Plan Administrator: WorldTrips | AM Best Rating: A "Excellent" | Underwriter: Lloyd's
MEMBER ELIGIBILITY
CERTIFICATE EFFECTIVE & TERMINATION DATES
CERTIFICATE EFFECTIVE DATE
Insurance hereunder is effective on the later of:
CERTIFICATE TERMINATION DATE
Insurance hereunder terminates on the earlier of:
Coverage provided under this Master Policy is for a maximum duration of 364 days.
Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole option, elect to cancel all members of the same sex, age, class or geographic location, provided we give no less than 30 days advance written notice by mail to your last known address.
Accident means a sudden, unintentional and unexpected occurrence caused by external, visible means and resulting in physical injury to you. The cause or one of the causes of such accident is external to your own body and occurs beyond your control.
Accidental Death means a sudden, unintentional and unexpected occurrence caused solely by external, visible means resulting in physical injury to you and your subsequent death. Death must occur within 30 days of the sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease.
Accidental Dismemberment means a sudden, unintentional and unexpected occurrence caused solely by external, visible means and resulting in complete severance from the body of one or more limbs or eyes and not contributed to by illness or disease. For purposes of the Accidental Death and Dismemberment benefit, the term “limb” shall mean: the arm when the severance is at or above (toward the elbow) the wrist, or the leg when the severance is at or above (toward the knee) the ankle. Loss of eye(s) shall mean: complete, permanent, irrevocable loss of sight.
Beneficiary means the individual named in your application to be the recipient of any Accidental Death or Common Carrier Accidental Death benefit. If you do not designate a beneficiary on the application, the beneficiary is automatically as follows:
Members age 18 or older: 1. Spouse (if any), 2. Children (if any) equally, 3. Your estate.
Members under age 18: 1. Custodial Parent(s) (if any), 2. Siblings (if any) equally, 3. Your estate.
Certificate means the document issued to you that provides evidence of benefits payable under the Master Policy and that will confirm the plan type, period of cover, home country, certificate number, special terms and/or conditions, deductible, chosen benefit list, and geographical area of cover.
Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date. The maximum certificate period is 364 days.
Common Carrier means an airplane, bus, train or watercraft operating for commercial purposes and carrying fare-paying passengers on regularly scheduled and published routes. Custodial Care means that type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist you in performing the activities of daily living. Custodial care also includes non- acute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients
Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.
Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.
Durable Medical Equipment means a standard basic hospital bed and/or a standard basic wheelchair.
Educational or Rehabilitative Care means care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an illness or injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy.
Emergency means a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing your life or limb in danger if medical attention is not provided within 24 hours.
Extended Care Facility means an institution, or a distinct part of an institution, which is licensed as a hospital, extended care facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a physician and the direct supervision of a registered nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a physician; and provides each patient with active treatment of an illnessor injury. Extended care facility does not include a facility primarily for rest, the aged, substance abuse treatment, custodial care, nursing care or for care of mental health disorders or the mentally incompetent.
Home Health Care Agency means a public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing home nursing care under the supervision of a registered nurse, and maintains a daily record on each patient, and provides each patient with a planned program of observation and treatment by a physician
Home Nursing Care means services provided by a home health care agency and supervised by a registered nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of medically necessary inpatient care in a hospital.
Hospital means an institution which operates as a hospital pursuant to law, and is licensed by the state or country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as inpatients; and provides 24-hour nursing service by registered nurses on duty or call; and has a staff of one or more physicians available at all times; and provides organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, long-term care facility, extended care facility, nursing, rest, custodial care or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.
Illness means a sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. For purposes of this insurance, illness includes Complications of Pregnancy during the first 26 weeks of pregnancy. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.
Injury means an unexpected and unforeseen harm to the body caused by an accident that requires medical treatment.
Inpatient means a patient who occupies a hospital bed for more than 24 hours for medical treatment and whose admission was recommended by a physician.
Intensive Care Unit means a cardiac care unit or other unit or area of a hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Investigational, Experimental or for Research Purposes means procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current medical practice.
Medically Necessary means a service or supply which is necessary and appropriate for the diagnosis or
treatment of an illness or injury based on generally accepted current medical practice as determined by us. A service or supply will not be considered medically necessary if is provided only as a convenience to you or the provider, and/or is not appropriate for your diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment of an illness or injury.
Member means an individual who is covered under this insurance.
Mental Health Disorder means a mental or emotional disease or disorder which generally denotes a disease of the brain with predominant behavioral symptoms; or a disease of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. Mental health disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, and those psychiatric illnesses listed in the current edition of the diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.
Observation means the use of a bed and periodic monitoring and/or short term treatment by a hospital’s nursing or other staff. These services are considered reasonable and necessary to evaluate a patient’s condition to determine the need for possible inpatient admission. Observation care provides a method of evaluation and treatment as an alternative to inpatient hospitalization. The services may be considered eligible for coverage only when provided under a physician’s order or under the order of another person who is authorized by state statute and the hospital’s by laws to admit patients and order outpatient testing. The observation services must be patient-specific and not part of a standard operating procedure or facility protocol for a given diagnosis or service.
Outpatient means a member who receives medically necessary treatment by a physician for injury or illness that does not require overnight stay in a hospital.
Physician means a Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DDM), Doctor of Podiatry (DPM), Doctor of Osteopathy (DO), a licensed Physical Therapist or Physiotherapist, and a Doctor of Psychiatry (Psy.D) and a Doctor of Psychology (Ph.D.). Physician also includes a Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), Nurse Midwife or a Physician Assistant (PA) under the direction of a medical doctor. A physician must be currently licensed by the jurisdiction in which the services are provided, and the services must be within the scope of that license and covered under this Master Policy.
Relative means biological or step parent; biological or step child; current spouse; biological or stepsiblings; or parent, children, or sibling in law.
Routine Physical Exam means and examination of the physical body by a physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition.
Sexually Transmitted Diseases means diseases including but not limited to syphilis, gonorrhea, chlamydiosis, trichomoniasis, genital herpes, and Human Papillomavirus (HPV).
Specialist Physician means a doctor of medicine (MD) who has completed the training for and has become certified in a specialty or sub-specialty of the medical arts. Specialist Physician does not include a Doctor of Chiropractic (DC), a Doctor of Psychiatry (PsyD) or Doctor of Psychology (PhD). A physician must be currently licensed by the jurisdiction in which the services are provided, and the services must be within the scope of that license.
Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency.
Surgery or Surgical Procedure means an invasive diagnostic procedure or the treatment of illness or injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
Urgent Care Center means a U.S. medical facility separate from a hospital emergency department where ambulatory patients can be treated on a walk-in basis without an appointment and receive immediate, non-routine urgent care for an injury or illness presented on an episodic basis.
Usual, Reasonable and Customary means the lesser of the following:
You/Your means each insured person named in the certificate.
We/Us/Our means Tokio Marine HCC - Medical Insurance Services Group.