This Plan shall pay Reasonable and Customary charges for Covered Expenses, excess of the Deductible and Coinsurance up to the Medical Maximum, incurred by you due to a covered Injury or Illness which occurred during your Period of Coverage outside your Home Country (except as provided under the Home Country Coverage). All bodily disorders existing simultaneously which are due to the same or related causes shall be considered one Disablement. If a Disablement is due to causes which are the same or related to the cause of a prior Disablement, the Disablement shall be considered a continuation of the prior Disablement and not a separate Disablement. The initial Treatment of an Injury or Illness must occur within 30 days of the date of Injury or onset of Illness.
Only such expenses which are specifically enumerated in the following list of charges are incurred within your Period of Coverage, and which are not excluded shall be considered Covered Expenses:
When covered maternity expenses are incurred by You or Your eligible dependents, the Company will pay Reasonable Charges for medical expenses in excess of the Deductible and Coinsurance. In no event shall the Company’s maximum liability exceed the maximum stated in the Schedule of Benefits, as to Covered Expenses during any one period of individual coverage.
You or Your representative must notify the Company of a Pregnancy within the first trimester.
As stated in the Schedule of Benefits, benefits will be payable for covered expenses You incur before, during, and after delivery of a child, including physician, hospital, laboratory, and ultrasound services. Coverage for the Inpatient postpartum stay for You and Your 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 per their guidelines for perinatal care.
Coverage for a length of stay shorter than the minimum period mentioned above may be permitted if Your attending physician determines further Inpatient postpartum care is not necessary for You or Your newborn child provided the following are met:
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In the opinion of Your 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:
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The antepartum, intrapartum, postpartum course of the mother and infant;
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The gestational stage, birth weight, and clinical condition of the infant;
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The demonstrated ability of the mother to care for the infant after discharge; and
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The availability of post discharge follow up to verify the condition of the infant after discharge; and
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One (1) at-home post delivery care visit is provided to You at Your residence by a physician or nurse performed no later than forty-eight (48) hours following discharge for You and Your newborn child from the hospital. Coverage for this visit includes, but is not limited to:
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Parent education;
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Assistance and training in breast or bottle feeding; and
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Performance of any maternal or neonatal tests routinely performed during the usual course of Inpatient care for You or Your newborn child, including the collection of an adequate sample for the hereditary and metabolic newborn screening. (At Your discretion, this visit may occur at the physician’s office.)
Mental Illness
For the purpose of this section, only such expenses, incurred as the result of Treatment or Medication for Mental Illness, which are specifically enumerated in the following list of charges, and which are not excluded, shall be considered as Covered Expenses:
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Inpatient Care:
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Charges made by a Hospital or mental institution for room and board, floor nursing and other 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 or mental institution’s average charge for semi-private room and board accommodation.
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Charges made for diagnosis and Treatment by a Physician.
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Charges made for the cost and administration of anesthetics.
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Charges for Medication, x-ray services, laboratory tests and services, oxygen, and medical Treatment.
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Drugs and Medicines that can only be obtained upon a written prescription of a Physician.
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Outpatient care:
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Charges made for diagnosis and Treatment by a Physician.
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Charges made for the cost and administration of anesthetics.
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Charges for Medication, x-ray services, laboratory tests and services, oxygen, and medical Treatment.
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Drugs and Medicines that can only be obtained upon a written prescription of a Physician.
Only those expenses specifically described above which are incurred within the following Limits from the onset of the Mental Illness and which are not excluded are considered Covered Expenses. Mental Illness must first manifest itself during the Period of Coverage.
Inpatient Care – Shall be payable at 50% to $10,000, subject to a maximum of 45 days of Inpatient care.
Outpatient – Shall be payable at 80% up to a maximum of $500.
Alcohol and Drug abuse
Benefits are paid for Treatment or medication for Alcohol and Drug Abuse, which are not excluded and covered under this policy, shall be considered a Covered Expense. Benefits shall be payable at 50% up to $1,000.
Emergency Dental Treatment
Benefits are paid for Reasonable and Customary expenses in excess of the Deductible and Coinsurance of $250 per tooth up to a maximum of $500, for the emergency repair or replacement of sound, natural teeth damaged as the result of a Covered Accident.
Emergency Medical Evacuation & Repatriation
Benefits are paid for Covered Expenses incurred up to $100,000, for any covered Injury or Illness commencing during Your Period of Coverage that results in a Medically Necessary Emergency Medical Evacuation or Repatriation. The decision for an Emergency Medical Evacuation or Repatriation must be pre-approved and arranged by Seven Corners Assist in consultation with your local attending Physician.
Emergency Medical Evacuation or Repatriation means: a) your medical condition warrants immediate transportation from the place where you are located (due to inadequate medical facilities) to the nearest adequate medical facility where medical Treatment can be obtained; or b) after being treated at a local medical facility, your medical condition warrants transportation with a qualified medical attendant to your Home Country to obtain further medical Treatment or to recover; or c) both a) and b) above.
Covered Expenses are expenses for transportation, medical services and medical supplies necessarily incurred in connection with Emergency Medical Evacuation or Repatriation. All transportation arrangements must be by the most direct and economical route. Expenses for special transportation and medical supplies and services must be: a) pre-approved and ordered by the Assistance Company and b) required by the standard regulations of the conveyance transportation. Transportation means any land, water or air conveyance required to transport you. Special transportation includes, but is not limited to, licensed ground and air ambulances, commercial airlines, and private motor vehicles.
Return of Mortal Remains
Benefits will be paid for Reasonable and Customary Covered Expenses incurred up to $25,000, to return your remains to your Home Country, if you should die. Covered Expenses include, but are not limited to, expenses for embalming or Cremation, a minimally necessary container appropriate for transportation, shipping costs, and the necessary government authorizations. All Covered Expenses in connection with a Return of Mortal Remains or Cremation must be pre-approved and arranged by Seven Corners Assist.
Emergency Medical Reunion
When Seven Corners Assist and your attending Physician determine that it is necessary and prudent for you to have an Emergency Medical Evacuation or Repatriation, this Plan will arrange to bring an individual of your choice, from your Home Country, to be at your side while you are hospitalized and then accompany you during your return to your Home Country. Benefits will be paid up to $5,000 for a round-trip economy airfare ticket as well as for reasonable travel and accommodation expenses up to a maximum of 10 days, as pre-approved and arranged by Seven Corners Assist.
Accidental Death & Dismemberment
Benefits shall be paid to you if you sustain an accidental Injury or Loss. The Injury must occur during the Period of Coverage and death or dismemberment as a result of that accident must occur within 365 days from the date of Accident. Benefits payable for any such loss shall be in accordance with the following table: If you incur more than one Loss stated in the following Table as the result of one Accident, only the largest amount, shall be payable.
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Description of loss |
Percent of principal sum |
|
Life |
100% |
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Both Hands or Both Feet or Sight of Both Eyes |
100% |
|
One Hand and One Foot |
100% |
|
Either Hand or Foot and Sight of One Eye 100% |
100% |
|
Either Hand or Foot |
50% |
Spinal Manipulation
Benefits shall be paid for Spinal Manipulation which is prescribed, performed, or ordered by a licensed chiropractor for the relief of pain. Benefits are payable up to $500.
Home Country Coverage
Incidental Trips to the Home Country – During Your Period of Coverage, the Insured may return to their Home Country for incidental visits of up to 30 days per year (or pro-rata thereof). If during an incidental trip home, the Insured suffers an Injury or Illness, this Plan shall pay up to $1,000 of Covered Expenses for that Injury or Illness. Treatment for this Injury or Illness must occur within the Insured’s Home Country while on the incidental visit.
Home Country Extension of Benefits – The Plan shall pay up to a maximum of $1,000 for Covered Expenses incurred in your Home Country related to an Injury or Illness which occurred, was diagnosed and treated outside your Home Country during your Period of Coverage. Only those covered expenses incurred within 30 days of your return to your Home Country shall be considered eligible.