 | 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. $20,000 when coordinated &
approved through IMG |
| Emergency Reunion Expenses - U.S. $15,000 when coordinated
& approved through IMG |
| 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 Insurancesm 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 Insurancesm, 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.
Choosing Your Plan and Premium....
Maximum Trip Duration |
Annual
Premium |
Spouse & 2 Dependents |
Each Additional Dependent |
15
Days |
U.S.$200.00 |
U.S.$100.00 |
U.S.$40.00 |
30
Days |
U.S.$250.00 |
|
|
Underwritten by: Sirius
International Insurance Corporation (publ)
PE98
