Plan Administrator: Seven Corners | AM Best Rating: A "Excellent" | Underwriter: Lloyd's
All benefits listed in this Schedule of Benefits are in UNITED STATES Dollar amounts. All Medical and Dental benefits are subject to Deductible and Coinsurance. Also, all benefits except Loss of Checked Baggage are per Person per Period of Coverage.
Benefit or Service |
Elite |
COVERAGE LENGTH |
5 days to 1,092 days |
Coverage Area |
Worldwide "Excluding" the United States Worldwide "Including" the United States |
Medical Maximum Options |
Worldwide “Including” the United States as indicated on the attached rate sheets: |
Deductible Options (You Pay) |
$0; $100; $250; $500; $1,000; $2,500; $5,000 |
Coinsurance Options (The plan pays) |
Outside the United States: 100% |
Inside the United States In PPO Network: 100% Coinsurance Out of PPO Network: 90% of the first $5,000, then 100% to the Medical Maximum |
|
Hospital Room & Board |
URC Up to Plan Maximum |
Inpatient Hospital Services |
URC Up to Plan Maximum |
Outpatient Hospital / Clinical Services |
URC Up to Plan Maximum |
Emergency Room Services |
URC Up to Plan Maximum |
Doctor's Office Visits |
URC Up to Plan Maximum |
Prescription Drugs |
URC Up to Plan Maximum |
Home Healthcare |
$2,500 |
Local Ambulance Benefit: |
Medical Maximum |
Hospital Indemnity (outside the United State & Canada) |
$250 per day to a maximum of 30 days |
Coma Benefit |
$50,000 (In addition to Medical Maximum) |
Precertification – 25% penalty |
Required inside the United States |
Extension of Benefits to Home Country |
$20,000 |
Incidental Trips to Home Country |
$50,000 |
Waiver of Pre-existing Condition: United States Residents outside of the United States |
With a Primary Health Plan: Age 0-64 Up to the Medical Maximum Without a Primary Health Plan: Age 0-64 Up to $50,000 Ages 65+ $2,500 |
Acute Onset of a Pre-existing Condition: Non-United States Residents traveling to the United States |
Age 0-69: $50,000 Age 70 & over: $10,000 Emergency Services & Assistance Limited to $25,000 |
Dental - Sudden Relief of Pain: |
$250 |
Dental - Accident: |
Medical Maximum |
Emergency Medical Evacuation & Repatriation: |
$1,000,000 (In addition to the Medical Maximum) |
Emergency Medical Reunion: |
Up to $200 per day $100,000 maximum limit |
Return of Child(ren): |
$100,000 |
Return of Mortal Remains |
$100,000 |
Local Burial or Cremation |
$5,000 |
Natural Disaster Evacuation |
$100,000 |
Natural Disaster Daily Benefit |
$250 per day, 10-day limit |
Political Evacuation & Repatriation |
$100,000 |
Felonious Assault |
$20,000 |
Terrorism |
Up to Med Max |
24/7 TRAVEL ASSISTANCE SERVICES |
Included |
Accidental Death and Dismemberment (AD&D) |
$50,000 Primary Insured or Travel Companion $10,000 Child Aggregate Limit of $250,000 for Total Number of Insureds on Plan |
Common Carrier Accidental Death and Dismemberment |
$100,000 Primary Insured or Travel Companion $20,000 Child Aggregate Limit of $250,000 for Total Number of Insureds on Plan |
Loss of Checked Luggage |
Up to $50 per article $1,000 per occurrence maximum |
Trip Interruption |
$10,000 |
Personal liability |
$100,000 |
Hazardous Activities (Optional) |
Up to Plan Maximum |
Benefit Period |
180 Days |
Patient Protection and Affordable Care Act (“PPACA”). THE INSURANCE PROVIDED HEREUNDER IS NOT SUBJECT TO, IS NOT INTENDED TO COMPLY WITH, AND DOES NOT PROVIDE ALL BENEFITS REQUIRED BY PPACA. THIS INSURANCE IS NOT QUALIFYING HEALTH COVERAGE (“MINIMUM ESSENTIAL COVERAGE”) THAT SATISFIES THE HEALTH CARE COVERAGE REQUIREMENT OF PPACA. IF AN INSURED PERSON DOE NOT HAVE MINIMUM ESSENTIAL COVERAGE, HE OR SHE MAY OWE AN ADDITIONAL PAYMENT WITH HIS OR HER TAXES. INSURED PERSONS ARE RESPONSIBLE FOR DETERMINING IF AND HOW PPACA IS APPLICABLE TO HIM OR HER AND SHOULD CONSULT HIS OR HER OWN TAX ADVISORS. NEITHER THE COMPANY NOR THE ADMINISTRATOR SHALL HAVE LIABILITY WHATSOVER FOR AN INSURED PERSON’S FAILURE TO OBTAIN PPACA-COMPLIANCE COVERAGE.
THIS INSURANCE IS ISSUED PURSUANT TO APPLICABLE SURPLUS LINES LAW. PERSONS INSURED BY SURPLUS LINES CARRIERS DO NOT HAVE THE PROTECTION OF STATE INSURANCE GUARANTY LAWS TO THE EXTENT OF ANY RIGHT OF RECOVERY FOR THE OBLIGATION OF AN INSOLVENT UNLICENSED INSURER.