| PLAN INFORMATION |
|
| Plan Maximum |
$50,000, $100,000, $500,000, $1,00,000, $2,000,000 |
| Deductible |
Your choice of $0, $100, $250, $500, $1,000 or $2,500 |
| Coinsurance |
As described below |
For treatment received outside the U.S. & Canada: No coinsurance [100% up to the Policy Maximum]
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. |
|
| 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 |
| 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 |
| 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. |
|
| 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. |
| 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), a break-in at the insured?s principle
residence, or the substantial destruction of the insured?s principal residence
due to a fire or natural disaster, 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 and Activities Coverage |
|
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.
Some of these sports and activities include, but are
not limited to, motor cycle/motorscooter riding,
scuba diving (to 10m), snorkeling, wakeboarding, and
water skiing. 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 Adventure
Sports Rider is purchased: abseiling, BMX, bobsleigh, bungee jumping,
canyoning, caving, hang gliding, heli-skiing, high diving, horseback riding,
hot air ballooning, inline skating, jet skiing, kayaking, mountain biking,
paragliding, parascending, piloting a non-commercial aircraft, rappelling,
rock climbing or mountaineering (ropes and guides to 4500m
from ground level), scuba diving (to 50m), skydiving, snow boarding,
snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater
rafting (to Class V), and wildlife safaris. To be covered under the
Adventure Sports Rider, these adventure activities must be engaged in
solely for leisure, recreation, or entertainment purposes.
Injury sustained while participating in contact sports of any kind, racing
of any kind, BASE jumping, kiteboarding, mountaineering or 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, scuba below
50 meters; and/or adventure sports not expressly covered hereunder
are excluded regardless of which plan or rider is selected. |
| 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. |
| Hospital Daily Indemnity |
(U.S. citizens only) Patriot International Group will pay directly to the
insured person $100 for each night of a required overnight stay in a
hospital up to a maximum of 10 days. However, the hospital stay must
be covered under this plan in order to receive this benefit. |
| Description of Optional Riders: ADVENTURE SPORTS RIDER: |
The Adventure Sports Rider is
available on both Patriot plans for those up to the age of 65. The
following activities are covered to
the lifetime maximum amounts
listed on page four: abseiling,
BMX, bobsleigh, bungee jumping,
canyoning, caving, hang gliding,
heli-skiing, high diving, horseback
riding, hot air ballooning, inline
skating, jet skiing, kayaking,
mountain biking, paragliding,
parascending, piloting a noncommercial
aircraft, rappelling,
rock climbing or mountaineering
(ropes and guides to 4500m from
ground level), scuba diving (to
50m), skydiving, snow boarding, snowmobiling, snow skiing, spelunking,
surfing, trekking, whitewater rafting (to Class V), and wildlife
safaris. These adventure activities must be engaged in solely for
leisure, recreation, or entertainment purposes. |
| ENHANCED AD&D RIDER |
This optional coverage is available for the primary insured person only. This
coverage is in addition to the Accidental Death and Dismemberment already included in the Patriot plans.
Coverage must be purchased for a minimum of one month. |
| This rider is available with a minimum purchase of one month of medical
and AD&D rider coverage. |
| Up to US$100,000 additional coverage |
US$8 |
| Up to US$200,000 additional coverage |
US$16 |
| Up to US$300,000 additional coverage |
US$24 |
| Up to US$400,000 additional coverage |
US$32 |
| EVACUATION PLUS RIDER |
This optional rider is available to insureds up to age 65 and it provides
coverage for medical evacuations for medical conditions that are non
life-threatening and evacuations as a result of a natural disaster. This
rider must be purchased for a minimum of one month regardless
of the minimum number of days being traveled. |