Safe Travels for Visitors to the USA

Plan Detail

Plan Administrator: Trawick International | AM Best Rating: B++ | Underwriter: GBG Insurance Limited

Benefits


MEDICAL SCHEDULE OF BENEFITS

  ECONOMY
AGE 14 DAYS TO AGE 69
BASIC
AGE 14 DAYS TO AGE 69
SILVER
AGE 14 DAYS TO AGE 69
GOLD
AGE 14 DAYS TO AGE 69
PLATINUM
AGE 14 DAYS TO AGE 69
DIAMOND
AGE 50 TO AGE 89
Policy Maximums $25,000 Max per Injury/Sickness

Cardiac Conditions/Treatment $25,000 per Policy Period Limit
$50,000 Max per Injury/Sickness

Cardiac Conditions/Treatment $25,000 per Policy Period Limit
$75,000 Max per Injury/Sickness

Cardiac Conditions/Treatment $25,000 per Policy Period Limit
$100,000 Max per Injury/Sickness

Cardiac Conditions/Treatment $25,000 per Policy Period Limit
$175,000 Max per Injury/Sickness

Cardiac Conditions/Treatment $25,000 per Policy Period Limit
$50,000 Max Diamond $100,000 Max Diamond Plus Annual Policy Max

Cardiac Conditions/Treatment $25,000 per Policy Period Limit up to age 69 at age 70, it is limited to $15,000
Deductible options (per Incidence) $0, $50 $100 $100 or $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 $1400/day, 30 day max Up to $1400/day, 30 day max Up to $1750/day, 30 day max Up to $2000/day, 30 day max Up to $2700/day, 30 day max Up to $1500 /day, 15 day max
Hospital Intensive Care Unit Additional $700/day, 8 day Max Additional $700/day, 8 day Max Additional $800/day, 8 day Max Additional $900/day, 8 day Max Additional $1150/day, 10 day Max Additional $800/day, 8 day Max
Surgical Treatment Up to $3500 Up to $3500 Up to $4750 Up to $6000 Up to $7500 Up to $3500
Anesthetist Up to $850 Up to $850 Up to $1200 Up to $1400 Up to $1800 Up to $850
Assistant Surgeon Up to $850 Up to $850 Up to $1200 Up to $1400 Up to $1800 Up to $850
Physician’s Non-Surgical Visits Up to $55/visit, 1/day, 30 visits Max Up to $55/visit, 1/day, 30 visits Max Up to $70/visit, 1/day, 30 visits Max Up to $85/visit, 1/day, 30 visits Max Up to $115/visit, 1/day, 30 visits Max Up to $55/visit, 1/day, 30 visits Max
A Consulting Physician, when requested by attending Physician Up to $450 Up to $450 Up to $550 Up to $550 Up to $700 Up to $450
Private Duty Nurse Up to $450 Up to $450 Up to $550 Up to $550 Up to $700 Up to $450
Pre-Admission Tests w/in 7 days before admission Up to $1100 Up to $1100 Up to $1100 Up to $1200 Up to $1500 Up to $1100

OUTPATIENT

Maximum Daily Benefit All Services $10,000

Surgical Treatment Up to $3500 Up to $3500 Up to $4750 Up to $6000 Up to $7500 Up to $3000
Anesthetist Up to $850 Up to $850 Up to $1200 Up to $1400 Up to $1800 Up to $700
Assistant Surgeon Up to $850 Up to $850 Up to $1200 Up to $1400 Up to $1800 Up to $700
Physician’s Visits/Urgent Care Up to $55/visit,1/day, 30 visits Max Up to $55/visit,1/day, 30 visits Max Up to $70/visit,1/day, 30 visits Max Up to $85/visit,1/day, 30 visits Max Up to $115/visit,1/day, 30 visits Max Up to $55/visit,1/day, 30 visits Max
Diagnostic X-rays & Lab Services Scans, PET scan or MRI $450
Up to $650 Scan PET scan or MRI
$450
Up to $650 Scan PET scan or MRI
$475
$875 scan, PET scan or MRI
$500
Up to $1050 scan, PET scan or MRI
$675
Up to $1300 Scan, PET scan or MRI
$450
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. 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. 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. Up to $550 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. 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. 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 Up to $350 Up to $450 Up to $550 Up to $800 Up to $350
Prescription Drugs (outpatient) Per Sickness/Injury Up to $100 Up to $100 Up to $125 Up to $150 Up to $200 Up to $90
Outpatient Surgical Facility Up to $1000 Up to $1000 Up to $1150 Up to $1275 Up to $1400 Up to $1000
Ambulance Services Up to $500 Up to $500 Up to $500 Up to $500 Up to $750 Up to $500
Initial Orthopedic Prosthesis/brace Up to $1,100 Up to $1,100 Up to $1225 Up to $1,350 Up to $1,750 Up to $1100
Chemotherapy &/or radiation therapy Up to $1,100 Up to $1,100 Up to $1,225 Up to $1,350 Up to $1,750 Up to $1100
Dental Treatment for Injury to Sound, Natural Teeth Up to $600 Up to $600 Up to $600 Up to $600 Up to $600 Up to $600
Mental & Nervous Disorder & Substance Abuse Up to $5,000 Up to $5,000 Up to $5,000 Up to $5,000 Up to $20,000
30 days Max
Up to $5,000
Outpatient Physical Therapy Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max
Emergency Medical Evacuation* $100,000 $100,000 $100,000 Unlimited Unlimited $50,000
Repatriation of Remains* $7,500 $7,500 $10,000 $20,000 $25,000 $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 Disaster, Political Evacuation & Repatriation* Up to $500 Up to $500 Up to $1,000 Up to $1,500 Up to $2,000 Up to $500
Return of Minor Children or Grand-Children* Up to $5,000 Up to $5,000 Up to $7,500 Up to $7,500 Up to $10,000 Up to $5,000
Felonious Assault AD&D* Up to $5,000 Up to $5,000 Up to $7,500 Up to $7,500 Up to $10,000 Up to $5,000
Return to Home Coverage* Up to 30 days per 12 months Max $2,000 Up to 30 days per 12 months Max $2,000 Up to 60 days per 12 months Max $2,500 Up to 60 days per 12 months Max $2,500 Up to 90 days per 12 months Max $7,500 N/A
AD&D Principal Sum* $25,000 Common Carrier $25,000 Common Carrier $35,000 Common Carrier $35,000 Common Carrier $35,000 Common Carrier N/A
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 Policy Period 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 age 70 benefits will be reduced to a Medical Maximum of $25,000, 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.
Pre- certification Requirement 50% reduction of Eligible Medical Expenses if Pre-certification provisions are not met 50% reduction of Eligible Medical Expenses if Pre-certification provisions are not met 50% reduction of Eligible Medical Expenses if Pre-certification provisions are not met 50% reduction of Eligible Medical Expenses if Pre-certification provisions are not met 50% reduction of Eligible Medical Expenses if Pre-certification provisions are not met 50% reduction of Eligible Medical Expenses if Pre-certification provisions are not met
Travel Assistance by GBG Assist Included
*Not Subject to the Deductible

POLICY TERMS & CONDITIONS

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.

Sudden and Acute Onset of a Pre-Existing Condition(s)

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 age 70 Acute Onset benefits will be reduced to a Maximum of $35,000, 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

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%
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.

Emergency Assistance: GBG Assist

24 hours a day, 7 days per week. These services include pre-certification, hospital admission and referrals. For medical emergencies and assistance with medical care, contact GBG Assist at US / Canada Toll Free: 1-877-916-7920 or Worldwide collect 1-949-916-7941