Plan Detail

Plan Administrator:  International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius Group, Sirius Specialty Insurance Corporation

ELIGIBILITY: If an Insured Person is not eligible, this Certificate is void ab initio and all Premium paid will be refunded. In order to be eligible and qualified for coverage under this insurance, a person must meet all of the following requirements:

• be an active Participant, Spouse of the Participant, or Children traveling with the Participant and residing outside his/her primary Country of Residence for a temporary period of time
• be at least thirty-one (31) days old but not yet sixty-five (65) years old
• complete and sign an Application as the Insured Person (or be listed thereon by proxy as an applicant and proposed Insured Person), and/or as the Insured Person’s Spouse and/or Child
• on the Effective Date and on subsequent renewal dates, be physically and legally residing in the Destination Country with the intent to reside there for at least thirty (30) days
• pay the required Premium on or before the Effective Date of Coverage
• receive written acceptance of his/her Application or renewal from the Company
• not be Pregnant, Hospitalized or Disabled on the Initial Effective Date
• not be HIV+ on the Initial Effective Date

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) Chemotherapy
(b) Extended Care Facility
(c) Home Nursing Care
(d) Inpatient Hospitalization
(e) Interfacility Ambulance Transfer
(f) Maternity
(g) Radiation Therapy
(h) Surgery or Surgical procedure

GENERAL REQUIREMENTS: To comply with the Pre-certification requirements of this insurance for the Treatments and/or supplies or services listed in the SPECIFIC REQUIREMENTS provision, above, the Insured Person or his/her Physician or healthcare provider must perform all of the following:

(a) contact the Company through the Plan Administrator at the contact information below and on the Insured Person's ID card, as soon as possible and before the Treatment or supply is to be obtained.

Inside the United States: +1.800.628.4664

Outside the United States: +1.317.655.4500 (Collect if necessary)

E-mail: acm@imglobal.com

Website: www.imglobal.com/member/precertification

(b) comply with the instructions of the Company and submit any information or documents required by the Company
(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.
(3) MATERNITY PRE-CERTIFICATION REQUIREMENTS: To comply with the Maternity Pre-certification requirements, the Insured Person must:
(a) contact the Company as soon as possible but always within sixty (60) days of expected delivery
(b) comply with the instructions of the Company and submit any information or documents required by the Company
(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
(d) If the Insured Person complies with the Maternity Pre-certification requirements and the expenses are Pre-certified, the Company will pay Maternity and Newborn Care benefits, subject to all Terms, conditions, provisions and exclusions herein. If the Insured Person does not comply with the Maternity Pre-certification requirements, or if the expenses are not Pre-certified, all Maternity and Newborn Care benefits are reduced by the amount shown in the BENEFIT SUMMARY, the Deductible will be subtracted from the remaining amount; and Coinsurance will be applied. If for any reason after initial Maternity Pre-certification the Insured Person shall become aware of complications during Pregnancy, the Insured Person must Pre-certify again, in accordance with the General Requirements for Pre-certification.