursing service; and

4. is supervised by one or more Physicians.

A Hospital does not include:

1. a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care;

2. a facility that is, other than incidentally, a rest home, nursing home, convalescent home or home for the aged; nor does it include any ward, room, wing, or other section of the hospital that is used for such purposes; or

3. any military or veterans hospital or soldiers home or any hospital contracted for or operated by any national government or government agency for the treatment of members or ex-members of the armed forces.

Hospital Confined as used in this Rider means a stay of 48 or more consecutive hours as a registered resident bed-patient in a Hospital

Intensive Care Unit (ICU) as used in this Rider means specifically designated facility of the Hospital that is designed to provide intensive care services on an interdisciplinary basis to critically ill inpatients. provides the highest level of medical care and that is restricted to those patients who are critically ill or injured and need constant medical care. Such care must be ordered by a Physician. The facility must provide: room and board, registered nursing care, and special equipment and supplies on a standby basis. Such facilities must be separate and apart from the surgical recovery room and from rooms, beds, and wards customarily used for patient confinement.

Medically Necessary - as used in this Rider refers to a Covered Medical Service that:

1. is essential for diagnosis, treatment or care of the Covered Injury or Sickness for which it is prescribed or performed;

2. meets generally accepted standards of medical practice; and

3. is ordered by a Physician and performed under his care, supervision or order

Physiotherapy as used in this Rider means any form of the following: physical or mechanical therapy, diathermy, ultrasonic therapy; heat treatment in any form; manipulation or massage administered by a Physician. It does not include chiropractic care.

Prescription Drugs as used in this Rider means 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a Physician; and 4 Injectable insulin.

Physician as used in this Rider means a licensed health care provider practicing within the scope of his license and rendering care and treatment to the Insured Person that is appropriate for the condition and locality, and who is not:

1. the Insured Person;

2. an Immediate Family Member of either the Insured Person or the Insured Person's Spouse;

3. a person living in the Insured Person's household; or

4. a person providing homeopathic, aroma-therapeutic, or herbal therapeutic services.

Sickness as used in this Rider means disease or illness, including related conditions and recurrent symptoms, which begin after the effective date of an Insured Person’s coverage and while coverage is in force under this Rider.

Usual and Customary Charge(s) - as used in this Rider means a charge that:

1. is made for a Covered Medical Service;

2. does not exceed the usual level of charges for similar treatment, services or supplies in the locality where the expense is incurred (for a Hospital room and board charge, other than for a Medically Necessary stay in an intensive care unit or a cardiac care unit, does not exceed the Hospital’s most common charge for semi-private room and board); and

3. does not include charges that would not have been made if no insurance existed.

NON DUPLICATION OF PAYMENT

This Rider provides benefits in accordance with all of its provisions only to the extent that benefits are not provided by any Other Health Care Plan. If the Insured Person is covered by an Other Health Care Plan, all benefits payable by such insurance will be determined before benefits will be paid by this Rider. If the Insured Person is insured under group or blanket insurance that is also excess to other coverage, this Rider pays a maximum of 50% of the benefits otherwise payable. To the extent that The Company pays a benefit that is payable by an Other Health Care Plan, the Insured Person shall assist Us in recovering this amount from such Other Health Care Plan.

In no situations shall benefits paid by this Rider exceed: (1) the Benefit Period; and (2) 100% of the compensable expenses incurred when combined with benefits paid by any Other Health Care Plan