| SCHEDULE
OF BENEFITS (all amounts listed are
in U.S. dollars) |
| MEDICAL BENEFITS |
Usual, reasonable and
customary charges, subject to deductible and
coinsurance |
|
Hospital Room and Board |
Up to
Policy Maximum for average semi-private room
rate |
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|
Intensive Care |
Up to
Policy Maximum |
|
|
Medical Expenses |
Up to
Policy Maximum |
|
|
Outpatient Medical |
Up to
Policy Maximum |
|
| Local
Ambulance |
Up to
Policy Maximum |
|
|
Prescription Drugs |
Up to
Policy Maximum |
|
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|
Emergency Room |
As described below |
Charges
incurred for the use of the Emergency Room
due to an accident are covered up to the
Policy Maximum.
Charges incurred for the use of the
Emergency Room for treatment of an illness
are subject to an additional (extra) $250
deductible if treatment does not require
admittance to the hospital. |
| Dental |
As
described below |
Injury
due to an accident: Each Patriot
plan covers the cost of emergency dental
treatment and dental procedures necessary to
restore sound natural teeth lost or damaged
in an accident up to the Policy Maximum.
Sudden dental pain: Each
plan will pay up to $100 for the necessary
treatment of sudden, unexpected pain to
sound natural teeth. |
|
|
INTERNATIONAL EMERGENCY CARE (when
coordinated through the Plan Administrator) |
|
Emergency Evacuation |
Up to
$500,000 lifetime maximum (independent of
policy maximum) |
| Each Patriot
plan includes coverage for Emergency Medical
Evacuations to the nearest qualified medical
facility; expenses for reasonable travel and
accommodations resulting from the
evacuation; and the cost of returning to
either the home country or the country where
the evacuation occurred, up to $500,000. |
|
Emergency Reunion |
Up to
$50,000 |
| Each Patriot
plan also provides emergency reunion
coverage, up to $50,000 for a maximum of 15
days, for the reasonable travel and lodging
expenses of a relative or friend during an
Emergency Medical Evacuation: either the
cost of accompanying the insured during the
evacuation or traveling from the home
country to be reunited with the insured.
|
| Return
of Mortal Remains |
Up to
$50,000 |
| If a covered
illness/injury results in death, expenses
for Repatriation of bodily remains or ashes
to the home country will be covered up to a
maximum of $50,000. |
|
Returning Minor Children |
Up to
$50,000 |
| If an insured
person is hospitalized due to a covered
illness/injury and is traveling alone with
child(ren) 19 or under that otherwise would
be left unattended, the Patriot plans will
pay up to $50,000 for one way economy fare
to their home country, including a
chaperone, if necessary, for the safety of
the child(ren). |
|
Political Evacuation |
Up to
$10,000 |
| If the United
States Department of State, Bureau of
Consular Affairs issues a travel advisory
that becomes effective on or after the
Insured Person’s date of arrival in the Host
Country, the Company will pay up to $10,000
for transportation to the nearest place of
safety or for repatriation to the Insured
Person’s home country or country of
residence provided that: |
- The Insured Person contacts the
Company within 10 days of the United
States Department of State, Bureau of
Consular affairs issues the travel
advisory;
- Political Evacuation and
Repatriation is approved and coordinated
by the Company.
|
To be eligible for the Evacuation, Reunion
and Return benefits, these must be
recommended by the attending physician in
critical medical situations, and approved in
advance and coordinated by IMG.
|
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| PLAN
INFORMATION |
|
Deductible |
Your
choice of $0, $100, $250, $500, $1,000 or
$2,500 |
| On the
Application Form, you will be asked to
circle your choice of a deductible. Your
premium rate is dependent on the deductible
you choose. Please see the Application Form
for more information. |
|
Coinsurance |
As
described below |
For
treatment received outside the U.S. &
Canada: No coinsurance
For treatment received within the
U.S. & Canada:
In the PPO Network: The plan pays 90% of
eligible expenses up to $5,000, then 100% up
to the Policy Maximum
Outside the PPO Network: The plan pays 80%
of eligible expenses up to $5,000, then 100%
up to the Policy Maximum |
|
Benefit Period |
Six
months |
| If a covered
injury or illness requires continuing
treatment after the Period of Coverage
expires, the six-month Benefit Period may
provide continued coverage. When the
certificate expires, the Company will review
the date of initial treatment for the
covered injury or illness. If treatment
began less than six months before the Period
of Coverage expired, benefits for the
covered injury or illness will continue
subject to the Policy Limits and the other
terms of the plan until there have been six
months of continuous coverage for the
covered injury or illness. |
|
| ADDITIONAL
BENEFITS |
| Home
Country Coverage |
As
described below |
Incidental Home Country Coverage -
During the Period of Coverage an insured
person may return to their home country for
incidental visits up to a cumulative two
weeks total, subject to: a.
The insured person must have left their home
country, b. The total
Period of Coverage must be for a minimum of
30 days, and c. The return
to the home country may not be taken to
receive treatment for an illness or injury
incurred while traveling.
End of Trip Home Country Coverage -
For every five months of continuous coverage
you purchase, you can purchase one
additional month of home country coverage as
an accommodation and supplemental travel
benefit, up to a maximum of two months. To
purchase this special home country extension
coverage, please check the appropriate box
on the Application Form, and calculate your
premium to include the additional month(s).
|
|
Natural Disaster |
$100
per day for five days |
| This benefit is
available in the event an insured person is
required to depart his/her destination due
to an evacuation order issued by prevailing
authorities in connection with a Natural
Disaster. Natural Disaster is defined as
widespread disruption of human lives by
disasters such as flood, drought, tidal
wave, fire, hurricane, earthquake,
windstorm, or other storm, landslide, or
other natural catastrophe or event resulting
in migration of the population for its
safety. |
| Trip
Interruption |
Up to
$5,000 |
| If, during a
covered trip, there is a death of an
immediate family member (spouse, child,
parent or sibling) or the substantial
destruction of the insured’s principal
residence, each Patriot plan will pay to
return the insured to the area of principal
residence. The plan will pay for a one way
air or ground transportation ticket of the
same class as the unused travel ticket, less
the value of the unused return ticket. |
| Lost
Luggage |
Up to
$50 per item of personal property; maximum
of $250 per Period of Coverage |
| This benefit
will be paid in the event that the Common
Carrier permanently loses an insured
person’s checked luggage. This coverage is
secondary to any other available coverage,
including the Carrier’s. |
| Common
Carrier Accidental Death |
$50,000 to Beneficiary; maximum of
$250,000 per family |
| If accidental
death should occur while traveling on a
commercial Common Carrier, $50,000 will be
paid to the designated beneficiary, to a
maximum of $250,000 per family. |
| Sports
& Activities Coverage |
Up to
Policy Maximum for basic sports Coverage as
described below |
Each Patriot
plan covers injuries incurred during amateur
athletic activities which are non-contact
and engaged in by the insured person solely
for leisure, recreation, entertainment or
fitness purposes. However, activities not
covered include amateur or professional
sports or other athletic activity which is
organized and/or sanctioned, or which
involves regular or scheduled practices,
games or competition.
The following hazardous activities are
excluded unless the Extreme Sports Rider is
purchased: abseiling, aviation (except when
traveling as a passenger in a commercial
aircraft), BMX, bobsleigh, bungee jumping,
canyoning, caving, high diving, hang
gliding, heli-skiing, hot air ballooning,
inline skating, jet skiing, kayaking,
mountain biking, paragliding, parascending,
rappelling, rock climbing, sky diving, snow
skiing, snowboarding, snowmobiling,
spelunking, surfing, trekking, wind-surfing
and whitewater rafting.
Racing of any kind, BASE jumping,
mountaineering, climbing or trekking above
elevation 4500 meters above ground level or
without proper ropes or guides; luge,
motocross, Moto-X, rodeo activity, ski
jumping, whitewater rafting exceeding Class
V difficulty; and/or extreme sports not
expressly covered hereunder are excluded
regardless of which plan or rider is
selected.
Optional Extreme Sports Rider:
Please see the brochure for more
information. |
|
Accidental Death & Dismemberment |
$25,000 principal sum |
| Each Patriot
plan includes $25,000 principal sum benefit
for Accidental Death and Dismemberment
occurring during the Period of Coverage: •
Accidental Loss of life - principal sum; •
Accidental Loss of two Members - principal
sum; • Accidental Loss of one Member - 50%
of principal sum. “Member” means hand, foot
or eye. |
|
Terrorism Coverage |
Up to
$50,000 lifetime maximum |
| Each Patriot
plan provides coverage for injuries and
illness incurred as a result of an act of
Terrorism, limited in amount and by
circumstances. If an insured person is
injured as a result of an act of Terrorism,
and the insured person has no direct or
indirect participation in the act, the plan
will reimburse eligible medical claims
subject to a $50,000 lifetime maximum.
However, claims incurred as a result of
radiological, nuclear, chemical or
biological weapons or events are not
covered.
Terrorism is defined as the systematic or
planned use of violence, fear, or threat of
violence in order to intimidate a population
or government, especially as a means of
coercion or to obtain a granting of any
demand. However, this benefit does not cover
an act of Terrorism in any country or
location where the United States government
has issued a travel advisory that has been
in effect within the 6 months prior to the
insured person's date of arrival.
This benefit also does not cover an act
of Terrorism in the event that an advisory
to leave a certain country or location is
issued by the United States government after
the insured person's arrival date, and the
insured person unreasonably fails or refuses
to depart the country or location.
|
|
Identity Theft Assistance |
Up to
$500 per Period of Coverage |
| If an imposter
obtains key personal information such as a
Social Security or Driver's License number,
or other method of identifying an insured
person in order to impersonate or obtain
credit, merchandise or services in the
insured person’s name, the Patriot plans
will provide coverage for the reasonable,
customary and necessary costs incurred by
the insured for: re-filing a loan or other
credit application that is rejected solely
as a result of the stolen identity event;
notarization of legal documents,
long-distance telephone calls, and postage
that has resulted solely as a result of
reporting, amending and/or rectifying
records as a result of the stolen identity
event; up to three credit reports obtained
within one year of the insured person’s
knowledge of the stolen identity event; and
stop payment orders placed on missing or
unauthorized checks as a result of the
stolen identity event.
The identity theft event must occur
during the Period of Coverage and must be
reported within 6 months of the termination
of coverage date.
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|
| Additional
Benefits for U.S. Citizens |
|
Sudden Recurrence of a Pre-existing
Condition |
| Up to $15,000
will be paid for the eligible expenses of a
sudden and unexpected recurrence of a
Pre-existing Condition while traveling
outside of the U.S.. In addition, up to
$25,000 will be paid for the eligible costs
and expenses of an Emergency Medical
Evacuation arising or resulting from a
sudden and unexpected recurrence of a
Pre-existing Condition. For the definition
of a Pre-existing Condition, please see
Exclusion number 1 in the Patriot Travel
Medical Insurance brochure. |
|
Indemnity |
| Patriot
International will pay directly to the
insured person $100 for each night of a
required overnight stay in a hospital.
However, the hospital stay must be covered
under this plan in order to receive this
benefit. |
|
| This web page contains
only a consolidated and summary description
of all current Patriot Travel Medical
Insurance benefits, conditions, limitations
and exclusions. A certificate containing the
complete Certificate Wording with all terms,
conditions and exclusions will be included
in the fulfillment kit. IMG reserves the
right to issue the most current Certificate
Wording for this insurance plan in the event
this application and/or brochure has
expired, is modified, or is replaced with a
newer version. Current Certificate Wordings
are available upon request. |
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