MEDICAL INSURANCE

Coverage Area
 

Policy Maximum Per Individual

Hospitalization
Semi-private room and board • Nursing services • Prescription medication • Physician charges • Diagnostic and laboratory testing • X-rays • Chemotherapy and radiation • Durable medical equipment • Treatment, services and supplies routinely provided

Intensive Care Unit

Surgery
Surgical care • Second surgical opinion • Anesthetics • Physician charges for surgery • Treatment, services and supplies routinely provided

Transplants
Limited to certain transplants and covered only within IMG's independent PPO Transplant Facilities

Outpatient
Emergency treatment of illness or injury • Surgery • Rehabilitative treatment • Treatment, services or supplies routinely provided • Prescription medication

Emergency
Surgery or dental treatment following an accident • Emergency room following an accident

Emergency Transportation by
Ground Ambulance

Emergency Medical Evacuation
Included with Emergency Medical Evacuation is an Emergency Reunion benefit of US$10,000 lifetime

Repatriation

US$25,000

Supplemental Accident
The first $300 will be covered for each accidental injury

US$300 per occurrence (not subject to the deductible or coinsurance)

Maternity
Available after 12 months of continuous coverage • Pre and Post-natal care • Normal delivery or C-section • Well baby care and treatment of newborn for first 31 days

Newborns
Eligible newborn children may be added without evidence of insurability under certain circumstances • An application form must be submitted within 31 days of child's birth

Child Wellness
Available for eligible children from 14 days to 18 years of age after 12 months of continuous coverage

US$50 maximum per visit; US$150 per policy period (not subject to deductible or coinsurance)

Pre-existing Conditions
After 24 months of continuous coverage

US$50,000 lifetime (maximum of US$5,000 per policy period)

Mental/Nervous Care
Available after 12 months of continuous coverage • Inpatient and outpatient care by a licensed psychiatrist

Wellness
Females age 35 and over after 24 months on the plan • Routine physicals • Mammogram, ob/gyn visit, etc. (exams must be separated by 12 months)

Males age 35 and over, after 24 months on the plan • Routine physicals (exams must be separated by 12 months)

Complementary Medicine

Acupuncture

Aroma Therapy

Herbal Therapy

Magnetic Therapy

Massage Therapy

Vitamin Therapy

Other
Chiropractor when referred by a physician • Radiation treatment • Home nursing care • Hospice care • Physical therapy (maximum US$50 per visit) • Prosthetic devices

Incidental Home Country Coverage - During the period of coverage an insured person may return to their country of citizenship for incidental visits of up to two weeks total, subject to: a. The insured person must have left their country of citizenship, b. The Total Period of Coverage must be for a minimum of 30 days, and c. The return to the country of citizenship may not be taken to receive treatment for a condition incurred while traveling.
End of Trip Home Country Coverage-For every six (6) months of coverage you purchase, you can purchase one (1) month of home country coverage up to a maximum of 2 months.

For treatment receivd within the US & Canada: The plan pays 80% of eligible expenses up to US$5,000 then 100% up to the Policy Maximum.

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• Deductible - $250 per insured person, per each and every Claim. The deductible shall be waived for Claims incurred as a result of a covered Accident.
• Maximum Policy Limit- U.S. $1,000,000 per insured Person per Policy Period
• Pre-Existing Condition Benefit- U.S. $5,000 maximum per Insured Person per Policy Period
• Emergency Medical Evacuation Expenses - U.S. $25,000 per Insured Person for Evacuations resulting from a Pre-existing Condition. U.S. $50,000 per Insured Person for Evacuations resulting from other covered Incidents.
• Repatriation Expenses - U.S. $25,000 when coordinated & approved through IMG
• Emergency Reunion Expenses - U.S. $15,000 when coordinated & approved through IMG
• Returning Minor Children benefit of up to US$5,000 when coordinated & approved through IMG
• Trip Cancellation benefit of up to US$5,000
• Lost Luggage benefit of up to US$50 per item; maximum of US$250
• Common Carrier Accidental Death benefit of up to US$50,000 to beneficiary; maximum of US$250,000
• Local Ambulance Expense - U.S. $2,500
• Accidental Death and Dismemberment - U.S. $25,000 principal sum
• Hospital Room and Board - Average semi-private room rate up to the Policy Maximum
• Intensive Care - 3x the average semi-private room rate up to the Policy Maximum
• Medical Expenses - Usual, reasonable and customary up to the Policy Maximum
• Outpatient Medical Expenses - Usual, reasonable and customary up to the Policy Maximum
• Benefit Period - Six months
• Period of Coverage - The period of time beginning on the date the Insured Person departs the home country and ending on the date the Insured Person arrives back in the home country. The Period of Coverage can be no longer that the option specified on the Insured's Enrollment Form and in any event no longer than thirty days.
• Maximum Duration of Any One Trip: Your choice , 15 days or 30 days. Trips for covered dependents will be limited to 15 days for any one trip.

Precertification

All proposed hospital admissions and surgeries, whether inpatient or outpatient, will be subject to Precertification. You or your attending physician must call the number listed on your Confirmation of Coverage prior to admittance to a hospital or performance of a surgery. In the event of an Emergency Admission, the Precertification call must be made within 48 hours after the admission, or as soon as reasonably possible. In the event an admission or surgery is not pre-certified, eligible expenses will be reduced by 50%.

Benefit Period

The Benefit Period is the period of time specified in the Policy Limits. It begins once an eligible incident occurs to the insured. While coverage is in effect under this policy, the Benefit Period does not apply. When coverage under this policy terminates as defined, Patriot Executive Insurance^SM will pay eligible expenses for covered Injuries or Illnesses which commenced during the period of coverage for up to, but not exceeding the Benefit Period, subject to the Policy Limits.

This is only a summary of the coverage provided. Other conditions and exclusions may apply. Please consult the policy itself for a full description of the coverage. In support of Patriot Executive Insurance^SM, IMG has established the Group Health, Accident and Travel Insurance Trust, in Washington D.C. The trust owns a master group international insurance policy. Individual certificates of insurance are issued from the master policy. Rates include 2% surplus lines tax.

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Incidental Home Country Coverage - During the period of coverage an insured person may return to their country of citizenship for incidental visits of up to two weeks total, subject to: a. The insured person must have left their country of citizenship, b. The Total Period of Coverage must be for a minimum of 30 days, and c. The return to the country of citizenship may not be taken to receive treatment for a condition incurred while traveling.
End of Trip Home Country Coverage-You may purchase up to one additional month of home country coverage at the time of enrollment, if you are enrolling in a Patriot plan for a minimum of 6 months.