Benefits

Period of Coverage	Twelve (12) continuous months of maximum coverage
Certificate Period	Refer to the Declaration page for the Effective and termination dates of coverage
Period of Coverage limit per Inquiry or Illness Maximum Limit	Age 14 days-79 years of age: $25,000 Age 80 years of age and older: $10,000
Area of Coverage	United States
Deductible for Eligible Medical Expenses Per Certificate Period up to the Maximum Period of Coverage
Deductible	Refer to the Declaration page
Coinsurance for Eligible Medical Expenses Per Certificate Period up to the Maximum Period of Coverage
Coinsurance	Plan Pays: 100% of scheduled Benefit Limit The insured is responsible for Charges that are not considered Eligible Medical Expenses and exceed the Maximum Limits stated in the Inpatient Services, Outpatient Services, Emergency Services, and Other Services sections of this Benefit Summary

Pre-existing Condition Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance.

Acute Onset of Pre-existing Condition Subject to any and all scheduled benefits, daily limits and/or sub-limits Charges are Subject to Usual, Reasonable, and Customary Limits per Certificate Period up to the Maximum Period of Coverage

Benefit Limits Acute Onset of Pre-existing Conditions  Insured Person must be under 70 years of age  Refer to the ACUTE ONSET OF PRE-EXISTING CONDITIONS provision for further details and requirements Maximum Limit: $25,000   Emergency Medical Evacuation  Arises or results directly from a covered Acute Onset of a Pre-existing Condition  Insured Person must be under 70 years of age   Maximum Limit: $25,000

Pre-certification

BENEFIT SUMMARY – PLAN B

 

BENEFIT SUMMARY – PLAN C

BENEFIT PERIOD AND HOME COUNTRY COVERAGE

SCHEDULE OF BENEFITS / BENEFIT SUMMARY: Subject to the Terms of this insurance and the insurance plan shown in the Declaration, the insurance plan is available to the Insured Person while outside his/her Home Country and offers benefits and coverage arising out of Injury or Illness incurred while the insurance plan shown in the Declaration is in effect.

Home Country: For United States citizens, the Home Country is the United States. For non-United States citizens, the Home Country is the country of which the Insured Person is a citizen or national; including any country where the Insured Person maintains his/her primary residence or usual place of abode and any country of which the Insured Person pays income taxes or is the possessor of a validly issued passport. In the event there is more than one Home Country under the above-listed criteria or the person has dual citizenship, the Home Country is the country meeting the above-listed criteria and listed by the Insured Person as his or her Home Country on the Application.

INCIDENTAL HOME COUNTRY COVERAGE: As an accommodation and supplemental benefit, the Insured Person will be covered under this insurance during incidental return trips to his/her Home Country (“Incidental Trips”) up to fourteen (14) days during the Period of Coverage, beginning with the date the Insured Person first arrives back in his/her Home Country, provided:

(1) the Insured Person has departed his/her Home Country prior to any Incidental Trip; and

(2) the Insured Person has timely paid applicable Premium for at least thirty (30) days of continuous coverage; and

(3) the intention or purpose of the Insured Person’s return trip to the Home Country is not to receive Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Home Country; and

(4) the Insured Person’s return trip to the Home Country does not result in receiving Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Home Country.

Pre-existing Condition

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 three (3) years 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.

ELIGIBLE MEDICAL EXPENSES

Subject to the Terms of this insurance, and the insurance plan shown in the Declaration, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the following costs, Charges and expenses incurred by the Insured Person during the Certificate Period with respect to an Illness or Injury suffered or sustained by the Insured Person during the Certificate Period and while this Certificate is in effect, so long as the Illness or Injury is covered under this Certificate, Charges are Usual, Reasonable and Customary, and Charges are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”):

(1) Charges incurred at a Hospital for Inpatient Treatment:

(a) daily room and board, nursing services, Ancillary Services including the use of the observation, operating, Treatment or recovery room

(b) daily room and board, nursing services and Ancillary Services in an Intensive Care Unit

(c) Extended Care Facility following an acute Hospital Inpatient stay are to be included in the per day Hospital room and board limits shown in the BENEFIT SUMMARY

(d) services and supplies that are routinely provided by the Hospital to persons for use while an Inpatient including medications and to be included in the per day Hospital room and board limits shown in the BENEFIT SUMMARY

(e) Surgery including services and supplies

(f) Inpatient Physician and specialist consultation visits

(g) surgeon and assistant surgeon including services and supplies

(h) anesthetics and their administration by a Physician

(i) private duty nursing

(2) Charges incurred for Surgery at an Outpatient Surgical Facility, including services and supplies

(3) Charges incurred for Outpatient Treatment:

(a) Emergency Treatment of an Injury, even if Hospital confinement is not required

(b) Emergency Treatment of an Illness; however, Charges for use of the Emergency room itself will not be covered unless the Insured Person is directly admitted to the Hospital as Inpatient for further Treatment of that Illness

(c) Emergency Local Ambulance Transport necessarily incurred in connection with: (i) an Injury

(ii) an Illness resulting in Hospital confinement as an Inpatient

(d) dressings, sutures, casts or other supplies that are Medically Necessary to be included in Physician visits

(e) diagnostic testing using Radiology, ultrasonography or laboratory services. Laboratory services billed for professional component fees are covered if the pathologist has direct involvement in providing a written report or verbal consultation for specimen-specific pathology services

(f) pre-admission testing

(g) Outpatient Physician visit

(h) Telemedicine consultations through an established Telemedicine protocol system will be considered individually based on medical necessity and appropriateness as determined by the Company under the plan subject to the Outpatient Physician Maximum Limits shown in the BENEFIT SUMMARY

(i) surgeon and assistant surgeon including services and supplies

(j) anesthetics and their administration by a Physician

(k) radiation therapy or Treatment, and chemotherapy

(l) drugs that require a prescription by a Physician for Treatment of Illness or Injury, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of ninety (90) days of any one (1) prescription

(m) Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from an acute care Hospital

(n) Durable Medical Equipment, as defined herein, deemed to be Medically Necessary

(o) physical therapy prescribed by a Physician and performed by a professional physical therapist and necessarily incurred to continue recovery from a covered Injury or covered Illness

(p) Emergency Dental Treatment and Dental Surgery necessary to restore or replace sound natural teeth lost or damaged in an Accident that is covered under this insurance.

COMMON CARRIER ACCIDENTAL DEATH

Subject to the Terms of this insurance, including the EXCLUSIONS provision, and in the event of an Unexpected death of an Insured Person during the Certificate Period as a result of an Accident that occurred during the Certificate Period and while the Insured Person was traveling on a Common Carrier, the Company will reimburse a Common Carrier Accidental Death benefit up to the amount shown in the BENEFIT SUMMARY provided, however, that such Common Carrier Accidental Death benefits shall not exceed the maximum amount shown in the BENEFIT SUMMARY per Family involved in the same Accident. (1) The Company will pay the benefit owed, upon proper application therefor, in the following order: (a) to the beneficiary designated in writing by the Insured Person

(b) to the Insured Person’s closest surviving Relative

(c) the Insured Person’s estate

(d) to a claimant entitled to payment under applicable small estate affidavit laws.

EMERGENCY MEDICAL EVACUATION

(1) Subject to the Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraphs below, the Company will reimburse the Insured Person for the following transportation costs when the Company or Plan Administrator arranges such transportation and expenses incurred by the Insured Person arising out of or in connection with an Emergency Medical Evacuation outside the Insured Person’s Home Country during the Certificate Period: (a) Emergency air transportation to a suitable airport nearest to the Hospital where the Insured Person will receive Treatment

(b) Emergency ground transportation necessarily preceding Emergency air transportation and from the destination airport to the Hospital where the Insured Person will receive Treatment

(c) Return ground and air transportation, upon medical release by the attending Physician, to the country where the evacuation initially occurred or to the Insured Person’s Country of Residence, at the Insured Person’s option.

CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Emergency Medical Evacuation benefits, the Insured Person must be in compliance with all Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when the condition, Illness, Injury or occurrence giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when all of the following conditions and restrictions are met: (a) The Company will provide Emergency Medical Evacuation benefits only when the Insured Person is outside his/her Country of Residence when the condition giving rise to the Emergency Medical Evacuation arises. The Company will not provide Emergency Medical Evacuation from the Insured Person’s Country of Residence to any other country, or to another location within the Insured Person’s Country of Residence

(b) Medically Necessary Treatment cannot be provided locally

(c) transportation by any other means or methods would result in loss of the Insured Person’s life or limb within twenty-four (24) hours, based upon a reasonable medical certainty

(d) Emergency Medical Evacuation is recommended by the attending Physician who certifies to the matters in subparagraphs (a) and (b), above

(e) Emergency Medical Evacuation is agreed to by the Insured Person or a Relative of the Insured Person

(f) Emergency Medical Evacuation is provided by designated, licensed, qualified, professional emergency personnel acting within the scope of such license and approved in advance and all arrangements are coordinated by the Company

(g) the condition, Illness, Injury or occurrence giving rise to the need for the Emergency Medical Evacuation: (i) occurred outside the Insured Person’s Country of Residence suddenly, Unexpectedly, and spontaneously, and without: (1) advance warning, or (2) advance Treatment, diagnosis or recommendation for Treatment by a Physician, or (3) prior manifestation of symptoms or conditions that would have caused a reasonably prudent person to seek medical attention prior to the onset of the Emergency

(ii) was not a Pre-existing Condition.

The Company will cover reimbursement for the above-described costs and expenses and will arrange Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary Treatment to prevent the Insured Person's loss of life or limb.

The Insured Person may select a different Hospital in his/her Country of Residence at his/her option, but in such event the Insured Person shall be solely responsible for all costs and expenses in excess of the amounts that would have been incurred had the Insured Person used the nearest qualified Hospital. If a Hospital other than the nearest qualified Hospital is selected by the Insured Person, then the attending Physician, Insured Person or a Relative of the Insured Person shall certify to the Company the Insured Person’s understanding and acknowledgement of such responsibility for excess costs and expenses in addition to the matters set forth in the CONDITIONS AND RESTRICTIONS subparagraph, above. In all cases the Company will make the necessary arrangements for the Emergency Medical Evacuation and will use its best efforts to arrange with independent, third-party contractors any Emergency Medical Evacuation within the least amount of time reasonably possible.

By acceptance of this Certificate and request for Emergency Medical Evacuation benefits hereunder, the Insured Person understands, acknowledges and agrees that the timeliness, duration, occurrences during and outcome of an Emergency Medical Evacuation can be directly and indirectly affected by events and/or circumstances that are not within the supervision or control of the Company, including but not limited to: the availability, limitations, physical condition, reliability, maintenance and training schedules and procedures and performance or non-performance of competent transportation equipment, supplies and/or staff of such third-party contractors; delays or restrictions on flights or other modes or means of transportation caused by mechanical problems, government officials, telecommunications problems, non-availability of routes, and/or other travel, geographical or weather conditions; and other acts of God and unforeseeable and/or uncontrollable occurrences.

The Insured Person agrees to release and to hold the Company, the Plan Administrator and their agents and representatives harmless from, and agrees that the Company, the Plan Administrator and their agents and representatives shall not be held liable or responsible for, any delays, losses, damages, further Injuries or Illnesses or any other claims that arise from or are caused in whole or in part by the acts or omissions of such independent third-party contractors or their agents, employees or representatives, or that arise from or are caused in whole or in part by any acts, omissions, events or circumstances that are not within the direct and immediate supervision and control of the Company, the Plan Administrator and/or their authorized agents and representatives, including without limitation the events and circumstances set forth above.

The Insured Person further agrees that upon seeking an Emergency Medical Evacuation, he or she will cooperate fully as required by the CONDITIONS AND GENERAL PROVISIONS, COOPERATION provision. Failure to so cooperate and/or failure to use or accept Emergency Medical Evacuation once it has been arranged by the Company or Plan Administrator will require the Insured Person to reimburse the Company for costs incurred for any Emergency Medical Evacuation that was arranged, but not used, by the Insured Person. Furthermore, the Insured Person may be required to arrange for payment of any subsequent Emergency Medical Evacuation and seek reimbursement thereafter for eligible costs associated with that subsequent Emergency Medical Evacuation.

INCIDENTAL TRIP: As an accommodation and supplemental benefit and subject to the Terms of this insurance, the Insured Person will be covered under this insurance during incidental return trips to his/her Country of Residence up to the number of days shown in the BENEFIT SUMMARY during the Certificate Period beginning with the date the Insured Person first arrives back in his/her Country of Residence provided that:

(1) the Insured Person has departed his/her Country of Residence prior to any Incidental Trip

(2) the Insured Person has timely paid applicable Premium for at least thirty (30) days of continuous coverage

(3) the intention or purpose of the Insured Person’s return trip to the Country of Residence is not to receive Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Country of Residence

(4) the Insured Person’s return trip to the Country of Residence does not result in receiving Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Country of Residence.

RETURN OF MORTAL REMAINS: In the event of the death of the Insured Person during the Certificate Period as a result of an Illness or Injury covered under this insurance while the Insured Person is outside of his/her Country of Residence, the Company will reimburse the authorized personal representative or the estate of the Insured Person up to the amount shown in the BENEFIT SUMMARY for the costs and expenses incurred to return the Insured Person's Mortal Remains to his/her Country of Residence and thereafter to the place of burial or other final disposition (but not including any costs of burial or other disposition); provided, however, that the Company must approve all costs and expenses related to the return of the Insured Person's Mortal Remains in advance as a condition to the availability of this benefit; or up to the amount shown in the BENEFIT SUMMARY for preparation, local burial or cremation of the Insured Person’s Mortal Remains at the place of death in accordance with the commonly accepted cultural and religious beliefs practiced by the Insured Person. Coverage is not provided for burial and cremation costs incurred for religious practitioners, flowers, music, food or beverages.

PUBLIC HEALTH EMERGENCY: Subject to all other Terms of this Insurance, in the event of a public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak or Natural Disaster, that may affect an Insured Person’s health, the company will cover an Illness or Injury incurred during the Period of Coverage and caused by the Public Health Emergency of International Concern, Epidemic, Pandemic other disease outbreak, or Natural Disaster when, prior to the Issuance of a travel warning for the Destination Country or a Global Travel Warning:

1) The Effective Date of Coverage has occurred; and

2) The Insured Person has arrived in the Destination Country or Affected Area.

In the event the applicable Travel Warning is removed for the Destination Country or Affected Area, coverage for an Illness or Injury incurred during the Period of Coverage after the Travel Warning is removed, which was caused by the Public Health Emergency of International Concern, Epidemic ,Pandemic  other disease outbreak, or Natural Disaster will be considered by the company the same as any other Illness or Injury, subject to all other Terms and conditions of this insurance.

Notwithstanding the above provisions of this section PUBLIC HEALTH EMERGENCY, COVID-19/SARS-CoV-2 shall be considered by the company the same as any other illness or injury, subject to all other terms and conditions of this insurance.