Plan Administrator: International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius International
BENEFIT SUMMARY
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Coverage Limit / Maximum Amount for Eligible Medical Expenses |
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Period of Coverage |
Five (5) days up to twelve (12) months |
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Benefit Period • Charges incurred in the United States are not eligible for coverage during the Benefit Period • Refer to the BENEFIT PERIOD provision for further details and requirements |
3 months |
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Period of Coverage limit As indicated on the Declaration |
• Through age 64: $50,000, $100,000, $500,000 or $1,000,000 • Ages 65 to 69: $50,000 or $100,000 · Ages 70 to 79: $50,000 · Ages 80 and older: $10,000 |
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Area of Coverage |
Worldwide excluding the Insured Person’s Country of Residence |
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Benefit Plan Features |
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Benefit Levels |
United States |
United States |
International |
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In-Network |
Out-of-Network |
International |
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Deductible for Eligible Medical Expenses |
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Deductible |
$0, $100, $250, $500, $1,000, or $2,500 per Insured Person, as indicated on the Declaration |
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Coinsurance for Eligible Medical Expenses |
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Coinsurance |
Plan pays 100% Insured pays 0% |
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Out of Pocket Maximum |
$0 |
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Pre-certification |
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• Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met. • Emergency Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage. • All other Treatments & supplies: fifty percent (50%) reduction of Eligible Medical Expenses if Pre-certification requirements are not met. • Deductible is taken after reduction. • Coinsurance is applied to remainder of the reduced amount. • Refer to PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification. |
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Pre-existing Conditions
Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance. |
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Acute Onset of Pre-existing Conditions Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
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Inpatient or Outpatient |
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Benefit |
Coinsurance |
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Eligible Medical Expenses |
100% |
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Physician Visits / Services |
100% |
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Urgent Care Center • Not subject to Deductible • Copayment: $25 • Copayment is not applicable if the Declaration states a $0 Deductible |
100% |
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Walk-in Clinic • Not subject to Deductible • Copayment $15 • Copayment is not applicable if the Declaration states a $0 Deductible |
100% |
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Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit |
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Benefit |
Coinsurance |
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Hospital Emergency Room: United States |
100% |
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Hospital Emergency Room: International |
100% |
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Hospitalization / Room & Board • Average semi-private room rate • Includes nursing, miscellaneous and Ancillary services |
100% |
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Intensive Care |
100% |
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Bedside Visit • Not subject to Deductible • Maximum Limit: $1,500 • Hospitalized in an Intensive Care Unit • Refer to the BEDSIDE VISIT provision for further details |
100% |
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Outpatient Surgical / Hospital Facility |
100% |
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Laboratory |
100% |
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Radiology / X-ray |
100% |
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Chemotherapy / Radiation Therapy |
100% |
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Pre-admission Testing |
100% |
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Surgery |
100% |
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Reconstructive Surgery • Surgery is incidental to or follows Surgery that was covered under the Plan |
100% |
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Assistant Surgeon • Twenty percent (20%) of the primary surgeon’s eligible fee |
100% |
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Anesthesia |
100% |
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Durable Medical Equipment |
100% |
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Chiropractic Care • Medical order or Treatment plan required |
100% |
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Physical Therapy • Medical order or Treatment plan required |
100% |
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Extended Care Facility • Upon direct transfer from an acute care Hospital |
100% |
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Home Nursing Care • Provided by a Home Health Care Agency • Upon direct transfer from an acute care Hospital |
100% |
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Prescriptions Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit |
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Benefit |
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Prescription Drugs and Medication Obtained through Retail Pharmacy, Inpatient and Outpatient Surgery, Emergency Room and Outpatient Office Visits Dispensing maximum for Retail Pharmacy: 90 days per prescription |
100% If the Certificate of Insurance Maximum Limit is $10,000, $50,000 or $100,000, the Prescription Drugs and Medications limit is up to the plan Maximum Limit If the Certificate of Insurance Maximum Limit is $500,000 or $1,000,000, the Prescription Drugs and Medications Maximum Limit is up to $250,000 per Period of Coverage |
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Emergency Services |
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Emergency Local Ambulance • Subject to Deductible and Coinsurance • Injury • Illness resulting in an Inpatient Hospital admission |
100% |
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Emergency Medical Evacuation • Maximum Limit: $1,000,000 • Must be approved in advance and coordinated by the Company |
100% |
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Emergency Reunion • Maximum Limit: $100,000 • Maximum days: 15 • Meal maximum: $25 per day • Reasonable and necessary travel costs and accommodations • Must be approved in advance by the Company |
100% |
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Interfacility Ambulance Transfer • Transfer from one licensed health care Facility to another licensed health care Facility resulting in an Inpatient Hospital admission |
100% |
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Natural Disaster Evacuation • Maximum Limit: $25,000 • Approved in advance by the Company |
100% |
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Political Evacuation and Repatriation • Maximum Limit: $100,000 • Must be approved in advance by the Company |
100% |
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Return of Minor Children • Maximum Limit: $100,000 • Must be approved in advance by the Company |
100% |
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Return of Mortal Remains • Up to the Period of Coverage limit • Local Burial / Cremation Maximum Limit: $5,000 • Return of Insured Person’s Mortal Remains to Country of Residence • Must be approved in advance by the Company |
100% |
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Other Services |
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Benefit |
In-Network |
Out-of-Network |
International |
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Accidental Death & Dismemberment • Principal Sum Maximum Limit: $50,000 • Death must occur within ninety (90) days of the Accident |
Accidental Death: 100% of Principal Sum |
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Dismemberment: Accidental Loss Percent of Principal Sum Sight of one eye 50% One hand or one foot 50% One hand and the loss of sight of one eye 100% One foot and the loss of sight of one eye 100% One hand and one foot 100% Both hands or both feet 100% Sight of both eyes 100% |
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Common Carrier Accidental Death • Maximum Limit per adult: $100,000 • Maximum Limit per Child: $25,000 • Maximum Limit per Family: $250,000 |
100% |
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Dental Treatment • Subject to Deductible and Coinsurance • Limit: $300 (Unexpected pain or Treatment due to an Accident) |
100% |
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Traumatic Dental Injury • Subject to Deductible and Coinsurance • Treatment at a Hospital due to an Accident • Additional Treatment for the same Injury rendered by a Dental Provider will be paid at one hundred percent (100%) |
100% |
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Hospital Indemnity • Overnight limit: $250 • Maximum nights: 10 • Outside Insured Person’s Country of Residence and the United States • Inpatient Hospitalization only |
100% |
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Emergency Eye Examination • Subject to Coinsurance • Deductible per occurrence: $50 (plan Deductible waived) • Limit: $150 • Loss or damage to prescription corrective lenses due to an Accident |
100% |
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Identity Theft • Limit: $500 |
100% |
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Incidental Trip • Maximum days: 14 • Insured Person’s Country of Residence is not the United States |
100% |
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Lost Luggage • Limit: $500 • Limit: $50 per item |
100% |
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Natural Disaster • Limit per day: $250 • Maximum days: 5 |
100% |
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Other Services |
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Benefit |
Coinsurance |
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Personal Liability • Secondary to any other insurance • No coverage for Injury to a related Third Party or damage to related Third Person’s property • Refer to the PERSONAL LIABILITY provision for further details and requirements |
Combined Maximum Limit: $25,000 |
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Injury to Third Person: • Per Injury Deductible: $100 Damage to Third Person’s property: • Per damage Deductible: $100 |
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Terrorism • Maximum Limit: $50,000 |
$100 |
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Pet Return • Limit: $1,000 • For a pet cat or dog travelling with the Insured Person |
$100 |
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Small Pet Common Air Carrier Accidental Death Benefit • Maximum Limit per pet: $500 • For a pet cat or dog up to 30 pounds travelling with the Insured Person |
$100 |
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Trip Interruption • Limit: $10,000 |
$100 |
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Incidental Services NOT Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit |
Combined Maximum Limit: $50,000 |
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Emergency Treatment While Traveling Through the United States • Must be Pre-certified and coordinated by the Company • Refer to the EMERGENCY TREATMENT WHILE TRAVELING THROUGH THE UNITED STATES provision for further details and requirements |
100% |
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Emergency Medical Evacuation to the United States and Associated Treatment • Must be Pre-certified and coordinated by the Company • Refer to the EMERGENCY MEDICAL EVACUATION TO THE UNITED STATES AND ASSOCIATED TREATMENT provision for further details and requirements |
100% |
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Emergency Treatment During Incidental Trip to Country of Residence • Maximum consecutive days: 14 (in addition to the combined Maximum Limit) • Must be Pre-certified and coordinated by the Company • Refer to the EMERGENCY TREATMENT DURING INCIDENTAL TRIP TO COUNTRY OF RESIDENCE provision for further details and requirements |
100% |
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Pre-existing Condition: Any Injury, Illness, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time during the three (3) years prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.
ELIGIBLE MEDICAL EXPENSES: Subject to the Terms of this insurance, and the insurance plan shown in the Declaration, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the following costs, Charges and expenses incurred by the Insured Person during the Period of Coverage with respect to an Illness or Injury suffered or sustained by the Insured Person during the Period of Coverage and while this Certificate is in effect, so long as the Illness or Injury is covered under this Certificate, Charges are Usual, Reasonable and Customary and are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”):
Charges incurred at a Hospital for:
(a) daily room and board, nursing services, and Ancillary Services not to exceed the average semi-private room rate. A private room will be considered when no semi-private room is available or if medical necessity warrants this type of room. The private room rate is not to exceed the average private room rate.
(b) daily room and board, nursing services, and Ancillary Services in an Intensive Care Unit
(c) use of operating, Treatment or recovery room
(d) services and supplies which are routinely provided by the Hospital to persons for use while an Inpatient
(e) Emergency Treatment of an Injury, even if Hospital confinement is not required
(f) Emergency Treatment of an Illness; however, an additional Deductible (as shown in the BENEFIT SUMMARY) will be required unless the Insured Person is directly admitted to the Hospital as Inpatient for further Treatment of that Illness
2) Charges incurred for Surgery at an Outpatient Surgical Facility, including services and supplies
(3) Charges by a Physician for professional services rendered, including Surgery; provided, however, that Charges by or for an assistant surgeon will be limited and covered at the rate of up to twenty percent (20%) of the Usual, Reasonable and Customary charge of the primary surgeon; and provided, further, that the standby availability of a Physician or surgeon will not be deemed to be a professional service and is not eligible for coverage
(4) Charges incurred for:
(a) dressings, sutures, casts or other supplies which are Medically Necessary
(b) diagnostic testing using Radiology, ultrasonography or laboratory services. Laboratory services billed for professional component fees are covered if the pathologist has direct involvement in providing a written report or verbal consultation for specimen-specific pathology services
(c) Implant devices that are Medically Necessary; however, any Implants provided outside the PPO network are limited to a payment of no more than one hundred fifty percent (150%) of the established invoice price and/or list price for that item
(d) basic functional artificial limbs, eye or larynx or breast prostheses, but not the replacement or repair thereof
(e) reconstructive Surgery when the Surgery is incidental to and follows Surgery which was covered hereunder
(f) radiation therapy or Treatment, and chemotherapy (g) hemodialysis for the Treatment of acute renal failure only and the Charges by a Hospital for processing and administration of blood or blood components
(h) oxygen and other gases and their administration
(i) anesthetics and their administration by a Physician
(j) drugs which require prescription by a Physician for Treatment of Illness or Injury, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of ninety (90) days of any one (1) prescription
(k) care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital
(l) Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from an acute care Hospital
(m) Emergency Local Ambulance Transport necessarily incurred in connection with:
(i) an Injury
(ii) an Illness resulting in Hospital confinement as an Inpatient.
(n) Interfacility Ambulance Transfer must be a result of an Inpatient Hospital Admission, Medically Necessary and from one licensed health care Facility to another licensed health care Facility via air or land ambulance
(o) chiropractic services prescribed by a Physician and performed by a professional chiropractor, and necessarily incurred to continue recovery from a covered Injury or covered Illness; services include manipulations, x-rays and laboratory tests ordered by the chiropractor
(p) physical therapy prescribed by a Physician and performed by a professional physical therapist, and necessarily incurred to continue recovery from a covered Injury or covered Illness
(q) Durable Medical Equipment, as defined herein, deemed to be Medically Necessary
(5) Charges incurred for Treatment at an Urgent Care Center
(6) Charges incurred for Treatment at a Walk-in Clinic
(7) Charges for Treatment of an Injury to the foot due to an Accident covered hereunder
(8) Charges for Treatment of an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment
(9) Charges for Dental Treatment as follows up to the amount shown in the BENEFIT SUMMARY:
(a) Charges for Treatment following Traumatic Dental Injury from a covered Accident that resulted in physical Injury to the Insured Person
(b) Charges for necessary Dental Treatment of Unexpected pain to sound natural teeth
(c) Charges incurred for non-emergency Dental Treatment necessary due to an Accident covered hereunder
(10) Charges for value-added tax (VAT) or like tax incurred on Eligible Medical Expenses
(11) Charges for an Emergency eye examination performed by a licensed optometrist or ophthalmologist to obtain a Medically Necessary prescription for corrective lenses that were lost or damaged due to an Accident covered hereunder, but not for the replacement of prescription corrective lenses or contact lenses
ACCIDENTAL DEATH AND DISMEMBERMENT:
ACCIDENTAL DEATH: Subject to the Terms of this insurance, and in the event the Insured Person has an Accident during the Period of Coverage which results in death during the Period of Coverage, the Company will pay an Accidental Death benefit in the amount of the Principal Sum shown in the BENEFIT SUMMARY.
The Insured Person’s death must occur within ninety (90) days of the Accident and result, directly and independently of all other causes, from an accidental bodily Injury which is unintended, unexpected, and unforeseen. The bodily Injury must be evidenced by a visible contusion or wound, except in the case of accidental drowning. The bodily Injury must be the sole cause of death. The Company will pay the benefit owed upon proper application therefor, in the following order:
(a) to the beneficiary designated in writing by the Insured Person; or
(b) to the Insured Person’s closest surviving Relative; or
(c) the Insured Person’s estate; or
(d) to a claimant entitled to payment under applicable small estate affidavit laws.
DISMEMBERMENT: Subject to the Terms of this insurance and if the Insured Person has an Accident during the Period of Coverage which results in a loss identified in the BENEFIT SUMMARY within ninety (90) days from the date of the Accident and during the Period of Coverage, the Company will reimburse the Insured Person the applicable loss/dismemberment shown in the BENEFIT SUMMARY.
The maximum benefit payable for all dismemberments or losses resulting from any one (1) Accident or Injury shall not exceed the Principal Sum shown in the BENEFIT SUMMARY for Accidental Death.
The loss of a hand or foot means the complete severance at or above the wrist or ankle joint. The loss of sight means the entire and irrecoverable loss of sight. The Insured Person’s dismemberment must result, directly and independently of all other causes, from an accidental bodily Injury which is unintended, unexpected, and unforeseen. The bodily Injury must be evidenced by a visible contusion or wound. The bodily Injury must be the sole cause of dismemberment.
BEDSIDE VISIT: Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and if the Insured Person is Hospitalized as an Inpatient in the Intensive Care unit of a Hospital for a covered life-threatening Injury or Illness during the Period of Coverage, the Company will reimburse the cost of a round-trip economy commercial airline ticket for one (1) Relative from the airport nearest to the location of the Relative at the time of the Insured Person’s Inpatient Intensive Care Hospitalization to the airport serving the area where the Insured Person is Hospitalized
COMMON CARRIER ACCIDENTAL DEATH: Subject to the Terms of this insurance, including the EXCLUSIONS provision, and in the event of an Unexpected death of an Insured Person during the Period of Coverage as a result of an Accident that occurred during the Period of Coverage and while the Insured Person was traveling on a Common Carrier, the Company will reimburse a Common Carrier Accidental Death benefit up to the amount shown in the BENEFIT SUMMARY provided, however, that such Common Carrier Accidental Death benefits shall not exceed the maximum amount shown in the BENEFIT SUMMARY per Family involved in the same Accident.
The Company will pay the benefit owed, upon proper application therefor, in the following order:
(a) to the beneficiary designated in writing by the Insured Person; or
(b) to the Insured Person’s closest surviving Relative; or
(c) the Insured Person’s estate; or
(d) to a claimant entitled to payment under applicable small estate affidavit laws.
EMERGENCY MEDICAL EVACUATION:
Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraph below, the Company will reimburse the Insured Person for the following transportation costs, when the Company or Plan Administrator arranges such transportation and expenses incurred by the Insured Person arising out of or in connection with an Emergency Medical Evacuation occurring while this Certificate is in effect and during the Period of Coverage:
(a) Emergency air transportation to a suitable airport nearest to the Hospital where the Insured Person will receive Treatment
(b) Emergency ground transportation necessarily preceding Emergency air transportation and from the destination airport to the Hospital where the Insured Person will receive Treatment
(c) Return ground and air transportation, upon medical release by the attending Physician, to the country where the evacuation initially occurred or to the Insured Person’s Country of Residence, at the Insured Person’s option.
CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Emergency Medical Evacuation benefits, the Insured Person must be in compliance with all Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when the condition, Illness, Injury or occurrence giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when all of the following conditions and restrictions are met:
(a) Medically Necessary Treatment cannot be provided locally
(b) transportation by any other means or methods would result in loss of the Insured Person’s life or limb within twentyfour (24) hours, based upon a reasonable medical certainty
(c) Emergency Medical Evacuation is recommended by the attending Physician who certifies to the matters in subparagraphs (a) and (b), above
(d) Emergency Medical Evacuation is agreed to by the Insured Person or a Relative of the Insured Person
(e) Emergency Medical Evacuation is provided by designated, licensed, qualified, professional emergency personnel acting within the scope of such license and approved in advance and all arrangements are coordinated by the Company
(f) the condition, Illness, Injury or occurrence giving rise to the need for the Emergency Medical Evacuation:
(i) occurred outside the Insured Person’s Country of Residence suddenly, Unexpectedly, and spontaneously, and without: (1) advance warning, or (2) advance Treatment, diagnosis or recommendation for Treatment by a Physician, or (3) prior manifestation of symptoms or conditions which would have caused a reasonably prudent person to seek medical attention prior to the onset of the Emergency
(ii) was not a Pre-existing Condition.
G)The Company will cover reimbursement for the above-described costs and expenses and will arrange Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary Treatment to prevent the Insured Person's loss of life or limb.
The Insured Person may select a different Hospital in his/her Country of Residence at his/her option, but in such event the Insured Person shall be solely responsible for all costs and expenses in excess of the amounts that would have been incurred had the Insured Person used the nearest qualified Hospital. If a Hospital other than the nearest qualified Hospital is selected by the Insured Person, then the attending Physician, Insured Person, or a Relative of the Insured Person shall certify to the Company the Insured Person’s understanding and acknowledgement of such responsibility for excess costs and expenses in addition to the matters set forth in the CONDITIONS AND RESTRICTIONS subparagraph, above. In all cases the Company will make the necessary arrangements for the Emergency Medical Evacuation and will use its best efforts to arrange with independent, third-party contractors any Emergency Medical Evacuation within the least amount of time reasonably possible.
By acceptance of this Certificate and request for Emergency Medical Evacuation benefits hereunder, the Insured Person understands, acknowledges and agrees that the timeliness, duration, occurrences during, and outcome of an Emergency Medical Evacuation can be directly and indirectly affected by events and/or circumstances which are not within the supervision or control of the Company, including but not limited to: the availability, limitations, physical condition, reliability, maintenance and training schedules and procedures, and performance or non-performance of competent transportation equipment, supplies and/or staff of such third-party contractors; delays or restrictions on flights or other modes or means of transportation caused by mechanical problems, government officials, telecommunications problems, non-availability of routes, and/or other travel, geographical or weather conditions; and other acts of God and unforeseeable and/or uncontrollable occurrences.
The Insured Person agrees to release and to hold the Company, the Plan Administrator and their agents and representatives harmless from, and agrees that the Company, the Plan Administrator and their agents and representatives shall not be held liable or responsible for, any delays, losses, damages, further Injuries or Illnesses, or any other claims that arise from or are caused in whole or in part by the acts or omissions of such independent thirdparty contractors or their agents, employees or representatives, or that arise from or are caused in whole or in part by any acts, omissions, events or circumstances that are not within the direct and immediate supervision and control of the Company, the Plan Administrator and/or their authorized agents and representatives, including without limitation the events and circumstances set forth above.
he Insured Person further agrees that upon seeking an Emergency Medical Evacuation, he or she will cooperate fully as required by the CONDITIONS AND GENERAL PROVISIONS, COOPERATION provision. Failure to so cooperate and/or failure to use or accept Emergency Medical Evacuation once it has been arranged by the Company or Plan Administrator will require the Insured Person to reimburse the Company for costs incurred for any Emergency Medical Evacuation that was arranged, but not used, by the Insured Person. Furthermore, the Insured Person may be required to arrange for payment of any subsequent Emergency Medical Evacuation and seek reimbursement thereafter for eligible costs associated with that subsequent Emergency Medical Evacuation.
EMERGENCY REUNION:
Subject to the Terms of this insurance, including without limitation the CONDITIONS AND RESTRICTIONS subparagraph below, Emergency Reunion expenses will be reimbursed to an Insured Person as outlined in the BENEFIT SUMMARY, in cases where there has been an Emergency Medical Evacuation covered under the Terms of this insurance. Subject to the applicable Deductible and Coinsurance and other limits and sub-limits as specified in the BENEFIT SUMMARY, and subject to the CONDITIONS AND RESTRICTIONS subparagraph below, the following costs and expenses incurred in respect of travel by a Relative or friend of the Insured Person will be reimbursable to the Insured Person upon the recommendation and prior approval of the Company
a) the cost of a round-trip economy commercial airline ticket for one (1) Relative or friend from the airport nearest to the location of the Relative or friend at the time of the Emergency to the airport serving the area where the Insured Person is Hospitalized as a result of the Emergency or is to be Hospitalized as a result of the Emergency Medical Evacuation (to be determined pursuant to the Terms of the CONDITIONS AND RESTRICTIONS, subparagraph below), and return from whichever of such locations is actually selected to the point of the original departure
b) reasonable and necessary travel costs, meals (up to the amount shown in the BENEFIT SUMMARY), transportation and accommodation expenses incurred in relation to the Emergency Reunion (but excluding entertainment).
CONDITIONS AND RESTRICTIONS:
(a) The allowable maximum coverage for the Emergency Reunion shall not exceed fifteen (15) days, including travel days, and all costs and expenses incurred beyond such Period of Coverage shall be retained for the sole account and responsibility of the Insured Person, Relative, or friend
(b) the Emergency Reunion must be due to an Emergency Medical Evacuation covered under the Terms of this insurance
(c) the Insured Person must be so seriously ill that the attending Physician deems it necessary and recommends the presence of a Relative or friend at either the location where the Insured Person is being evacuated from or the destination of the Emergency Medical Evacuation, whichever is considered by the attending Physician and the Company to be the more reasonable
(d) all Emergency Reunion travel, transportation and accommodation arrangements and benefits must be approved in advance by the Company in order to be eligible for coverage under this insurance
(e) The Insured Person, Relative and/or friend must submit to the Company upon completion of the Emergency Reunion travel legible and verifiable copies of all paid receipts for the travel and transportation costs and expenses so incurred for which reimbursement is sought.
HOSPITAL INDEMNITY: Subject to the Terms of this insurance and in the event the Insured Person has been Hospitalized in a Facility outside the Country of Residence and the United States, during the Period of Coverage, the Company will pay the Insured Person the amount shown in the BENEFIT SUMMARY for each overnight Hospitalization as an Inpatient, so long as the Treatment received during the overnight Hospitalization is considered to be an Eligible Medical Expense
IDENTITY THEFT: Subject to the Terms of this insurance and in the event the Insured Person’s identity is stolen, the Company will reimburse the Insured Person the Reasonable and Customary costs incurred by the Insured Person up to the amount shown in the BENEFIT SUMMARY for:
(1) re-filing loan or other credit applications that are rejected solely as a result of the Insured Person’s stolen identity
(2) notarization of legal documents
(3) long distance telephone calls, and postage incurred solely as a result of necessary reporting of the Insured Person’s stolen identity
(4) amending and/or rectifying records as a result of the Insured Person’s stolen identity
(5) up to three (3) credit reports obtained within one (1) year of the Insured Person’s knowledge of the stolen identity
(6) stop payment orders placed on missing or unauthorized checks as a result of the Insured Person’s stolen identity
INCIDENTAL TRIP: As an accommodation and supplemental benefit and subject to the Terms of this insurance, the Insured Person will be covered under this insurance during incidental return trips to his/her Country of Residence up to the number of days shown in the BENEFIT SUMMARY during the Period of Coverage beginning with the date the Insured Person first arrives back in his/her Country of Residence provided that:
(1) The Insured Person has departed his/her Country of Residence prior to any Incidental Trip
(2) The Insured Person has timely paid applicable Premium for at least thirty (30) days of continuous coverage
(3) The Country of Residence is not the United States
(4) The intention or purpose of the Insured Person’s return trip to the Country of Residence is not to receive Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Country of Residence
(5) The Insured Person’s return trip to the Country of Residence does not result in receiving Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Country of Residence.
LOST LUGGAGE: Subject to Terms of this insurance and the limits set forth in the BENEFIT SUMMARY, the Company will reimburse the Insured Person for the cost of Lost Checked Luggage when such Luggage was permanently lost in transit by a Common Carrier during the Period of Coverage, subject to the following conditions:
(1) The Insured Person must submit to the Company a copy of the Common Carrier’s claim form and such other documentation as the Company may reasonably require proof that the Insured Person’s Luggage was permanently lost
(2) The Common Carrier must first reimburse the Insured Person the full amount that it is legally required to pay for Lost Checked Luggage, and proof of such reimbursement shall be provided to the Company by the Insured Person. Lost Luggage benefits under this insurance will be provided only if and to the extent the amount of the Insured Person’s loss suffered as a result of Lost Luggage exceeds any such reimbursement by the Common Carrier
NATURAL DISASTER: Subject to the Terms of this insurance and in the event of a Natural Disaster that occurred during the Period of Coverage, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY if the Insured Person is displaced from scheduled, paid accommodations due to an evacuation before a forecasted Natural Disaster or following a Natural Disaster. The evacuation must have been ordered and mandated by the governmental authorities having jurisdiction over the location of the predicted or actual Natural Disaster.
NATURAL DISASTER EVACUATION:
(1) Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraph below, the Company will reimburse the Insured Person for the following transportation and accommodation costs, when the Company or Plan Administrator arranges such transportation and accommodations, and expenses incurred by the Insured Person arise out of or in connection with an evacuation due to a Natural Disaster that makes your Destination Country Uninhabitable during the Period of Coverage:
(a) air or ground transportation to the nearest safe location
(b) the cost of a one-way economy commercial airline ticket, if the Conditions and Restrictions are met below, to return the Insured Person to his/her Country of Residence following the Natural Disaster evacuation
(c) a maximum of three (3) days for reasonable and necessary lodging accommodations if the Insured Person is delayed in a safe location and unable to return to his/her Country of Residence.
CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Natural Disaster Evacuation benefits, the Insured Person must be in compliance with all Terms of this insurance. Expenses for non-emergency transportation are the Insured Person’s sole responsibility. The Company will provide Natural Disaster Evacuation benefits only when all of the following conditions and restrictions are met:
(a) the Natural Disaster Evacuation must have been ordered and mandated by the recognized governmental authorities having jurisdiction over the location within the Insured Person’s Destination Country
(b) the Insured Person is unable to leave their Destination Country by normal means, including but not limited to changing an existing Common Carrier reservation to arrange for an earlier return due to the Natural Disaster
(c) the Insured Person is unable to obtain commercial transportation within the Destination Country to travel to the nearest safe location in a time period that would:
(i) avoid Imminent Bodily Harm
(ii) comply with the time allowed to leave the Destination Country pursuant to the orders of the recognized government of the Insured Person’s Destination Country
(iii) comply with the time allowed by officials of the Destination Country or the U.S. Embassy
(d) the Insured Person’s location in the Destination Country is deemed Uninhabitable by the Company
(e) the Insured Person must contact the Company as soon as reasonably possible after the Destination Country has issued an official disaster declaration
(f) Natural Disaster Evacuation is approved in advance by the Company.
By acceptance of this Certificate and request for Natural Disaster Evacuation benefits hereunder, the Insured Person understands, acknowledges and agrees that the timeliness, duration, occurrences during and outcome of an Natural Disaster Evacuation can be directly and indirectly affected by events and/or circumstances that are not within the supervision or control of the Company, including but not limited to: the availability, limitations, physical condition, reliability, maintenance and training schedules and procedures and performance or non-performance of competent transportation equipment, supplies and/or staff of such third-party contractors; delays or restrictions on flights or other modes or means of transportation caused by mechanical problems, government officials, telecommunications problems, non-availability of routes, and/or other travel, geographical or weather conditions; and other acts of God and unforeseeable and/or uncontrollable occurrences.
The Insured Person agrees to release and to hold the Company, the Plan Administrator and their agents and representatives harmless from, and agrees that the Company, the Plan Administrator and their agents and representatives shall not be held liable or responsible for, any delays, losses, damages, further Injuries or Illnesses, or any other claims that arise from or are caused in whole or in part by the acts or omissions of such independent third-party contractors or their agents, employees or representatives, or that arise from or are caused in whole or in part by any acts, omissions, events or circumstances that are not within the direct and immediate supervision and control of the Company, the Plan Administrator and/or their authorized agents and representatives, including without limitation the events and circumstances set forth above.
The Insured Person further agrees that upon seeking a Natural Disaster Evacuation, he or she will cooperate fully as required by the CONDITIONS AND GENERAL PROVISIONS, COOPERATION provision. Failure to so cooperate and/or failure to use or accept Natural Disaster Evacuation once it has been arranged by the Company or Plan Administrator will require the Insured Person to reimburse the Company for costs incurred for any Natural Disaster Evacuation that was arranged, but not used, by the Insured Person. Furthermore, the Insured Person may be required to arrange for payment of any subsequent Natural Disaster Evacuation and seek reimbursement thereafter for eligible costs associated with that subsequent Natural Disaster Evacuation.
PERSONAL LIABILITY: Subject to the Terms of this insurance, including without limitation the various limits and sub-limits set forth in the BENEFIT SUMMARY and the conditions precedent and including the EXCLUSIONS provision, the Company will pay or reimburse an Insured Person for eligible court-entered judgments or Company approved settlements arising as a result of or in connection with the personal liability of the Insured Person incurred for acts, omissions and other occurrences covered under this insurance for losses or damages solely, directly and proximately caused by the negligent acts or omissions of the Insured Person during the Period of Coverage that result in the following:
(1) Injury to a Third Person occurring during the Period of Coverage, subject to the limits and sub-limits set forth in the BENEFIT SUMMARY
(2) Damage or loss to a Third Person’s personal property during the Period of Coverage, subject to the limits and sub-limits set forth in the BENEFIT SUMMARY.
As a condition precedent to the provision of any coverage or benefits to any Insured Person for Personal Liability, the Insured Person must notify the Company within five (5) days of any act, omission or occurrence that may create or impose any Personal Liability upon the Insured Person, and also within five (5) days of the initiation or receipt of service of any actual or threatened lawsuit, notice of claim, or proceeding filed or threatened to be filed against the Insured Person with respect to same. In addition, such notification(s) to the Company shall include a recitation of all circumstances, facts, and known or presumed causes of any loss or damage, and a description of the nature and approximate amount of any damages suffered by any Third Person. In addition, immediately upon receipt thereof the Insured Person shall provide to the Company copies of any pleadings, complaints, lawsuits, petitions, demand letters, notices, orders, summonses, subpoenas, opinions, briefs, motions, letters from opposing counsel, and any other documents or papers with respect to any such lawsuit or proceeding that are received or issued by, addressed to or from, remitted to or by, or served by or upon the Insured Person or his/her counsel. Any failure to so notify or provide papers or documents to the Company in strict accordance with the foregoing shall be deemed to be and will result in a forfeiture and waiver of any and all benefits, claims or coverage otherwise provided by this insurance under this provision.
PET RETURN: Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and if the Insured Person is Hospitalized for Treatment of an Illness or Injury during the Period of Coverage, the Company will reimburse the cost of a one-way economy commercial airline or ground transportation ticket to return a pet cat or dog to the airport within the Insured Person’s Country of Residence, provided that all of the following conditions are met:
(1) the Insured person is over the age of eighteen (18) and travelling alone with a pet cat or dog
(2) the Insured Person’s pet cat or dog will be left unattended for thirty-six (36) hours or longer.
POLITICAL EVACUATION AND REPATRIATION: If the United States Department of State, Bureau of Consular Affairs or similar government organization of the Insured Person’s Country of Residence orders the evacuation of all non-emergency government personnel from the Destination Country, due to political unrest, that becomes effective on or after the Insured Person’s date of arrival in the Destination Country, the Company will reimburse up to the amount shown in the BENEFIT SUMMARY for transportation to the nearest place of safety or for repatriation to the Insured Person’s Country of Residence provided that all of the following conditions are met:
(1) the Insured Person contacts the Company within ten (10) days of the United States Department of State, Bureau of Consular Affairs or similar government organization of the Insured Person’s Country of Residence issuing the evacuation order
(2) the evacuation order pertains to persons from the same Country of Residence as the Insured Person
(3) Political Evacuation and Repatriation is approved by the Company
In no event will the Company pay for a Political Evacuation if there is a Travel Warning or Emergency Travel Advisory in effect on or within six (6) months prior to the Insured Person’s date of arrival in the Destination Country. This coverage will provide the most appropriate and economical means of travel consistent under the circumstances of the Insured Person’s health and safety.
REMOTE TRANSPORTATION: (1) Subject to the Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the CONDITIONS AND RESTRICTIONS subparagraph below, the Company will reimburse the Insured Person for the following expenses incurred by the Insured Person arising out of or in connection with a Remote Transportation expenses occurring while this Certificate is in effect: (a) direct costs and other reasonable and customary expenses arising out of travel to the nearest Qualified Facility where the Insured Person will receive Treatment (b) (2) CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Remote Transportation benefits the Insured Person must be in compliance with all Terms of this insurance. The Company will provide Remote Transportation benefits only when the condition, Illness, Injury or occurrence giving rise to the Remote Transportation is covered under the Terms of this insurance. The Company will provide Remote Transportation benefits only when all of the following conditions are met: (a) if, after the Insured Person receives the first Treatment required to stabilize or diagnose the medical situation in a (i) life-threatening by the Treating Physician (ii) a critical medical situation which is not necessarily immediately life-threatening, but is severe enough to result in death or a permanent disability if not Treated right away (iii) a critical medical situation for which no official diagnosis can be obtained at the current Facility (b) Remote Transportation is recommended by the attending Physician who certifies to the matters in subparagraphs (2)(a)(i) thru (iii), above (c) Remote Transportation is agreed to by the Insured Person or a Relative of the Insured Person (d) Remote Transportation is approved in advance by the Company (e) the severity of the critical medical situation, the absence of a Qualified Facility, and the necessity of the Remote Transportation must be confirmed by both the local Treating Physician and the Company
RETURN OF MINOR CHILDREN: Subject to the Terms of this insurance, in the event the Insured Person is Hospitalized for a covered Injury or Illness as an Inpatient or dies during the Period of Coverage and at the time of such Hospitalization the Insured Person was traveling alone with a Child, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the cost of a one-way economy commercial airline ticket to return the Child to his/her Country of Residence, including such economy commercial airline ticket cost for a chaperone if necessary and required by the airline for the safety of the Child, subject to the following conditions and limitations:
(1) The Insured Person must be outside the Country of Residence at the time of the Hospitalization as an Inpatient
(2) The return of the Child must occur during the Insured Person’s Hospitalization
(3) Reimbursable costs are only for a one-way economy commercial airline ticket from the International airport nearest to the Child at the time of the Insured Person’s Hospitalization to the International airport nearest to the Child’s Country of Residence
(4) All travel and transportation arrangements for the Child must be approved in advance by the Company in order to be eligible for coverage under this insurance
(5) The Company will deduct from the return transportation benefits payable hereunder the value, if any, of the unused commercial airline return ticket(s) possessed by or for the benefit of the Child at the time of the Insured Person’s Hospitalization. The Insured Person and/or the Child must first attempt to receive credit for or deduct toward the costs of the return trip.
The Company will not provide any benefits, reimbursements or coverages for any costs or expenses incurred by the Insured Person and/or by the Child for a return trip, if any, to the original location of the Child at the time of the Hospitalization.
RETURN OF MORTAL REMAINS: In the event of the death of the Insured Person during the Period of Coverage as a result of an Illness or Injury covered under this insurance while the Insured Person is outside of his/her Country of Residence, the Company will reimburse the authorized personal representative or the estate of the Insured Person up to the amount shown in the BENEFIT SUMMARY for the costs and expenses incurred to return the Insured Person's Mortal Remains to his/her Country of Residence and thereafter to the place of burial or other final disposition (but not including any costs of burial or other disposition); provided, however, that the Company must approve all costs and expenses related to the return of the Insured Person's Mortal Remains in advance as a condition to the availability of this benefit; or up to the amount shown in the BENEFIT SUMMARY for preparation, local burial or cremation of the Insured Person’s Mortal Remains at the place of death in accordance with the commonly accepted cultural and religious beliefs practiced by the Insured Person. Coverage is not provided for burial and cremation costs incurred for religious practitioners, flowers, music, food or beverages.
SMALL PET COMMON AIR CARRIER ACCIDENTAL DEATH BENEFIT:Subject to the Terms of this insurance, in the event of the Unexpected death of a pet cat or dog, up to thirty (30) pounds in weight, travelling with a covered Insured Person on a common air carrier, the Company will pay to the Insured Person up to the amount shown in the BENEFIT SUMMARY. This benefit applies only to the Insured Person’s originating flight from his Country of Residence and returning flight to his Country of Residence, and the pet must be checked in with the air carrier, whether traveling in the airplane cabin with the Insured Person or in the cargo/baggage area of the airplane.
BB. SUPPLEMENTAL ACCIDENT BENEFIT: In the event of an Accident which gives rise to benefits covered under the Terms of this insurance, as a supplemental benefit the Company will also reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY related to the Treatment of an Injury resulting from such Accident, before applying any Deductible.
RETURN TRAVEL: Subject to the Terms of this insurance and in the event of the Unexpected death of a Relative of the Insured Person, or in the event the Insured Person’s trip or travel plans must be cancelled or interrupted as a result of a break-in or substantial destruction due to a fire or Natural Disaster of the Insured Person’s principal residence in his/her Country of Residence, the Company will reimburse the Insured Person’s actual expense up to the amount shown in the BENEFIT SUMMARY for the costs of a one-way commercial airline or ground transportation ticket of the same class as the unused travel ticket to transport the Insured Person from the International airport nearest to where the Insured Person was located at the time of learning of such death or destruction to the International airport nearest to (1) the location of the Relative’s funeral or place of burial, or (2) the Insured Person’s destroyed principal residence; subject to the following conditions and limitations:
(1) The Insured Person must be outside of his/her Country of Residence at the time of the Unexpected death of the Relative or the substantial destruction of the principal residence
(2) The Unexpected death of the Relative or the substantial destruction of the residence must have occurred during the Period of Coverage and was not caused by, due to, or a result of negligence or willful misconduct by the Insured Person
(3) The Company will deduct from any Trip Interruption benefits payable hereunder the value of any unused, return tickets held by the Insured Person at the time of the event. The Insured Person must promptly undertake all necessary actions to apply for and receive credit for any unused tickets.
The Company will not provide any benefits, reimbursements or coverages for any of the costs or expenses incurred by the Insured Person for a return trip, if any, to the location of the Insured Person at the time of learning of such death or destruction