Safe Travels for Visitors to the USA

Plan Detail

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

Benefits


BENEFITS


SCHEDULE of BENEFITS per Person

ECONOMY Policy

Policy Maximum 

$25,000 Max per Injury/Sickness

Deductible (per Incidence) Choices

$0

Well Doctor Visit 

Pays up to $75 - One Visit per person per Policy Period. The Well Doctor Visit must occur within the first 21 days from the effective date of coverage. To be eligible you must purchase at least 30 days of coverage initially.

INPATIENT

 

Hospital Room & Board including Laboratory Tests, X-Rays, Prescription  Medical and other miscellaneous

Up to $1400/day, 30 day Max

Hospital Intensive Care Unit

Additional $700/day, 8 day Max

Surgical Treatment

Up to $3500

Anesthetist

Up to $850

Assistant Surgeon

Up to $850

Physician’s Non-Surgical Visits 

Up to $55/visit, 1/day, 30 visits Max

A Consulting Physician, when requested by attending Physician 

Up to $450

Private Duty Nurse 

Up to $450

Pre-Admission Tests w/in 7 days before admission

Up to $1100

OUTPATIENT  Maximum Daily Benefit All Services $10,000

 

Surgical Treatment

Up to $3500

Anesthetist 

Up to $850

Assistant Surgeon 

Up to $850

Physician’s Visits/Urgent Care

Up to $850

Diagnostic X-rays & Lab Services 

Up to $55/visit, 1/day, 30 visits max

Scans, PET scan or MRI 

Up to $650 Scan PET scan or MRI

Hospital Emergency Room (all expenses incurred therein) For Emergency Room Illness with no direct Hospital Admission

Up to $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.

Hospital Emergency Room (all expenses incurred therein) For Injury/Accident or Illness with direct Hospital Admission

Up to $350

Prescription Drugs (outpatient)

Up to $100

Outpatient Surgical Facility 

Up to $1000

OTHER TREATMENT AND SERVICES

 

Acute Onset of Pre-Existing Condition(s) per Policy Period  Subject to the sub limits for each benefit listed

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.

Ambulance Services

Up to $500

Initial Orthopedic Prosthesis/brace 

Up to $1100

Chemotherapy and/or radiation therapy

Up to $1100

Dental Treatment for Injury to Sound, Natural Teeth

Up to $600

Mental & Nervous Disorder & Substance Abuse 

Up to $5000

Outpatient Physical Therapy 

Up to $40/visit, 1/day, 12 visits max

Emergency Medical Evacuation*

$100,000

Repatriation of Remains*

$7,500

Local Burial/Cremation 

$5,000 Maximum Limit per person for preparation, local burial or cremation of the Insured Person’s mortal remains at the time of death. Must be approved in advance and coordinated by GBG Assist.

Natural Disasters, Political Evacuation and Repatriation* 

Up to $500

Return of Minor Children or Grand-Children* 

Up to $5,000

Felonious Assault AD&D* 

Up to $5,000

Return to Home Coverage

Up to 30 days per 12 months Max $2000

AD&D Principal Sum*

$25,000 Common Carrier

Pre-certification

50% reduction of Eligible Medical Expenses if Pre- certification provisions are not met

Travel Assistance by GBG Assist 

Included

SCHEDULE of BENEFITS per Person

BASIC Policy

Policy Maximum 

$50,000 Max per Injury/Sickness

Deductible (per Incidence) Choices

$0

Well Doctor Visit 

Pays up to $75 - One Visit per person per Policy Period. The Well Doctor Visit must occur within the first 21 days from the effective date of coverage. To be eligible you must purchase at least 30 days of coverage initially.

INPATIENT

 

Hospital Room & Board including Laboratory Tests, X-Rays, Prescription Medical and other miscellaneous

Up to $1400/day, 30 day Max

Hospital Intensive Care Unit

Additional $700/day, 8 day Max

Surgical Treatment 

Up to $3500

Anesthetist 

Up to $850

Assistant Surgeon

Up to $850

Physician’s Non-Surgical Visits 

Up to $55/visit, 1/day, 30 visits Max

A Consulting Physician, when requested by attending Physician

Up to $450

Private Duty Nurse

Up to $450

Pre-Admission Tests w/in 7 days before admission

Up to $1100

OUTPATIENT  Maximum Daily Benefit All Services $10,000

 

Surgical Treatment

Up to $3500

Anesthetist 

Up to $850

Assistant Surgeon

Up to $850

Physician’s Visits/Urgent Care

Up to $55/visit, 1/day, 30 visits max

Diagnostic X-rays & Lab Services 

$450

Scans, PET scan or MRI

Up to $650 Scan PET scan or MRI

Hospital Emergency Room (all expenses incurred therein) For Emergency Room Illness with no direct Hospital Admission

Up to $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.

Hospital Emergency Room (all expenses incurred therein) For Injury/Accident or Illness with direct Hospital Admission

Up to $350

Prescription Drugs (outpatient)

Up to $100

Outpatient Surgical Facility

Up to $1000

OTHER TREATMENT AND SERVICES

 

Acute Onset of Pre-Existing Condition(s) per Policy Period Subject to the sub limits for each
benefit listed

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.

Ambulance Services 

Up to $500

Initial Orthopedic Prosthesis/brace

Up to $1100

Chemotherapy and/or radiation therapy 

Up to $1100

Dental Treatment for Injury to Sound, Natural Teeth

Up to $600

Mental & Nervous Disorder & Substance Abuse

Up to $5000

Outpatient Physical Therapy 

Up to $40/visit, 1/day, 12 visits max

Emergency Medical Evacuation* 

$100,000

Repatriation of Remains*

$7,500

Local Burial/Cremation

$5,000 Maximum Limit per person for preparation, local burial or cremation of the Insured Person’s mortal remains at the time of death. Must be approved in advance and coordinated by GBG Assist.

Natural Disasters, Political Evacuation and Repatriation* 

Up to $500

Return of Minor Children or Grand-Children*

Up to $5,000

Felonious Assault AD&D*

Up to $5,000

Pre-certification

50% reduction of Eligible Medical Expenses if Pre- certification provisions are not met

Travel Assistance by GBG Assist 

Included

SCHEDULE of BENEFITS per Person

Silver Policy

Policy Maximum

$75,000 Max per Injury/Sickness

Deductible (per Incidence) Choices

$0

Well Doctor Visit

Pays up to $75 - One Visit per person per Policy Period. The Well Doctor Visit must occur within the first 21 days from the effective date of coverage. To be eligible you must purchase at least 30 days of coverage initially.

INPATIENT

 

Hospital Room & Board including Laboratory Tests, X-Rays, Prescription  Medical and other miscellaneous

Up to $1750/day, 30 day Max

Hospital Intensive Care Unit 

Additional $800/day, 8 day Max

Surgical Treatment

Up to $4750

Anesthetist

Up to $1200

Assistant Surgeon

Up to $1200

Physician’s Non-Surgical Visits

Up to $70/visit, 1/day, 30 visits max

A Consulting Physician, when requested by attending Physician

Up to $550

Private Duty Nurse

Up to $550

Pre-Admission Tests w/in 7 days before admission

Up to $1100

OUTPATIENT  Maximum Daily Benefit All Services $10,000

 

Surgical Treatment

Up to $4750

Anesthetist

Up to $1200

Assistant Surgeon

Up to $1200

Physician’s Visits/Urgent Care 

Up to $70/visit, 1/day, 30 visits max

Diagnostic X-rays & Lab Services

$475

Scans, PET scan or MRI

Up to $875 scan, PET scan or MRI

Hospital Emergency Room (all expenses incurred therein) For Emergency Room Illness with no direct Hospital Admission

Up to $450 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.

Hospital Emergency Room (all expenses incurred therein) For Injury/Accident or Illness with direct Hospital Admission

Up to $450

Prescription Drugs (outpatient)

Up to $125

Outpatient Surgical Facility 

Up to $1150

OTHER TREATMENT AND SERVICES

 

Acute Onset of Pre-Existing Condition(s) per Policy Period  Subject to the sub limits for each benefit listed

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 69and $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 or 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.

Ambulance Services

Up to $500

Initial Orthopedic Prosthesis/brace

Up to $1225

Chemotherapy and/or radiation therapy 

Up to $1225

Dental Treatment for Injury to Sound, Natural Teeth

Up to $600

Mental & Nervous Disorder & Substance Abuse

Up to $5000

Outpatient Physical Therapy

Up to $40/visit, 1/day, 12 visits max

Emergency Medical Evacuation*

$100,000

Repatriation of Remains*

$10,000

Local Burial/Cremation 

$5,000 Maximum Limit per person for preparation, local burial or cremation of the Insured Person’s mortal remains at the time of death. Must be approved in advance and coordinated by GBG Assist.

Natural Disasters, Political Evacuation and Repatriation*

Up to $1,000

Return of Minor Children or Grand-Children*

Up to $7,500

Felonious Assault AD&D*

Up to $7,500

Pre-certification

50% reduction of Eligible Medical Expenses if Pre- certification provisions are not met

Travel Assistance by GBG Assist

Included

SCHEDULE of BENEFITS per Person

Gold Policy

Policy Maximum

$100,000 Max per Injury/Sickness

Deductible (per Incidence) Choices

$0

Well Doctor Visit

Pays up to $75 - One Visit per person per Policy Period. The Well Doctor Visit must occur within the first 21 days from the effective date of coverage. To be eligible you must purchase at least 30 days of coverage initially.

INPATIENT

 

Hospital Room & Board including Laboratory Tests, X-Rays, Prescription Medical and other miscellaneous

Up to $2000/day, 30 day max

Hospital Intensive Care Unit

Additional $900/day, 8 day max

Surgical Treatment

Up to $6000

Anesthetist

Up to $1400

Assistant Surgeon 

Up to $1400

Physician’s Non-Surgical Visits

Up to $85/visit, 1/day, 30 visits max

A Consulting Physician, when requested by attending Physician

Up to $550

Private Duty Nurse

Up to $550

Pre-Admission Tests w/in 7 days before admission

Up to $1200

OUTPATIENT  Maximum Daily Benefit All Services $10,000

 

Surgical Treatment 

Up to $6000

Anesthetist 

Up to $1400

Assistant Surgeon 

Up to $1400

Physician’s Visits/Urgent Care 

Up to $85/visit, 1/day, 30 visits max

Diagnostic X-rays & Lab Services

Up to $500

Scans, PET scan or MRI

Up to $1050 scan, PET scan or MRI

Hospital Emergency Room (all expenses incurred therein) For Emergency Room Illness with no direct Hospital Admission

Up to $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.

Hospital Emergency Room (all expenses incurred therein) For Injury/Accident or Illness with direct Hospital Admission

Up to $350

Hospital Emergency Room (all expenses incurred therein)

Up to Up to $550

Prescription Drugs (outpatient)

Up to $150

Outpatient Surgical Facility 

Up to $1275

OTHER TREATMENT AND SERVICES

 

Acute Onset of Pre-Existing Condition(s) per Policy Period  Subject to the sub limits for each benefit listed

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.

Ambulance Services

Up to $500

Initial Orthopedic Prosthesis/brace

Up to $1350

Chemotherapy and/or radiation therapy

Up to $1350

Dental Treatment for Injury to Sound, Natural Teeth

Up to $600

Mental & Nervous Disorder & Substance Abuse 

Up to $5000

Outpatient Physical Therapy

Up to $40/visit, 1/day, 12 visits max

Emergency Medical Evacuation*

Unlimited

Repatriation of Remains* 

$20,000

Local Burial/Cremation 

$5,000 Maximum Limit per person for preparation, local burial or cremation of the Insured Person’s mortal remains at the time of death. Must be approved in advance and coordinated by GBG Assist

Natural Disasters, Political Evacuation and Repatriation*

Up to $1,500

Return of Minor Children or Grand-Children*

Up to $7,500

Felonious Assault AD&D* 

Up to $7,500

Return to Home Coverage

Up to 60 days per 12 months Max Benefit $5000

AD&D Principal Sum*

$35,000 Common Carrier

Pre-certification

50% reduction of Eligible Medical Expenses if Pre- certification provisions are not met

Travel Assistance by GBG Assist

Included

SCHEDULE of BENEFITS per Person

Platinum Policy

Policy Maximum

$175,000 Max per Injury/Sickness

Deductible (per Incidence) Choices

$0

Well Doctor Visit

Pays up to $75 - One Visit per person per Policy Period. The Well Doctor Visit must occur within the first 21 days from the effective date of coverage. To be eligible you must purchase at least 30 days of coverage initially

INPATIENT

 

Hospital Room & Board including Laboratory Tests, X-Rays, Prescription  Medical and other miscellaneous

Up to $2700/day, 30-day max

Hospital Intensive Care Unit

Additional $1150/day, 10-day max

Surgical Treatment

Up to $7500

Anesthetist 

Up to $1800

Assistant Surgeon 

Up to $1800

Physician’s Non-Surgical Visits 

Up to $115/visit, 1/day, 30 visits max

A Consulting Physician, when requested by attending Physician

Up to $700

Private Duty Nurse

Up to $700

Pre-Admission Tests w/in 7 days before admission 

Up to $1500

OUTPATIENT  Maximum Daily Benefit All Services $10,000

 

Surgical Treatment

Up to $7500

Anesthetist

Up to $1800

Assistant Surgeon

Up to $1800

Physician’s Visits/Urgent Care

Up to $115/visit, 1/day, 30 visits max

Diagnostic X-rays & Lab Services

$675

Scans, PET scan or MRI

Up to $1300 Scan, PET scan or MRI

Hospital Emergency Room (all expenses incurred therein) For Emergency Room Illness with no direct Hospital Admission

Up to $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.

Hospital Emergency Room (all expenses incurred therein) For Injury/Accident or Illness with direct Hospital Admission

Up to $800

Prescription Drugs (outpatient)

Up to $200

Outpatient Surgical Facility

Up to $1400

OTHER TREATMENT AND SERVICES

 

Acute Onset of Pre-Existing Condition(s) per Policy
Period  Subject to the sub limits for each benefit
listed

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.

Ambulance Services 

Up to $750

Initial Orthopedic Prosthesis/brace

Up to $1750

Chemotherapy and/or radiation therapy 

Up to $1750

Dental Treatment for Injury to Sound, Natural Teeth

Up to $600

Mental & Nervous Disorder & Substance Abuse

Up to $20,000 30 days max

Outpatient Physical Therapy 

Up to $60/visit, 1/day, 12 visits max

Emergency Medical Evacuation*

Unlimited

Repatriation of Remains*

$25,000

Local Burial/Cremation 

$5,000 Maximum Limit per person for preparation, local burial or cremation of the Insured Person’s mortal remains at the time of death. Must be approved in advance and coordinated by GBG Assist.

Natural Disasters, Political Evacuation and Repatriation* 

Up to $2,000

Return of Minor Children or Grand-Children*

Up to $10,000

Felonious Assault AD&D* 

Up to $10,000

Pre-certification

50% reduction of Eligible Medical Expenses if Pre- certification provisions are not met

Travel Assistance by GBG Assist 

Included

SCHEDULE of BENEFITS per Person

Diamond Policy

Policy Maximum

$50,000 Annual Max

Deductible (per Incidence) Choices

$100, $200

Well Doctor Visit 

Pays up to $75 - One Visit per person per Policy Period. The Well Doctor Visit must occur within the first 21 days from the effective date of coverage. To be eligible you must purchase at least 30 days of coverage initially.

INPATIENT

 

Hospital Room & Board including Laboratory Tests, X-Rays,Prescription Medical and other miscellaneous

Up to $1500/day, 15 day Max

Hospital Intensive Care Unit 

Additional $800/day, 8 day Max

Surgical Treatment 

Up to $3500

Anesthetist 

Up to $850

Assistant Surgeon

Up to $850

Physician’s Non-Surgical Visits

Up to $55/visit, 1/day, 30 visits max

A Consulting Physician, when requested by attending Physician

Up to $450

Private Duty Nurse

Up to $450

Pre-Admission Tests w/in 7 days before admission

Up to $1100

OUTPATIENT  Maximum Daily Benefit All Services $10,000

 

Surgical Treatment 

Up to $3000

Anesthetist 

Up to $700

Assistant Surgeon

Up to $700

Physician’s Visits/ Urgent Care

Up to $55/visit, 1/day, 30 visits Max

Diagnostic X-rays & Lab Services

$450

Scans, PET scan or MRI

Up to $650 Scan PET scan or MRI

Hospital Emergency Room (all expenses incurred therein) For Emergency Room Illness with no direct Hospital Admission

Up to $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.

Hospital Emergency Room (all expenses incurred therein) For Injury/Accident or Illness with direct Hospital Admission

Up to $350

Prescription Drugs (outpatient) Per Sickness/Injury 

Up to $90

Outpatient Surgical Facility 

Up to $1000

OTHER TREATMENT AND SERVICES

 

Acute Onset of Pre-Existing Condition(s) per Policy Period Subject to the sub limits for each benefit listed

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.

Ambulance Services 

Up to $500

Initial Orthopedic Prosthesis/brace

Up to $1100

Chemotherapy and/or radiation therapy

Up to $1100

Dental Treatment for Injury to Sound, Natural Teeth

Up to $600

Mental & Nervous Disorder & Substance Abuse 

Up to $5000

Outpatient Physical Therapy 

Up to $40/visit, 1/day, 12 visits Max

Emergency Medical Evacuation*

$50,000

Repatriation of Remains*

$7,500

Local Burial/Cremation

$5,000 Maximum Limit per person for preparation, local burial or cremation of the Insured Person’s mortal remains at the time of death. Must be approved in advance and coordinated by GBG Assist.

Natural Disasters, Political Evacuation and Repatriation*

Up to $500

Return of Minor Children or Grand-Children*

Up to $5,000

Felonious Assault AD&D* 

Up to $5,000

Pre-certification

50% reduction of Eligible Medical Expenses if Pre- certification provisions are not met

Travel Assistance by GBG Assist

Included

SCHEDULE of BENEFITS per Person

Diamond Plus Policy

Policy Maximum

$100,000 Annual Max

Deductible (per Incidence) Choices

$100, $200

Well Doctor Visit 

Pays up to $75 - One Visit per person per Policy Period. The Well Doctor Visit must occur within the first 21 days from the effective date of coverage. To be eligible you must purchase at least 30 days of coverage initially.

INPATIENT

 

Hospital Room & Board including Laboratory Tests, X-Rays, Prescription Medical and other miscellaneous

Up to $1500/day, 15 day Max

Hospital Intensive Care Unit 

Additional $800/day, 8 day Max

Surgical Treatment

Up to $3500

Anesthetist 

Up to $850

Assistant Surgeon

Up to $850

Physician’s Non-Surgical Visits 

Up to $55/visit, 1/day, 30 visits max

A Consulting Physician, when requested by attending Physician

Up to $450

Private Duty Nurse 

Up to $450

Pre-Admission Tests w/in 7 days before admission

Up to $1100

OUTPATIENT  Maximum Daily Benefit All Services $10,000

 

Surgical Treatment 

Up to $3000

Anesthetist

Up to $700

Assistant Surgeon 

Up to $700

Physician’s Visits/Urgent Care

Up to $55/visit, 1/day, 30 visits Max

Diagnostic X-rays & Lab Services 

$450

Scans, PET scan or MRI

Up to $650 Scan PET scan or MRI

Hospital Emergency Room (all expenses incurred therein) For Emergency Room Illness with no direct Hospital Admission

Up to $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.

Hospital Emergency Room (all expenses incurred therein) For Injury/Accident or Illness with direct Hospital Admission

Up to $350

Hospital Emergency Room (all expenses incurred therein)

Up to $350

Prescription Drugs (outpatient)

Up to $90

Outpatient Surgical Facility

Up to $1000

OTHER TREATMENT AND SERVICES

 

Acute Onset of Pre-Existing Condition(s) per Policy Period  Subject to the sub limits for each benefit listed

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.

Ambulance Services 

Up to $500

Initial Orthopedic Prosthesis/brace

Up to $1100

Chemotherapy and/or radiation therapy 

Up to $1100

Dental Treatment for Injury to Sound, Natural Teeth

Up to $600

Mental & Nervous Disorder & Substance Abuse 

Up to $5000

Outpatient Physical Therapy

Up to $40/visit, 1/day, 12 visits Max

Emergency Medical Evacuation*

$50,000

Repatriation of Remains*

$7,500

Local Burial/Cremation 

$5,000 Maximum Limit per person for preparation, local burial or cremation of the Insured Person’s mortal remains at the time of death. Must be approved in advance and coordinated by GBG Assist.

Natural Disasters, Political Evacuation and Repatriation* 

Up to $500

Return of Minor Children or Grand-Children*

Up to $5,000

Felonious Assault AD&D*

Up to $5,000

Pre-certification

50% reduction of Eligible Medical Expenses if Pre- certification provisions are not met

Travel Assistance by GBG Assist

Included

Not subject to the deductible

GENERAL TERMS OF COVERAGE

  1. This policy is compliant with European Schengen and visa requirements for most countries. Entry requirements change frequently,please check with your respective country of destination about visa and entry requirements. GBG and/or its subsidiaries and business partners are not responsible for compliance with these regulations.
  2. A renewal notice will be emailed before the Policy Period ends and includes links to renew prior to your termination date.
  3. You are subject to the following rules at renewal: Coverage may be renewed if it is initially purchased for a minimum of 5 days. If available, additional periods are charged at the premium rate in force at the time of renewal. The total Policy Period cannot exceed 24 months. Five days premium is the minimum acceptable renewal premium and twelve months premium is the maximum. There are no grace periods for renewals. Once the policy has lapsed, you would need to reapply. Please note: once you reapply for a new policy, the Pre-Existing Condition exclusion, deductible and co-insurance start over.
  4. Maximum Age: Coverage ceases on the Insured Person’s 90th birthday.
  5. All claims must be submitted within 90 days from date of incident or they will be denied. Circumstances may exist in which this is not always possible. Any submissions after 90 days will be considered based on those circumstances.
  6. All claims arising under this insurance shall be governed by the Laws of the Bailiwick of Guernsey, Channel Islands, whose courts alone shall have jurisdiction in any dispute arising hereunder.
  7. If the Insured Person or any person acting on his/her behalf shall make any claim or statement knowing the same to be false or fraudulent in regards to amount or otherwise, then this Insurance shall become void and all claims hereunder shall be forfeited without refund of premium.
  8. The Insurer may at their own expense take proceedings in the name of the Insured Person to recover compensation or secure an indemnity from any third party in respect of any loss, damage or expense covered by this Insurance and any amount so recovered or secured shall belong to the Insurer.
  9. The Insured Person must exercise reasonable care to prevent accident, Injury, loss or damage and at all times act as if uninsured.
  10. Client must notify the Plan Administrator within 30 days of a change of address or domicile.
  11.  This policy does not cover any type of sports Injury or Sickness.
  12. The Company maintains its right to investigate to verify that the eligibility requirements have been met. If and whenever the Company discovers that the eligibility requirements have not been met, its only obligation is refund of premium. Greencard Holders are not eligible for this coverage.
  13. The Insured must arrive in the USA before traveling to other countries.
  14. Coverage in countries outside the USA and your Home Country is available for up to 180 days during your Policy Period.
  15. Sudden and 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.
  16. Safe Travels for Visitors to the USA provides coverage to non-US citizens who reside outside the USA and are traveling outside of their Home Country while visiting the United States or to the United States and Worldwide.

Hospital Benefits

Inpatient Hospital Benefits – As specified in the Schedule of Benefits

Inpatient means a person was admitted to an approved Hospital or other health care facility for a medically necessary overnight stay. Hospitalization services include, but are not limited to, semi-private room and board (as listed in the Schedule of Benefits and as designated by your plan selection), 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 to include x-ray, laboratory and other diagnostic tests, drugs, medications, biological anesthesia and oxygen services, radiation therapy, inhalation therapy, chemotherapy and administration of blood products. All inpatient ancillary benefits are paid in accordance with the current Schedule of Benefits.

Inpatient Services

Benefits are provided per the Schedule of Benefits for medically necessary inpatient Hospital care.

Accommodations

Coverage is provided for room and board, special diets and general nursing care. All charges in excess of the allowable semiprivate rate are the responsibility of the Insured.

Intensive Care Units

Intensive Care Units Benefits will be provided based on the Allowable Charge for medically necessary Intensive Care services.

Inpatient Ancillary Hospital Services

If medically necessary for the Diagnosis and treatment of the Sickness or Injury for which an Insured Person is hospitalized, the following services are also covered:

Use of operation room 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 proven malignancy or neoplastic 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 condition of 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.

Hospital Outpatient Benefit – See Hospital Benefits

Outpatient Hospital Benefits – As specified in the schedule of benefits Outpatient means a person is admitted to an approved hospital or other healthcare facility for treatment that does not require an overnight stay. This policy provides the same level of benefits whether you are an INPATIENT or OUTPATIENT. However, as an outpatient there is no coverage for hospital stay or board.

Other Treatment and Services:

Emergency Ground Ambulance Services

Benefits are provided for medically necessary emergency ground ambulance transportation to the nearest Hospital able to provide the required level of care and are payable in accordance with the Schedule of Benefits;

Initial Orthopedic Prosthesis/brace

Prosthesis and corrective devices such as Durable Medical Equipment which 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; more wheels; comfort items such as telephone 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;

Chemotherapy and/or radiation therapy-covered under Inpatient Ancillary Hospital Services

Emergency Dental Benefit - Emergency dental treatment and restoration of sound natural teeth; required as a result of an Accident; Benefit limited to $600; Routine dental treatment not covered.

Mental Health Benefits - Inpatient/Outpatient Services Benefits are provided for psychotherapeutic treatment and psychiatric counseling and treatment for an approved psychiatric Diagnosis and are payable as follows and in accordance with the current Schedule of Benefits.

Outpatient Mental Health-As set forth in the Schedule of Benefits

Benefits are for both inpatient mental 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 Pre-authorized. The following services are excluded: Aptitude testing, educational testing and services; Services for conditions not determined by Insurer 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.

Well Doctor Visit

We will pay up to $75 for one Well Doctor Visit per person per Policy Period. You may use any doctor or facility. Visit must be in person.

Telemedicine is not eligible. To be covered:

1) the visit must occur within the first 21 days from the effective date of coverage; and

2) you must purchase at least 30 days of coverage initially; and

3) the Provider must use specific ICD10 codes for the Well Visit which are 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 at https://TrawickInternational.com/wellness/Register

Outpatient Physical Therapy - See the Schedule of Benefits

Emergency Medical Evacuation

The plan covers the cost of emergency evacuation – when deemed necessary and pre-approved by GBG Assist – to a suitable location to render immediate and appropriate care. GBG Assist will 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 GBG Assist, GBG reserves the right to deny coverage or assess a 20% co-payment for the associated costs. Limit of $25,000 for Medical Evacuation due to Acute Onset of a Pre- Existing Condition.

Repatriation for Medical Treatment: GBG reserves the right to review any case in which the Insured Person is medically stable and upon advice of GBG Assist medical doctors can be evacuated at GBG’s discretion to the home country of residence.

Repatriation of Mortal Remains

We will pay 100% up to the amount listed in the Schedule of Benefits for preparation and return of your body to your Home Country if you die due to a Covered Injury or Sickness. 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 GBG Assist. This benefit excludes fees for return of personal effects, religious or secular memorial services, clergymen, flowers, music, announcements, guest expenses and similar personal burial preferences.

Local Burial Benefit

We will pay up to $5,000 Maximum Limit per person for preparation, local burial or cremation of the Insured Person’s mortal remains at the time of death. Must be approved in advance and coordinated by GBG Assist. Includes death due to a Pre-existing Condition. The Company will pay the reasonable Covered Expenses incurred up to the maximum states in the Schedule of Benefits for preparation, local burial or cremation of your mortal remains at the country of death in accordance with the commonly accepted cultural and religious belief’s practiced by You. 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. Failure to utilize GBG Assist to arrange for these services will result in the denial of benefits. Restrictions: Must use Assistance Provider to arrange for the services. Cannot use with the Repatriation of Remains Benefit. Exclusions: Coverage is not provided for burial and cremation costs incurred for religious practitioner, flowers, music, food or beverages.

Natural Disasters, Political Evacuation and Repatriation

Provides a benefit for evacuation during a period of civil unrest, insurrection or natural disasters that could not have been foreseen prior to departure from 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 or country of residence. The coverage amount is in the Schedule of Benefits.

Return of Minor Children

If traveling alone and with a child under the age of 18 and the Insured Person falls ill and is hospitalized due to a covered Sickness resulting in a minor child being left unattended. The plan will pay for one-way transportation via economy commercial common carrier to their Home Country including the cost of an escort should that be deemed required for the safety and wellbeing of the minor.

Continuation of Treatment Period

If a covered Injury or Illness requires continuing Treatment after the expiration of the Period of Coverage, an Insured Person may receive continuing Treatment for the covered Injury or Illness for up to 6 months per Injury or Illness, subject to the following: if the Period of Coverage expires while the Insured Person is outside the Home Country, a covered Injury or Illness incurred while outside and prior to returning to the Home Country, and that covered Injury or Illness requires continuing Treatment, the Company will review and determine the date of initial Treatment for the covered Injury or Illness, and if such date is prior to the expiration of the Period of Coverage, Eligible Medical Expenses for the covered Injury or Illness will continue to be reimbursed until there has been at least the minimum number of days of continuous Treatment for the covered Injury or Illness, subject to the limits set forth in the Schedule of Benefits/Limits, and all other Terms of the insurance plan. In order to be eligible for coverage under the Continuation of Treatment Period provision, the Insured Person must be covered by an insurance policy, benefit plan, or Other Coverage for expenses or charges incurred by the Insured Person, and the Other Coverage remains in effect during the duration of coverage with the Company. (Not available on Diamond or Diamond Plus).

Common Carrier AD&D Principal Sum

Accidental Death and Dismemberment will apply to covered accidents incurred while traveling/riding as a passenger in or on any public land, water or air conveyance (regularly scheduled and licensed) for transportation of passengers for hire. Losses must occur within one year (365 days) from the date of accident. (Not available on Diamond or Diamond Plus).

Loss of Life

100%

Loss of Speech and Loss of Hearing

100%

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

100%

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

100%

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%
100%

Quadriplegia

100%

Paraplegia

75%

Hemiplegia

50%

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

50%

Uniplegia

25%

Loss of Thumb and Index Finger of the same hand

25%

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.

Pre-Existing Condition” means 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 36 months 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. This specifically includes but is not limited to any medical condition, Sickness, Injury , Illness, disease, Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis,care or Treatment was recommended or received or for which a reasonably prudent person would have sought Treatment during the 36 month period immediately preceding the Effective Date of Coverage under this Certificate. 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.