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Plan Detail

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

Provider Network


Preferred Provider Network

The Company maintains a Preferred Provider Network both within and outside the United States. Within the United States, the Company recommends the use of the Preferred Provider Network for maximum benefit payment. Outside the U.S., the Company retains the right to require the use of a Network Provider, where available. Utilizing these providers may result in payments directly to the provider as well as referrals to licensed medical providers you can trust. You can find the link to the provider directory at https://www.trawickinternational.com/resources/healthcare-provider-search Or be subject to a 20% copayment on all claims.

In the United States, provider choices and reimbursement assessment will be based as follows:

In-Network Preferred Provider: This tier consists of all In-Network Providers as well as other preferred providers designated by the Company [and listed on the website]. In-Network Providers have agreed to accept a negotiated discount for services. This results in lower of out of-pocket costs.

Out-Of-Network Provider: Utilizing providers that are Out-of-Network is a more costly financial option for the Insured. The Company reimburses such providers up to a Reasonable and Customary amount as determined by the Company. The provider may bill the Insured the difference between the amounts reimbursed by the Company and the Provider’s billed charge.

Additionally, you will pay a Coinsurance amount that is higher than if an In-Network Provider were used. Amounts in excess of the Reasonable and Customary charges will not count toward the Out-of-Pocket Maximum, Deductibles or Plan Co-payments.

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 Person and/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.