Plan Administrator: INF Healthcare | AM Best Rating : "A++" | Underwriter: CHUBB American Insurance Company.
THIS IS THE POLICY DOCUMENT FOR POLICY NO. GLMN10783434S. THIS POLICY IS ADMINISTERED BY INFAND UNDERWRITTEN BY ACE AMERICAN INSURANCE COMPANY, A MEMBER OF THE CHUBB GROUP OF COMPANIES, PHILADELPHIA, PA.
MEDICAL EXPENSE BENEFITS – ACCIDENT AND SICKNESS
MEDICAL EXPENSE BENEFITS
We will pay Medical Expense Benefits for Covered Expenses that result directly, and from no other cause, from a Covered Accident or Sickness. These benefits are subject to a Deductible of $500 per person for each Injury and each Sickness. The Policy Maximum for all Accident and Sickness Benefits is $150,000 (Age 69 & under) and $75,000 (Ages 70-99). Benefits are also subject to the following:
Co-Insurance Limits:
In-Network: 80% of covered Network charges up to the overall maximum benefit.
Out-of-Network: 60% of covered Network charges up to the overall maximum benefit.
Deductible per individual sickness or injury: $500.
Policy Maximum Benefits per individual sickness or injury: $150,000 - Age 69 and under; $75,000 - Age 70-99.
Covered Medical Expenses include:
EMERGENCY MEDICAL EVACUATION AND REPATRIATION OF REMAINS BENEFITS*
Emergency Medical Evacuation Benefit- We will pay up to the maximum indicated above in the Schedule of Benefits for your medical evacuation if you: 1) suffer a Medical Emergency during the course of the Trip; 2) require Emergency Medical Evacuation; and 3) are traveling on a covered Trip.
Covered Expenses include;
1)Medical Transport: expenses for transportation under medical supervision to a different hospital, treatment facility or toyour place of residence for Medically Necessary treatment in the event of your Medical Emergency and upon the request of the Doctor designated by Our assistance provider in consultation with the local attending Doctor.
2)Dispatch of a Doctor or Specialist: the Doctor’s or specialist’s travel expenses and the medical services provided onlocation, if, based on the information available, your condition cannot be adequately assessed to evaluate the need for transport or evacuation and a doctor or specialist is dispatched by Our service provider to your location to make the assessment.
3)Return of Dependent Child (ren):expenses to return each Dependent child who is under age 18 to his or her principalresidence if a) you are age 18 or older; and b) you are the only person traveling with the minor Dependent child(ren); and c)you suffer a Medical Emergency and must be confined in a Hospital.
4)Escort Services: expenses for an Immediate Family Member or companion who is traveling with you to join you duringyour emergency medical evacuation to a different hospital, treatment facility or your place of residence.
Benefits for these Covered Expenses will not be payable unless: 1) the Doctor ordering the Emergency Medical Evacuation certifies the severity of your Medical Emergency requires an Emergency Medical Evacuation; 2) all transportation arrangements made for the Emergency Medical Evacuation are by the most direct and economical conveyance and route possible; 3) the charges incurred are Medically Necessary and do not exceed the Usual and Customary Charges for similar transportation, treatment, services or supplies in the locality where the expense is incurred; and 4) do not include charges that would not have been made if there were no insurance.
Benefits will not be payable unless We authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our assistance provider. In the event you refuse to be medically evacuated, we will not be liable for any medical expenses incurred after the date medical evacuation is recommended.
Repatriation of Remains Benefit
We will pay up to the maximum indicated above in the Schedule of Benefits for the preparation and return of your body to your home if you die as a result of a Medical Emergency while traveling on a covered Trip.
Covered expenses include: 1) expenses for embalming or cremation;2) the least costly coffin or receptacle adequate for transporting the remains; 3) transporting the remains; and 4) Escort Services which include expenses for an Immediate Family Member or companion who is traveling with you to join your body during the repatriation to your place of residence.
All transportation arrangements must be made by the most direct and economical route and conveyance possible and may not exceed the Usual and Customary Charges for similar transportation in the locality where the expense is incurred. Benefits will not be payable unless We authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our assistance provider
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS of $25,000**
Definition of Injury and Scope of Coverage – 24 Hour Coverage
Principal Sum for Covered Injury: $25,000
Accidental Death and Dismemberment Benefits - If your Injury results, within 365 days from the date of a Covered Accident, in any one of the losses shown below, We will pay the Benefit Amount shown below for that loss. Principal Sum for you and your Dependents (if you have elected Dependent coverage and the required premium has been paid) is $25,000. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Covered Accident.
Schedule of Covered Losses
Covered Loss Benefit Amount
Life......................... 100% of the Principal Sum
Two or more Members....................... 100% of the Principal Sum
One Member...................... 50% of the Principal Sum
“Member means Loss of Hand or Foot, and Loss of Sight. “Loss of Hand or Foot" means complete Severance through or above the wrist or ankle joint. “Loss of Sight” means the total, permanent Loss of Sight of one eye. “Severance” means the complete separation and dismemberment of the part from the body.
Aggregate Limit - We will not pay more than $125,000 for all losses. If, in the absence of this provision, We would pay more than this amount for all losses under the policy, then the benefits payable to each person with a valid claim will be reduced proportionately.