SCHEDULE OF MEDICAL BENEFITS
DESCRIPTION OF MEDICAL BENEFITS
BENEFIT PERIOD
EMERGENCY MEDICAL EVACUATION/REPATRIATION
RETURN OF MORTAL REMAINS
ASSISTANCE SERVICES
PRE-TRIP ASSISTANCE
MEDICAL ASSISTANCE WHILE TRAVELING
EMERGENCY CASH TRANSFER
LEGAL ASSISTANCE WHILE TRAVELING
GENERAL TRAVEL ASSISTANCE
PRE-EXISTING CONDITIONS
EXCLUSIONS:
THE INSURANCE COMPANY
SCHEDULE OF MEDICAL BENEFITS:
Accident / Sickness Medical Benefit: US $50,000 per insured person per policy period.
Deductible: Insured person pays the first US $250.00 of eligible expenses per policy period.
Coinsurance: After selected deductible, policy pays 80% of next US $5,000, thereafter policy pay 100% of eligible expenses up to selected Medical Benefit Limit.
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DESCRIPTION OF MEDICAL BENEFITS:
When a covered injury or illness is incurred by the insured person the Company will pay reasonable and customary medical charges for Covered Expenses, excess of the Deductible and Coinsurance as stated in the Schedule of Benefits. In no event shall the company’s maximum liability exceed the maximum stated in the Schedule of Benefits.
The Deductible and Coinsurance amount consists of Covered Expenses which would otherwise be payable under this Policy. These expenses must be borne by the insured person.
Only such expenses, incurred as the result of a disablement, which are specifically enumerated in the following list of charges, and which are not excluded in the Exclusions, shall be considered as Covered Expenses:
1. Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service and with the exception of personal services of a nonmedical nature; provided, however, that expenses do not exceed the Hospital’s average charge for semiprivate room and board accommodation.
2. Charges made for Intensive Care or Coronary Care charges and nursing services.
3. Charges made for diagnosis, treatment and Surgery by a Physician.
4. Charges made for an operating room.
5. Charges made for Outpatient treatment, same as any other treatment covered on an inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion consultations.
6. Charges made for the cost and administration of anesthetics.
7. Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood, transfusions, iron lungs, and medical treatment.
8. Charges for physiotherapy, if recommended by a Physician for the treatment of a specific disablement and administered by a licensed physiotherapist.
9. Hotel room charge, when the insured person, otherwise necessarily confined in a Hospital, shall be under the care of a duly qualified Physician in a hotel room owning to unavailability of a Hospital room by reason of capacity or distance or to any other circumstances beyond control of the insured person.
10. Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or Surgeon.
11. Charges made for artificial limbs, eyes, larynx, and orthotic appliances, but not for replacement of such items.
12. Local transportation to or from the nearest Hospital or to and from the nearest Hospital with facilities for required treatment. Such transportation shall be by licensed ground ambulance only, within the metropolitan area in which the insured person is located at that time the service is used. If the insured person is in a rural area, then licensed ground ambulance transportation to the nearest metropolitan are shall be considered a Covered Expense.
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BENEFIT PERIOD
Standard Group Policy is valid only for the dates of specific tour you are attending. If you are arriving prior to the scheduled tour dates or extending your trip past the scheduled departure date you will need to extend the group coverage to include additional days. Additional days may be added at the rate of $2.00 per day.
Only those expenses specifically described above which are incurred within six months from the onset of an injury or illness and which are not excluded (see “Exclusions”) are considered Covered Expenses. Initial treatment must occur within 60 days of the incident. Illness must first manifest itself during the Period of Coverage.
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EMERGENCY MEDICAL EVACUATION/REPATRIATION
The Company shall pay benefits for Covered Expenses incurred up to $50,000, if any covered injury or illness commencing during the period of coverage results in the medically necessary emergency medical evacuation or repatriation of the insured person. The emergency medical evacuation or repatriation must be ordered by the company’s appointed assistance company in consultation with the insured person’s local attending physician.
Emergency medical evacuation or repatriation means: a) the insured persons’s medical condition warrants immediate transportation from the place where the insured person is located to the nearest adequate medical facility where medical treatment can be obtained; or b) after being treated at a local medical facility as a result of a medical evacuation, the insured person’s medical condition warrants transportation with a qualified medical attendant to his/her home country to obtain further medical treatment or to recover; or c) both a) and b) above.
All transportation arrangements must be by the most direct and economical route.
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RETURN OF MORTAL REMAINS
The Company will pay the reasonable covered expenses incurred up to a maximum of $20,000 to return the insured person’s remains to his/her then current home country, if he or she dies.
NOTE: In the event of an emergency medical evacuation, repatriation of mortal remains benefit is needed, arrangements must be made by the assistance service provider. Complete details about required notification of the assistance service provider are contained in the certificate of insurance.
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ASSISTANCE SERVICES:
The travel assistance benefits described below are provided by Federal Assist Company. The office is staffed 24 hours a day, 7 days a week with multilingual representatives.
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PRE-TRIP ASSISTANCE
Telephone information about passports, visas.
Telephone information about health hazards in remote areas.
Telephone information about inoculations.
Help in arranging special medical treatment facilities needed while traveling.
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MEDICAL ASSISTANCE WHILE TRAVELING
24-hour telephone contact for travel medical emergencies help in locating medical care.
Arranging telephone conferences between your attending and home physicians.
Arranging second medical opinions in hospital cases.
Relaying emergency messages to family and employer during medical emergencies.
Guarantee or payment of medical bills using your available financial resources.
24-hour ticketing service to arrange family visits
Arranging emergency medical evacuation from medically under served areas.
Arranging evacuation for catastrophic claims.
Arranging medical transportation home after treatment.
Arranging escorts and transportation for unaccompanied children.
Arranging transfer of medical records.
Arranging repatriation of remains for deceased travelers.
Notify your health insurer of a claim.
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EMERGENCY CASH TRANSFER
Arranging for transfer of funds
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LEGAL ASSISTANCE WHILE TRAVELING
24-hour telephone contact for travel legal emergencies
Help in locating a consulate officer or attorney
Guarantee or payment of legal bills using your available financial resources.
Relaying emergency messages between family, employer and attorneys.
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GENERAL TRAVEL ASSISTANCE
24-hour telephone contact for baggage and other travel problems.
Advice on handling losses and delays.
Follow-up contact with airlines regarding baggage.
Help with lost passports, ticket and documents.
Guarantee or payment of emergency expenses using your available financial resources. Arranging shipments of forgotten, lost or stolen items.
Relaying emergency messages.
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PRE-EXISTING CONDITIONS
For medical expense benefits covered under this policy, this insurance does not cover:
Any injury or illness which meets the following criteria: 1) a condition that would have caused a person to seek medical advise, diagnosis, care or treatment during the 12 months prior to the effective date of coverage under this Policy; 2) a condition for which medical advise, diagnosis, care or treatment was recommended or received during 12 months prior to the effective date of coverage under this policy.
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EXCLUSIONS:
For medical benefits, this insurance does not cover:
1. Any injury or illness which meets the following criteria: 1) a condition that would have caused a person to seek medical advise, diagnosis, care or treatment during the 12 months prior to the effective date of coverage under this policy; 2) a condition for which medical advise, diagnosis, care or treatment was recommended or received during the 12 months prior to the effective date of coverage under this policy;
2. Injury or illness which is not presented to the Company for payment within 3 months of receiving treatment;
3. Charges for treatment which exceed reasonable and customary charges.
4. Charges incurred for surgeries or treatments which are investigational, experimental, or for research purposes.
5. Services, supplies or treatment, including any period of hospital confinement, which were not recommended, approved and certified as medically necessary and reasonable by a physician;
6. Suicide or any attempt there at, while sane or self destruction or any attempt there at, while insane; or expenses as a result or in connection with the commission of a felony offense;
7. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war;
8. Injury sustained while participating in professional, amateur or interscholastic athletics;
9. Routine physicals or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a disablement established by a prior call or attendance of a physician;
10. Treatment of the temporomandibular joint.
11. Vocational, speech, recreational or music therapy.
12. Services or supplies performed or provided by a relative of the insured person, or anyone who lives with the insured person.
13. Cosmetic or plastic surgery, except as the result of a covered accident, for the purposes of this policy, treatment of a deviated nasal septum shall be considered a cosmetic condition;
14. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids;
15. Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye glasses or for the fitting thereof, unless caused by accidental bodily injury incurred while insured hereunder;
16. Treatment in connection with alcoholism and drug addition, or use of any drug or narcotic agent;
17. Injury sustained while under the influence of or disablement due to wholly or partly to the effects of intoxicating liquor or drugs other than drugs taken in accordance with treatment prescribed and directed by a Physician for a condition which is covered hereunder;
18. Any mental and nervous disorders or rest cures;
19. Telephone consultations or failure to keep a scheduled appointment;
20. Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services;
21. Expenses which are nonmedical in nature.
22. The cost of the insured person’s unused airline ticket for the transportation back to the insured person’s home country, where an emergency medical evacuation or repatriation and/or return of mortal remains benefit is provided;
23. Expenses as a result or in connection with the commission of a felony offense;
24. Injury sustained while taking part in mountaineering where ropes or guides are normally used, hang gliding, parachuting, bungee jumping, racing by horse, motor vehicle or motorcycle, snowmobiling, motorcycle / motor scooter riding, scuba diving, involving underwater breathing apparatus, unless PADI certified, snorkeling, water skiing, snow skiing and snow boarding;
25. Treatment paid for or furnished under any other individual or group policy or charges provided at no cost to the insured person.
26. Treatment of venereal disease.
27. Dental care, except as the result of injury to natural teeth caused by accident (limited to $500);
28. For pregnancy or illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from accident.
29. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion;
30. Expenses incurred while the insured person is in their home country;
31. Expenses incurred during a hospital emergency room visit which is not of an emergency nature;
32. Covered expenses incurred for which travel to the U.S. was undertaken to seek medical treatment for a condition;
33. Covered expenses incurred after the insured person’s physician has limited or restricted travel.
NOTE: This is only a brief description of the plan benefits. The policy shall provide the only basis for coverage and claim.
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THE INSURANCE COMPANY
The MEGA Life and Health Insurance Company (MEGA) is a wholly owned subsidiary of UICI. MEGA is a leading force in the self-funded medical insurance, student accident and health, and college fund individual life markers. They are the largest writer of student insurance in the United States.
The MEGA Life and health insurance company, ranked “A” (Excellent) by A.M. Best and “AA-“ by Duff & Phelps Credit Rating Co. (claims paying ability).
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