Safe Travels for Visitors to the USA

Plan Detail

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

Description


MEMBER ELIGIBILITY

Dependent” means an Insured’s lawful spouse or Domestic Partner; or an Insured’s unmarried child, from 14 days to age 21, who is chiefly dependent on the Insured for support. A child, for eligibility purposes, includes an Insured’s natural child; adopted child, beginning with any waiting period pending finalization of the child’s adoption; or a stepchild who resides with the Insured or depends chiefly on the Insured for financial support. A Dependent may also include any person related to the Insured by blood or marriage and for whom the Insured is allowed a deduction under the Internal Revenue Code. Insurance will continue for any dependent child who reaches the age limit and continues to meet the following conditions: 1. the child is handicapped, 2. is not capable of self-support and 3. depends chiefly on the Insured for support and maintenance. The Insured must send Us satisfactory proof that the child meets these conditions, when requested. We will not ask for proof more than once a year.

"Effective Date” means the program shall become effective at 12:01 AM North American Central Time on the latest of the following dates: The Insured Person’s Departure from their Home Country. 1. The date the application and premium are received by the Administrator; or 2. The date the application and premium are accepted by the Administrator; or 3. The date requested on the application. “Event” Any one incident in which the Insured Person requires care for acute, sudden and unforeseen Medical and Accidental Emergencies and the direct consequence of the Event. Maximum coverage is limited to amounts specified in the Schedule of Benefits. Multiple Events independent of each other are covered to the Event maximum with no limits on the number of Events.

“Termination Date” means the coverage provided with respect to the Named Insured shall terminate at 12:01 AM North American Central Time on the earliest of the following dates: 1. The date shown on the insurance confirmation card, for which the premium is paid; or 2. The date the Insured Person returns to his Home Country; or 3. Three hundred and sixty-four (364) days after the Insured Person’s original original effective date, unless renewed; or 4. The date the Insured Person becomes a United States citizen. “Trip” means travel by air, land, or sea from the Insured Person’s Home Country.

"Accident” means a sudden, unexpected and unintended Event. Where the Insured Person sustaining bodily Injury caused by accidental, external, violent and visible means which shall solely and independently of any other cause.

“Common Carrier” means any public conveyance that is operated via a published schedule and to which a fare is paid. This is inclusive of Bus, Rail, Air and Sea transportation.

“Covered Accident” means an Accident that occurs while coverage is in force for an Insured Person and results in a loss or Injury covered by the Policy for which benefits are payable.

“Covered Expenses” means expenses actually incurred by or on behalf of an Insured Person for treatment, services and supplies covered by the Policy. Coverage under the Policy must remain continuously in force from the date of the Accident or Sickness until the date treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date such treatment, service or supply, that gave rise to the expense or the charge, was rendered or obtained.

"Covered Loss” or “Covered Losses” means an accidental death, dismemberment or other Injury covered under the Policy.

“Deductible” means the dollar amount of Covered Expenses that must be incurred as an out of-pocket expense by each Insured Person on a perincidence basis. The deductible must be met, by the Insured Person before Medical Expense Benefits can be paid or reimbursed. The deductible is applied to the first eligible claim processed.

“Dependent” means an Insured’s lawful spouse or Domestic Partner; or an Insured’s unmarried child, from 14 days to age 21, who is chiefly dependent on the Insured for support. A child, for eligibility purposes, includes an Insured’s natural child; adopted child, beginning with any waiting period pendingfinalization of the child’s adoption; or a stepchild who resides with the Insured or depends chiefly on the Insured for financial support. A Dependent may also include any person related to the Insured by blood or marriage and for whom the Insured is allowed a deduction under the Internal Revenue Code. Insurance will continue for any Dependent child who reaches the age limit and continues to meet the following conditions: 1. the child is handicapped, 2. is not capable of self-support and 3. depends chiefly on the Insured for support and maintenance. The Insured must send Us satisfactory proof that the child meets these conditions, when requested. We will not ask for proof more than once a year.

“Diagnosis” means the result of examination or test by a medical doctor or licensed physician providing a specific international CPT or ICD10 code. Failure to obtain a covered Diagnosis will result in the denial of the claim.

“Doctor” means a licensed health care provider acting within the scope of his or her license and rendering care or treatment to an Insured Person that is appropriate for the conditions and locality. It will not include an Insured Person or a member of the Insured Person’s Immediate Family or household.

“Family Member” means the spouse, parent, parent-in-law, grandparent, child, grandchild, brother, sister, fiancé, such person being resident in the Home Country (as declared on the application), of the Insured Person, or of the person with whom the Insured Person is travelling or had arranged to travel.

Home Country” means a country from which the Insured Person holds a passport. If the Insured Person holds passports from more than one country, his or her Home Country will be that country which the Insured Person has declared to Us in writing as his or her Home Country.

“Hospital” means an institution that: 1. operates as a Hospital pursuant to law for the care, treatment, and providing of in-patient services for sick or injured persons; 2. provides 24-hour nursing service by Registered Nurses on duty or call; 3. has a staff of one or more licensed Doctors available at all times; 4. provides organized facilities for Diagnosis, treatment and surgery, either: (i) on its premises; or (ii) in facilities available to it, on a pre-arranged basis; 5. is not primarily a nursing care facility, rest home, convalescent home, or similar establishment, or any separate ward, wing or section of a Hospital used as such; and 6. is not a place solely for drug addicts, alcoholics, or the aged or any separate ward of the Hospital.

“Hospital Stay/Confined” means an overnight stay as a registered resident bed-patient in a Hospital.

“Incident” Any situation in which the terms and conditions of the policy are activated for either a Sickness or Accident.

“Injury” means accidental bodily harm sustained by an Insured Person that results directly and independently from all other causes from a Covered Accident. All injuries sustained by one person in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury.

“Insured Person” means any Insured and Dependent in a Class of Eligible Persons for whom the required premium is paid making insurance in effect for that person.

“Medical Emergency” means a condition caused by an Injury or Sickness that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy.

“Medically Necessary” means a treatment, service or supply that is: 1. required to treat an Injury or Sickness; prescribed or ordered by a Doctor or furnished by a Hospital; 2. performed in the least costly setting required by the Insured Person’s condition (usual, reasonable and customary); and 3. consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered.

“Missing Person” means an Insured Person who disappeared for an unknown reason and whose disappearance was reported to the Appropriate Authority(ies).

“Natural Disaster” means storm (wind, rain, snow, sleet, hail, lightning, dust or sand) earthquake, flood, volcanic eruption, wildfire or other similar event that: 1. is due to natural causes; and 2. results in such severe and widespread damage that the area of damage is officially declared a disaster area by the government in which the Insured Person’s Trip occurs and the area is deemed to be uninhabitable or dangerous.

“Nearest Place of Safety” means a location determined by the Designated Security Consultant where: 1. the Insured Person can be resumed safe from the Occurrence that precipitated the Insured Person’s Political Evacuation; and the Insured Person has access to Transportation; and 2. the Insured Person has the availability of temporary lodging, if needed.

“Necessities” means personal hygiene items and clothing.

“Occurrence” means any of the following situations involving an Insured Person: 1. expulsion from a Host Country or being declared persona non-grata on the written authority of the recognized government if a Host Country; 2. political or military Events involving a Host Country, if the Appropriate Authorities issue an Advisory stating that citizens of the Insured Person’s Home Country or Country of Residence or citizens of the Host Country should leave the Host Country; 3. deliberate physical harm of the Insured Person confirmed by documentation or physical evidence or a threat against the Insured Person’s health and safety as confirmed by documentation and/or physical evidence; 4. Natural Disaster in the area you are traveling to and occurring after your effective date; 5. the Insured Person had been deemed kidnapped or a Missing Person by local or international authorities and, when found, his or her safety and/or well-being are in question within seven days of his or her being found.

"Policy Period” means the dates as shown on your certificate for which premium has been paid.

“Political Evacuation” means the extrication of an Insured Person from the Host Country due to an Occurrence which could result in grave physical harm or death to the Insured Person and is certified by a governing authority via declaration or warning.

“Pre-certification; Pre-certify” means a general determination of Medical Necessity only, made by the Company in reliance and based upon the completeness and accuracy of the information provided by the Insured Person and/or the Insured Person’s healthcare or medical service providers, guardians, Relatives and/or proxies at the time thereof. Pre-certification is not an assurance, authorization, pre- authorization or verification of coverage, a verification of benefits, or a guarantee of payment.

“Related Costs” means food, lodging and, if necessary, physical protection for the Insured Person during the Transport to the Nearest Place of Safety.“Sickness” means an illness, disease or condition of the Insured Person that causes a loss for which an Insured Person incurs medical expenses while covered under the Policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.

“Usual and Customary Charge” means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided.

“We”, “Insurer”, “Our”, “Us” means GBG Insurance Limited and or its affiliated insurers.

“Well Doctor Visit” means one visit to a provider that occurs within the first 21 days from the effective date and where the provider uses one of these ICD10 Diagnosis codes only - V70.0-Routine medical exam, Z00.00-Encounter for general adult medical examination without abnormal findings, Z00.129-Encounter for routine child health examination without abnormal findings.

Emergency Care: In an EMERGENCY SITUATION, call for emergency assistance (911 in the United States) and go to the closest emergency facility. If you are not sure where to go you may contact GBG Assist at the number on your ID card and they may be able to direct, you to the closest network facility. Remember, it is your health so you must act prudently in an emergency and seek the care you need.

Non-Emergency Care: When a non-emergency situation arises in which you need to visit a medical professional please utilize a local doctor, walk-in clinic or urgent care facility. You can locate one by using the web address on the back of your ID card. Going to a hospital emergency room for NON-Emergency care will result in additional expenses and out of pocket cost as specified in your Schedule of Benefits. Examples of Non-Emergency care include: sore throat, common cold, minor Injuries and Sicknesses that are not life threatening. NOTE: This policy excludes Injury or Sickness related to sports activity. Please see exclusion section.

Pre Certification/Notification: Pre-certification and notification to GBG Assist is mandatory. Failure to do so will result in a 50% reduction of the eligible claims Medical Expenses.

For pre-Certification please contact: GBG Assist Toll Free USA and Canada 877-916-7920 Worldwide Collect 949-916-7941.

Provisions/Requirements:

Pre-certification is a general determination of Medical Necessity, only, and all such determinations are made by the Company (acting through its authorized agents and representatives) in reliance and based upon the completeness and accuracy of the information provided by the Insured Personand/or his/her relatives, guardians and/or healthcare providers at the time of Pre-certification. The Company reserves the right to challenge, dispute and/or revoke a prior determination of Medical Necessity based upon subsequent information obtained. Precertification is not an assurance, authorization, preauthorization, or verification of Treatment or coverage, a verification of benefits, or a guarantee of payment. The fact that Treatment or supplies are Pre-certified by the Company does not guarantee the payment of benefits, the availability of coverage, or the amount of or eligibility for benefits. The Company’s consideration and determination of a Pre-certification request, as well as any subsequent review or adjudication of all medical claims submitted in connection therewith, shall remain subject to all of the Terms of the Master Policy and this Certificate, including exclusions for Pre- Existing Conditions and other designated exclusions, benefit limitations and sub-limitations, and the requirement that claims be Usual, Reasonable and Customary. Also, any consideration or determination of a Pre-certification request shall not be deemed or considered as the Company’s approval, authorization or ratification of, recommendation for, or consent to any diagnosis or proposed course of Treatment. Neither the Company nor the Plan Administrator (nor anyone acting on their respective behalves) has any authority or obligation to select Physicians, Hospitals, or other healthcare providers for the Insured Person, or to make any diagnosis or medical Treatment decisions on behalf of the Insured Person, and all such decisions must be made solely and exclusively by the Insured Person and/or his/her family members or guardians, treating Physicians and other healthcare providers. If the Insured Person and his/her healthcare providers comply with the Pre-certification requirements of the Master Policy and this Certificate, and the Treatment or supplies are Pre-certified as Medically Necessary, the Company will reimburse the Insured Person for Eligible Medical Expenses up to the amount shown in the Schedule of Benefits/Limits incurred in relation thereto, subject to all Terms of this insurance. Eligibility for and payment of benefits are subject to all of the Terms of this insurance.

Specific Requirements

The following must always be Pre-certified for Medical Necessity by the Company through the Plan Administrator before admission or receiving the Treatments and/or supplies:

a)  Inpatient status.
b)  any Surgery or Surgical procedure.
c)  any Treatment in an Extended Care Facility.
d)  Durable Medical Equipment.
e)  artificial limbs.
f)  Computerized Axial Tomography (CAT Scan).
g)  Magnetic Resonance Imaging (MRI).

General Requirements

To comply with the Pre-certification requirements of this insurance for the Treatments and/or supplies or services listed in the section, above, the Insured Person or his/her Physician or healthcare provider must
a)  contact the Company through the Plan Administrator at the telephone numbers printed on the Insured Person’s ID card, as soon as possible and before the Treatment or supply is to be obtained; and
b)  comply with the instructions of the Company and submit any information or documents required by the Company; and
c)  notify all Physicians, Hospitals and other healthcare providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with the Company.

Loss of Coverage/Benefits for Non-Compliance with Pre-Certification Requirements

If the Insured Person or his/her healthcare providers do not comply with the foregoing Pre-certification requirements, all Eligible Medical Expenses incurred with respect to said Treatments and/or supplies will first be reduced by fifty percent (50%), the applicable Deductible will be subtracted from the reduced amount, the Coinsurance will then be applied to the remainder of the reduced amount as applicable, and further benefits, if any under the insurance plan shown in the Declaration, will be available only for the remaining balance of the reduced amount thereafter.

Emergency Pre-certification - In the event of an Emergency Hospital admission, Pre-certification must be completed within forty-eight (48) hours after the admission, or as soon as is reasonably possible.