Safe Travels Elite

Plan Detail

Plan Administrator: Trawick International | AM Best Rating: A | Underwriter: Crum and Forster, SPC

Benefits


Safe Travels Elite Schedule Benefits byPlan

 

ECONOMY AGE 14 DAYS

TO AGE 69

BASIC AGE 14 DAYS

TO AGE 69

SILVER AGE 14 DAYS

TO AGE 69

GOLD AGE  14DAYS

TO AGE69

PLATINUM AGE 14 DAYS

TO AGE 69

DIAMOND and DIAMOND Plus AGE 70 TO AGE 89

Policy Maximums

$25,000 Max per Injury/Sickness

$50,000 Max per Injury/Sickness

$75,000 Max per Injury/Sickness

$100,000 Max per Injury/Sickness

$175,000 Max per Injury/Sickness

Diamond $50,000 AnnualMax

Diamond Plus $100,000 AnnualMax

 

Acute Onset of Cardiac Conditions/Treatment $25,000 per Policy Period Limit

Acute Onset of Cardiac Conditions/ Treatment

$15,000

Deductible options (per Incidence)

$0

$100 or $200

MEDICAL EXPENSE BENEFIT AND EXPENSES ARE PAYABLE UP TO THE MAXIMUM AMOUNT LISTED

Inpatient Hospital Expense

Hospital Room and Board Expenses

$1,400 per day to a maximum of 30 days

$2,000 per day to a maximum of 30 days

$2,000 per day to a maximum of 30 days

$2,000 per day to a maximum of 30 days

$3,000 per day to a maximum of 30 days

$1,500 per day to a maximum of 15 days

Hospital Intensive Care Unit Expenses

$2,100 per day to

a maximum of 10 days

$2,500 per day to

a maximum of 8 days

$2,500 per day to

a maximum of 8 days

$3,000 per day to

a maximum of 8 days

$4,500 per day

to a maximum of 8 days

$2,300 per day to

a maximum of 8 days

Inpatient Ancillary Hospital Services

Included under the Hospital Room and Board Expenses

Physician’s Surgical Treatment

$3,500 per Incident

$5,000 per Incident

$5,000 per Incident

$6,000 per Incident

$7,500 per Incident

$3,500 per Incident

Anesthesiologist Expense

$850 per Incident

$850 per Incident

$1,200 per Incident

$1,400 per Incident

$1,800 per Incident

$850 per Incident

Assistant Physician’s

Surgical Expenses

$850 per Incident

$850 per Incident

$1,200 per Incident

$1,400 per Incident

$1,800 per Incident

$850 per Incident

Physician’s Non-Surgical Visits

Limited to $55 per visit, one visit per day and 30 visits per Policy Period

Limited to $75 per visit, one visit per day and 30 visits per Policy Period

Limited to $75 per visit, one visit per day and 30 visits per Policy Period

Limited to $100 per visit, one visit per day and 30 visits per Policy Period

Limited to $130 per visit, one visit per day and 30 visits per Policy Period

Limited to $75 per visit, one visit per day and 30 visits per Policy Period

Consulting Physician

$450 per Incident

$450 per Incident

$550 per Incident

$550 per Incident

$700 per Incident

$450 per Incident

Private Duty Nurse

$450 per Incident

$450 per Incident

$550 per Incident

$550 per Incident

$700 per Incident

$450 per Incident

Pre-Admission Test within 7 days of Admission

$1,100 per Incident

$1,100 per Incident

$1,100 per Incident

$1,200 per Incident

$1,500 per Incident

$1,100 per Incident

OUTPATIENT - Maximum Daily Benefit All Services $10,000 – up to the selected policy maximum

Outpatient Surgical Facility

$1,000 per Incident

$1,100 per Incident

$1,150 per Incident

$1,275 per Incident

$1,400 per Incident

$1,100 per Incident

Physician’s Surgical Treatment

$3,500 per Incident

$5,000 per Incident

$5,000 per Incident

$6,000 per Incident

$7,500 per Incident

$3,500 per Incident

Anesthesiologist Expense

$850 per Incident

$850 per Incident

$1,200 per Incident

$1,400 per Incident

$1,800 per Incident

$700 per Incident

Assistant Physician’s

Surgical Expenses

$850 per Incident

$850 per Incident

$1,200 per Incident

$1,400 per Incident

$1,800 per Incident

$700 per Incident

Physician’s Visits/ Urgent Care or **Telemedicine

Limited to $55 per visit, one visit per day and 30 visits per Policy Period

Limited to $75 per visit, one visit per day and 30 visits per Policy Period

Limited to $75 per visit, one visit per day and 30 visits per Policy Period

Limited to $100 per visit, one visit per day and 30 visits per Policy Period

Limited to $130 per visit, one visit per day and 30 visits per Policy Period

Limited to $75 per visit, one visit per day and 30 visits per Policy Period

Diagnostic X-rays and Lab Services

$450 per Incident

$750 per Incident

$750 per Incident

$750 per Incident

$1,000 per Incident

$750 per Incident

Scans, Pet Scan or MRI

$650 per Incident

$650 per Incident

$875 per Incident

$1,050 per Incident

$1,300 per Incident

$650 per Incident

Emergency Room Illness with no direct Hospital Admission

$350 and an additional

$200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.

$500 and an additional

$200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.

$500 and an additional

$200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.

$600 and an additional

$200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.

$800 and an additional

$200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.

$500 and an additional

$200 Deductible per visit - Only applies when receiving care in an Emergency room for an Illness that does not result in a hospital admittance.

Emergency Room injury/Accident or Illness

with direct Hospital Admission

$350 per Incident

$500 per Incident

$500 per Incident

$600 per Incident

$800 per Incident

$500 per Incident

Prescription drugs and medications

$250 per Incident

$350 per Incident

$350 per Incident

$350 per Incident

$350 per Incident

$250 per Incident

 

ADDITIONAL MEDICAL TREATMENT AND SERVICES

COVID-19 EXPENSES

Covered and treated as any other Sickness

Acute Onset of a Pre- Existing Condition

For ages up to and including 69 the limit is up to the Medical Policy Maximum purchased per Period of Coverage except for any coverage related to cardiac disease or conditions, which will be limited to $25,000 up to and including age 69 and $15,000 for ages 70 and above. Upon attaining ages 70-79 Acute Onset benefits will be reduced to a Maximum of

$35,000, upon attaining age 80 Acute Onset benefits will be reduced to a Maximum of $15,000 with a $25,000 Maximum Lifetime Limit for Emergency Medical Evacuation. Provides coverage for an Acute Onset of a Pre-Existing Condition. Any repeat/reoccurrence within the same policy period will no longer be considered Acute Onset of a Pre-Existing Condition and will not be eligible for additional coverage. A Pre-Existing Condition which is a chronic or congenital condition or that gradually becomes worse over time and/or known, scheduled, required, or expected medical care, drugs or treatments existing or necessary prior to the Effective Date are not considered to be an Acute Onset. This benefit covers only ONE (1) Acute Onset episode of a Pre-Existing condition. Sudden and Acute Onset of a Pre-Existing Condition Coverage expires upon medical advice that the condition and Onset is no longer acute, or you are discharged from a medical facility.

Well Doctor Visit

Paysupto$125-OneVisitperpersonperPolicyPeriod.TheWellDoctorVisitmustoccurwithinthefirst21daysfrom theeffectivedateof coverage.Tobeeligibleyoumust purchase at least 30 days of coverageinitially.

BENEFITS

All benefits payable are subject to the Maximum Benefit Limits, and any applicable sub-limits, listed in the Schedule of Benefits.

MEDICAL EXPENSE BENEFIT If a covered Sickness orInjury occurs during the Policy Period, and the Covered Person requires medical orsurgicaltreatment, benefits are payable for the following covered expenses:

 INPATIENT HOSPITAL BENEFITS: Inpatient means a person was admitted to an approved Hospital or other health care facility for a Medically Necessary overnight stay. Inpatient Hospitalization services as specified in the Schedule of Benefits include, but are not limited to: • Hospital Room and Board Expenses: the average daily rate for a semi-private room when a Covered Person isHospital Confined (In computing the number of days payable under this benefit, the date of admission will be counted but not the date of discharge), and general nursing care and the following additional facilities; services and supplies as Medically Necessary and approved and covered by the Policy, meals and special diets (only for the patient). Use of operating room and related facilities, use of intensive care and related services.All charges in excess of the allowable semiprivate rate are the responsibility of the Covered Person

Hospital Room and Board Expenses: the average daily rate for a semi-private room when a Covered Person isHospital Confined (In computing the number of days payable under this benefit, the date of admission will be counted but not the date of discharge), and general nursing care and the following additional facilities; services and supplies as Medically Necessary and approved and covered by the Policy, meals and special diets (only for the patient). Use of operating room and related facilities, use of intensive care and related services.All charges in excess of the allowable semiprivate rate are the responsibility of the Covered Person.

Hospital Intensive Care Unit services will be provided based on the Allowable Charge for Medically NecessaryIntensive Care Services

Inpatient Ancillary Hospital Services - If medically necessary for the diagnosis and treatment of the Sickness or Injury for which a Covered Person is hospitalized, the following services are also covered: use of operationroom and recovery room; all medicines listed in the U.S. Pharmacopoeia or National Formulary; Blood transfusions, blood plasma, blood plasma expanders, and all related testing, components, equipment and services; Surgical dressings; Laboratory testing; Durable Medical Equipment; Diagnostic x-ray examinations; Radiation therapy rendered by a radiologist for provenmalignancyorneoplastic diseases; Respiratory therapy rendered by a Physician or registered respiratory therapist; chemotherapy rendered by a Physician or Nurse under the direction of a Physician; Physical and Occupational therapy (if covered) must be rendered by a Physician or registered physical or occupational therapist and relate specifically to the physician's written treatment plan. Therapy must: Produce significant improvement in the Insured's condition in a reasonable and predictable period of time, and be of such a level of complexity and sophistication, and/or the conditionof the patient must be such that the required therapy can safely and effectively be performed only by a registered physical or occupational therapist or be necessary to the establishment of an effective maintenance program. Maintenance itself is not covered. All Inpatient Ancillary benefits are paid in accordance with the current Schedule of Benefits.

Physician’s Surgical Treatmen

Anesthetist: Anesthesiologist expenses for pre-operative screening and administration of anesthesia during a surgical procedure on an inpatient basis

Assistance Physician’s Surgeon (When Medically Necessary)

Physician’s Non-Surgical Visits: Physician non-surgical treatment and examination expenses including the Physician’s initial visit, each Medically Necessary follow-up visit and consultation visits when referred by the attending Physician.

Consulting Physician, when requested by attending Physician

Private Duty Nurse

Pre-Admission Test within 7 days of Admission

OUTPATIENT HOSPITAL BENEFITS: Outpatient means a person is admitted to a Hospital or other healthcare facility for treatment that does not require an overnight stay. Outpatient Hospitalization services asspecified in the Schedule of Benefitsinclude, butare not limited to:

OUTPATIENT HOSPITAL BENEFITS:

Outpatient means a person is admitted to a Hospital or other healthcare facility for treatment that does not require an overnight stay.

Outpatient Hospitalization services asspecified in the Schedule of Benefitsinclude, butare not limited to:

Prescription drugs and medications

• Scans, PET scan or MRI •

Anesthetist: Anesthesiologist expenses for pre-operative screening and administration of anesthesia during a surgical procedure on an inpatient basis •

Physician’s Visits/Urgent Care/** Telemedicine (see benefit https://trawickinternational.com/telemedicine)

Hospital Emergency Room Visits. Emergency Room Visit for an Illness with no direct Hospital Admittance willbe subject to an additional deductible as outlined in the schedule of benefits.

ADDITIONAL MEDICAL TREATMENT AND SERVICES

Medically Necessary treatment for COVID-19, SARS-CoV-2, and any mutation or variation of SARS-CoV-2

Acute Onset of a Pre-existing Condition (Per Policy Period) Benefits are payable for an Acute Onset of a Pre-Existing Condition. Any repeat/reoccurrence within the same Policy Period will no longer be considered Acute Onset of a Pre-Existing Condition and will not be eligible for additional coverage. A Pre-Existing Condition which is a chronic or congenital condition or that gradually becomes worse over time and/or known, scheduled, required, or expected medical care, drugs or treatments existing or necessary prior to the Effective Date are not considered to be an Acute Onset. This benefit covers only one (1) Acute Onset episode of a Pre-Existing condition. Sudden and Acute Onset of a Pre-Existing Condition Coverage expires upon medical advice that the condition and onset is no longer acute, or the Covered Person is discharged from a medical facility.

Well Doctor Visit - Benefits will be payable for a Well Doctor Visit per person during the Policy Period. TheCovered Person may use any Physician. Telemedicine is not eligible. To be covered: 1. the visit must occurwithin the first 21 days from the effective date of coverage and 2. the Covered Person must purchase at least 30 days of coverage initially; and the Physician must use specific ICD10 codes for the Well Visit whichare the following three Diagnosis Codes only a) V70.0-Routine medical exam; b) Z00.00 - Encounter for general adult medical examination without abnormal findings c) Z00.129-Encounter for routine child health examination without abnormal findings. Visits with ICD10 Codes not listed here are not considered Well Doctor Visits and are not covered as such but may be covered under another policy benefit. Please register for this benefit with the Plan Administrator. https://TrawickInternational.com/wellness/Register

Emergency dental treatment and restoration of sound natural teeth, including x-rays, required as a resultof an Accident. Routine dental treatment is not covered.

Initial Orthopedic Prosthesis/brace: Prosthesis and corrective devices such as Durable Medical Equipmentwhich are medically required as an integral part of treatment prescribed by a physician; Prosthesis/ Durable Medical Equipment does not include: motor driven wheelchairs or bed; comfort items such astelephone arms and over bed tables; items used to alter air quality or temperature such as air conditioners, humidifiers, dehumidifiers, and purifiers (air cleaners); disposable supplies; exercise cycles, sun or heat lamps, heating pads, bidets, toilet seats, bathtub seats, sauna baths, elevators, whirlpool baths, exercise equipment, and similar items

Mental or nervous disorders or treatment. Benefits are provided for psychotherapeutic treatment and psychiatric counseling and treatment for an approved psychiatric diagnosis. Benefits are for both inpatientmental health treatment in Hospital, or approved facility and for outpatient mental health treatment will be applied toward the Policy Period per person Maximum. A Physician or a licensed clinical psychologist must provide all mental health care services. Services of a clinical psychologist must be rendered in the provider's office or in the outpatient department of a Hospital. Services Include treatment for Bulimia; Anorexia; Non-medical causes of insomnia; Outpatient & Inpatient rehabilitation all treatment programs must be Preauthorized. The following services are excluded: Aptitude testing, educational testing and services; Services for conditions not determined by Us as to be emotional or personality Sicknesses; Psychiatric services extending beyond the period necessary for evaluation and Diagnosis of mental deficiency or retardation; Services for mental disorders or Sickness which are not amenable to favorable modification; Bereavement; Family counseling of any kind; Marriage counseling of any kind.

Physiotherapy Physical Medicine/Chiropractic Expenses on an Inpatient or outpatient basis including treatment and office visits connected with such treatment when prescribed by a Physician, including diathermy, ultrasonic, whirlpool, heat treatments, adjustments, manipulation, or any form ofphysical therapy.

TRANSPORTATION BENEFITS AMBULANCE SERVICE BENEFITS

Ambulance Service Benefits are provided for medically necessary emergency ground ambulance transportationas required from the emergency site to the nearest Hospital able to provide the required level of care.

EMERGENCY MEDICAL EVACUATION Benefits are payable for the cost of emergency evacuation when deemed necessary and pre-approved by the Assistance Provider to a suitable location to render immediate and appropriate care. The Assistance Providerwill determine the destination country of the evacuation, and the country may or may not be the Home Country of origin. If the Insured does not obtain pre-approval from the Assistance Provider, We reserve the right to deny coverage or assess a 20 % co-payment for the associated costs.

MEDICAL REPATRIATION TO HOME COUNTRY Repatriation for Medical Treatment: The Assistance Provider reserves the right to review any case in which theCovered Person is medically stable and upon advice of the Assistance Provider’s medical doctors can be evacuated at the Assistance Provider's discretion to the Covered Person’s Home Country.

NATURAL DISASTERS, POLITICAL EVACUATION & REPATRIATION Provides a benefit for evacuation during a period of civil unrest, insurrection or Natural Disaster that could nothave been foreseen prior to departure from the Home Country of origin. Coverage is NOT valid in any country that was on verge, already in or under duress for a period of 60 days prior to departure from point of origin orcountry of residence. The coverage amount is in the Schedule of Benefits.

REPATRIATION OF MORTAL REMAINS Benefits are payable for preparation and return of a Covered Person’s body to Their Home Country if they die due to a covered Sickness or Injury.

Covered Expenses include: Expenses for embalming or cremation; The least costly coffin or receptacle adequate for transporting the remains; Transporting the remains by the most direct and least costly conveyance and route possible and pre-approved by the Assistance Provider. Benefits will not be payable ` unless We authorize in writing or by an authorized electronic or telephonic means all expenses in advance. This benefit excludesfeesforreturn of personal effects, religious or secular memorial services, clergymen, flowers, music, announcements, guest expenses and similar personal burial preferences.

LOCAL BURIAL / CREMATION Benefits are payable for preparation, local burial or cremation of the Covered Person's mortal remains at thecountry of death in accordance with the commonly accepted cultural and religious beliefs practiced by the Covered Person. Coverage is not provided for burial and cremation costs incurred for: religious practitioner, flowers, music, food or beverages. If the Local Cremation or Burial is chosen, the Return of Mortal Remains benefit will not apply. Expenses must be approved in advance by the Assistance Provider. Failure to utilize the Assistance Provider to approve these services will result in the denial of benefits.

ADDITIONAL BENEFITS

COMMON CARRIER ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) Accidental Death and Dismemberment will apply to Covered Accidents incurred while a Covered Person is traveling/riding as a passengerin or on any public land,wateror air conveyance (regularly scheduled and licensed)for transportation of passengers for hire. If Injury to the Covered Person results in any one of the losses shown below within 365 days from date of the Covered Accident, We will pay the Benefit Amount shown below for thatloss. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Covered Accident

COVERED LOSS

Benefit Amount

Loss of Life

100% of Principal Sum

Loss of Speech and Loss of Hearing

100% of Principal Sum

Loss of Speech and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye

100% of Principal Sum

Loss of Hearing and one of Loss of Hand, Loss of Foot or Loss of Sight of One Eye

100% of Principal Sum

Loss of Hands (Both), Loss of Feet (Both), Loss of Sight or a combination of any two of Loss of Hand, Loss of Foot or Loss of Sight of One Eye

100% of Principal Sum

Quadriplegia

100% of Principal Sum

Paraplegia

75% of Principal Sum

Hemiplegia

50% of Principal Sum

Loss of Hand, Loss of Foot or Loss of Sight of One Eye (any one of each)

50% of Principal Sum

Uniplegia

25% of Principal Sum

Loss of Thumb and Index Finger of the same hand

25% of Principal Sum

FELONIOUS ASSAULT We will pay the Benefit Amount for Felonious Assault shown in the Schedule of Benefits, if Accidental Bodily Injury resulting from Felonious Assault causes a Primary Insured Person to suffer Covered Loss. The Benefit Amount for Felonious Assault is payable in addition to any other applicable Benefit Amounts under this policy. Any assault by a family member is not covered under this benefit. RETURN TO HOME COVERAGE

You may return to your Home Country of residence for up to 30 days during the Policy Period. The benefitsavailable are those as outlined in the Schedule of Benefits and may ONLY be utilized after initially leaving the Home Country of residence and then returning for an Incidental Trip. The benefits are subject to any policy limitations and all of the exclusions.