Patriot America Group provides coverage for Non-US
citizens traveling outside their country of citizenship for a minimum
of 10 days up to a maximum of one year. Although the Patriot America group
plan is not renewable, it can be rewritten for succeeding or subsequent
coverage periods. New Deductible, Coinsurance, Eligibility, Conditions of
Coverage and Pre-Existing Condition Exclusions apply to any succeeding or
subsequent Period of Coverage. A new application also must be completed.
If any group member applying for coverage is age 65 or older, please see
the Eligibility section on page 14 for additional information.
Most travelers assume they will be covered by their standard medical plan. The truth is, while traditional plans may offer adequate domestic coverage, they may not be designed for international travel. Without even realizing it, you may be putting your health - & that of your family - at risk.
What if you are injured or become ill during your trip? Could you get quality treatment at an unfamiliar hospital? How would you deal with the language and currency barriers? What if the treatment you need isn't available nearby? Who do you call? Imagine trying to call your insurance company at 3:00 a.m. from a foreign country during a medical emergency! Will they be there when you need them the most?
You have enough things to worry about when you're traveling. Don't let your medical coverage be one of them.
The Experienced Plan Administrator:
Since 1990, International Medical Group has provided a unique, full-service approach to insurance coverage. Dedicated exclusively to international insurance market, IMG provides coverage services to individuals and families in more than 150 countries. Medical treatment while traveling is often an unfortunate fact of life. Our goal is to make the medical process a smooth and efficient one. IMG's multilingual claims administrators, on-site medical staff and customer service professionals work together to ensure that you medical needs are met. We process as many as 100,000 claims each year from countries throughout the world, and can confidently handle virtually any language or currency.
To give you true Global Peace of Mind, IMG representatives are available 24 hours a day, seven days a week, 365 days a year for medical emergencies, evacuations and precertifications. Our customer service is routinely rated among the highest in the industry. You can rest assured that IMG will be there for you, whether it be for routine treatment or during a medical emergency.
IMG gives you worldwide coverage experience, impeccable service and international expertise. Don't leave your medical care to chance. Let IMG reduce the uncertainties of international travel for you & your family.
Rates:
Patriot America With $250 Deducitble
Patriot America provides coverage for non-US citizens traveling outside their home country for a minimum of 5 days up to a maximum of two years.
All premium rates are in US dollars and are effective through 12/31/2006.
Rates include 2.5% surplus lines tax where applicable. A dependent child
is a child shown on the Application Form over 14 days and under 18 years
of age, traveling with the group as a dependent of a group member, and for
whom premium has been paid.
| POLICY LIMIT |
 |
$50,000 |
|
$100,000 |
|
$500,000 |
|
$1,000,000 |
| |
| AGE |
Monthly Rates |
| 18-29 |
|
$39.00 |
|
$45.00 |
|
$58.00 |
|
$68.00 |
| 30-39 |
|
$50.00 |
|
$60.00 |
|
$76.00 |
|
$87.00 |
| 40-49 |
|
$76.00 |
|
$86.00 |
|
$113.00 |
|
$128.00 |
| 50-59 |
|
$108.00 |
|
$132.00 |
|
$160.00 |
|
$185.00 |
| 60-64 |
|
$128.00 |
|
$157.00 |
|
$186.00 |
|
$223.00 |
| 65-69 |
|
$146.00 |
|
$187.00 |
|
$203.00 |
|
$243.00 |
| 70-79 |
|
$197.00 |
|
N/A |
|
N/A |
|
N/A |
| 80+* |
|
$343.00 |
|
N/A |
|
N/A |
|
N/A |
| DEP. CHILD |
|
$23.00 |
|
$25.00 |
|
$32.00 |
|
$35.00 |
| CHILD ALONE |
|
$35.00 |
|
$41.00 |
|
$53.00 |
|
$59.00 |
| |
| |
Daily Rates (Minimum length of coverage is 5 days) |
| 18-29 |
|
$1.30 |
|
$1.55 |
|
$1.95 |
|
$2.25 |
| 30-39 |
|
$1.65 |
|
$2.00 |
|
$2.55 |
|
$2.90 |
| 40-49 |
|
$2.55 |
|
$2.85 |
|
$3.80 |
|
$4.30 |
| 50-59 |
|
$3.60 |
|
$4.45 |
|
$5.40 |
|
$6.15 |
| 60-64 |
|
$4.30 |
|
$5.25 |
|
$6.25 |
|
$7.50 |
| 65-69 |
|
$4.90 |
|
$6.30 |
|
$6.80 |
|
$8.10 |
| 70-79 |
|
$6.60 |
|
N/A |
|
N/A |
|
N/A |
| 80+* |
|
$11.45 |
|
N/A |
|
N/A |
|
N/A |
| DEP. CHILD |
|
$0.75 |
|
$0.90 |
|
$1.10 |
|
$1.20 |
| CHILD ALONE |
|
$1.20 |
|
$1.40 |
|
$1.80 |
|
$2.00 |
* US$10,000 Maximum
Quality Guarantee
Your satisfaction is very important to the plan underwriter, and to IMG as the plan administrator. If, for any reason, you are not pleased with this product, you may submit a written request for cancellation and refund of your premium. In order to be considered for a full refund, your request for cancellation must be received by IMG prior to your effective date. If you do not have any claims filed with IMG, you may cancel your plan after your effective date, however, the following conditions will apply: 1) you will be required to pay a US$25 cancellation fee and 2) only full month premiums will be considered for refunds (e.g., if you choose to cancel your coverage two months and two weeks prior to the date your coverage ends, IMG will only consider the two full months for a refund). If you have filed claims, your premium is non-refundable.
Benefits
| MEDICAL BENEFITS |
|
Usual reasonable and customary charges, subject to deductible and coinsurance |
| Hospital Room and Board |
|
To Policy Maximum for average semi-private room rate |
| |
| Intensive Care |
|
To Policy Maximum |
| |
| Medical Expenses |
|
To Policy Maximum |
| |
| Outpatient Medical |
|
To Policy Maximum |
| |
| Local Ambulance |
|
To Policy Maximum |
| |
| 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) US$250 deductible if treatment does not require admittance to the hospital.
|
| Dental |
|
As described below |
Injury due to an accident: Each Patriot Group 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 US$100 for the necessary treatment of sudden, unexpected pain to sound natural teeth.
INTERNATIONAL EMERGENCY CARE
|
| Emergency Evacuation |
|
To Policy Maximum when coordinated through the Plan Administrator |
|
Each Patriot Group 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 the policy limit.
|
| Emergency Reunion |
|
To US$15,000 when coordinated through the Plan Administrator |
| Each Patriot Group plan also provides emergency reunion
coverage, up to US$15,000 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 |
|
To US$25,000 when coordinated through the Plan Administrator |
|
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 US$25,000.
|
| Returning Minor Children |
|
To US$5,000 when coordinated through the Plan Administrator |
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 Group plans will pay up to US$5,000 for one way economy fare to their home country, including a chaperone, if necessary, for the safety of the child(ren).
PLAN INFORMATION
|
| Deductible |
|
Your choice of US$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 US & Canada: No coinsurance
For treatment received within the US & Canada: The plan pays 80% of eligible expenses up to US$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.
SPECIAL COVERAGES
|
| 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).
|
| Trip Interruption |
|
To US$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
Group 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 |
|
To US$50 per item or personal property; maximum of US$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 |
|
US$50,000 to Beneficiary; maximum of US$250,000 per family |
| If accidental death should occur while traveling on
a commercial Common Carrier, US$50,000 will be paid to the designated
beneficiary, to a maximum of US$250,000 per family of group. |
| Sports & Activities Coverage |
|
To Policy Maximum for basic sports Coverage as described below |
Each Patriot Group 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: racing of any kind, aviation (except when traveling as a passenger in a commercial aircraft), BMX, BASE jumping, bobsleigh, bungee jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning, inline skating, jet skiing, kayaking, luge, motocross (moto-x), mountain biking, mountaineering, parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping, sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling, surfing, wakeboarding, water skiing, windsurfing and whitewater rafting.
Optional Leisure or Extreme Sports Riders: Please see the brochure for more information.
|
| Accidental Death & Dismemberment |
|
US$25,000 principal sum |
Each plan includes US$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. For more information, see the Conditions of Coverage section on page 13.
Additional Benefits for U.S. Citizens
|
| Sudden Recurrence of a Pre-existing Condition |
|
Up to US$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 US. In addition, up to US$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 on pages 11 of the Patriot Group brochure.
|
| Indemnity |
|
|
Patriot International will pay directly to the insured person US$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 Group Travel Medical Insurance benefits, conditions, limitations and exclusions. A certificate containing the complete Policy Wording with all terms, conditions and exclusions will be included with the fulfillment kit. IMG reserves the right to issue the most current Policy 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 Policy Wordings are available upon request.
|
Exclusions:
Charges for the following services, treatments and/or conditions, among
others, are excluded from coverage under the Patriot Group plans.
- Pre-existing Conditions. A pre-existing condition is defined as any
injury, illness, sickness, disease, or other physical, medical, mental
or nervous condition, disorder or ailment that, with reasonable medical
certainty, existed at the time of application or at any time during
the three years prior to the effective date of the insurance, whether
or not previously manifested or symptomatic, diagnosed, treated, or
disclosed prior to the effective date, including any subsequent, chronic
or recurring complications or consequences related thereto or arising
therefrom.
- Treatment or surgeries which are elective, investigational, experimental
or for research purposes.
- War, military action, terrorism, political insurrection, protest,
or any act thereof.
- Immunizations and routine physical exams.
- Treatment of Temporomandibular Joint or dental treatment, except as
expressly provided for in the certificate of insurance.
- Venereal disease, AIDS virus, AIDS related illness, ARC Syndrome,
or AIDS, and the cost of testing for these conditions, and charges for
treatment or surgeries which are incurred by any Insured who was HIV+
at time of enrollment into this insurance.
- Pregnancy, childbirth, birth control, artificial insemination, treatment
for infertility or impotency, sterilization or reversal thereof, or
abortion.
- 8. Injury sustained while participating in 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: racing of any kind,
aviation (except when traveling as a passenger in a commercial aircraft),
BMX, BASE jumping, bobsleigh, bungee jumping, canyoning, caving, high
diving, hang gliding, heli-skiing, hot air ballooning, inline skating,
jet skiing, kayaking, luge, motocross (moto-x), mountain biking, mountaineering,
parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping,
sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling,
surfing, wakeboarding, water skiing, wind-surfing and whitewater rafting.
- Vision or ear tests and the provision of visual or hearing aids.
- Vocational, recreational, speech or music therapy.
- Treatment while confined primarily to receive custodial care, educational
or rehabilitative care, or nursing services.
- Charges, injuries and/or illnesses resulting or arising from or occurring
during the commission or continuing perpetration of a violation of law
by the insured, including without limitation, the engaging in an illegal
occupation or act, but excluding minor traffic violations.
- Treatment for, and injuries and/or illnesses resulting or arising
from, substance abuse or drug addiction.
- Injury and/or illness resulting or arising from being under the influence
of alcohol or drugs; and injury or illness resulting from operating
any type of vehicle after consuming any alcohol or drugs.
- Willful self-inflicted injury or illness.
- Treatment required as a result of or arising from complications from
a treatment or condition not covered under the certificate.
- Any services or supplies performed or provided by a relative of the
Insured or provided at no cost to Insured.
- Treatment for mental and nervous disorders.
- Organ or tissue transplants or related services.
- Illness or injury where the trip to the host country is undertaken
for treatment or advice for such Illness or injury, except as expressly
provided for in the certificate of insurance.
- Treatment incurred as a result of or arising from exposure to nuclear
radiation, and/or radioactive material(s).
This web page contains only a consolidated and summary description of all current Patriot Group Travel Medical Insurance benefits, conditions, limitations and exclusions. A certificate containing the complete Policy Wording with all terms, conditions and exclusions will be included with the fulfillment kit. IMG reserves the right to issue the most current Policy 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 Policy Wordings are available upon request.
Visit Any Doctor-Any
Hospital
You may visit any doctor in the USA or outside the USA. There is no network of providers for the Patriot Group Travel Medical Insurance. If you are having difficulty locating a provider, IMG may be able to provide assistance. When you go to the doctor, you should present the IMG identification card. This card contains information the doctor's office needs to bill IMG directly, and contains a toll-free number where they can call to verify the coverage etc.
If the doctor does not accept the card, you will need to pay the doctor, and then file a claim for reimbursement by submitting your charges along with a fully completed claim form to IMG. You can either use the claim form you receive in the mail with the identification card or you can download the Claim Form from this website. IMG will process your claim usually within 2 weeks of receiving the complete information, including the claim form and the itemized bills.
Each proposed hospital admission, inpatient or outpatient surgery, and certain other medical procedures must be Pre-certified for medical necessity. This means the insured person or their attending physician must call the number listed on the IMG identification card prior to admittance to a hospital or performance of a surgery, or medical procedure. In the case of an emergency hospital admission, the Pre-certification call must be made within 48 hours of the admission, or as soon as reasonably possible. For a complete list of procedures requiring Pre-certification, please refer to your certificate wording.
If Pre-certification guidelines are not followed, eligible claims and expenses will be reduced by 50%.
FOR ADDITIONAL INFORMATION PLEASE CONTACT:
COMMUNITY INSURANCE AGENCY, INC.
QUALITY SERVICE TO THE COMMUNITY SINCE 1980
425 Huehl Road, Suite 22-A, Northbrook, IL 60062
Ph: 1-847-897-5120 - TOLL FREE PH: 1-800-344-9540
FAX: 1-847-897-5130 - E-mail: info@ciainsagency.com
Website: www.visitorsinsurance.com
|
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