All amounts shown are in U.S. dollars.
|Deductible||$250 per Period of Coverage|
|Coinsurance||As described below|
For treatment received outside the U.S. & Canada: No coinsurance
For treatment received within the U.S. & Canada:
Outside the PPO Network: The plan pays 80% of eligible expenses up to $5,000, then 100% up to the Maximum Limit
|MEDICAL BENEFITS||Usual, reasonable and customary charges, subject to deductible and coinsurance|
|Hospital Room and Board||Up to the Maximum Limit for average semi-private room rate|
|Intensive Care||Up to the Maximum Limit|
|Medical Expenses||Up to the Maximum Limit|
|Out-patient Medical||Up to the Maximum Limit|
|Local Ambulance||Up to the Maximum Limit|
|Emergency Room Accident||Up to the Maximum Limit|
|Emergency Illness - with In-patient Admission||Up to the Maximum Limit|
|Emergency Illness - without In-patient Admission||Up to the Maximum Limit with additional $250 deductible|
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 admission to the hospital.
|Dental||As described below|
|Injury due to an accident: Each Patriot Adventureplan covers the
cost of emergency dental treatment and dental surgical procedures
necessary to restore or replace sound natural teeth lost or damaged in
an accident up to the Maximum Limit. |
Sudden dental emergency: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 the Maximum Limit|
|Patriot Adventure offers coverage for Emergency Medical Evacuation from a medical facility to the nearest qualified medical facility; expenses for reasonable transportation resulting from the evacuation; and the cost of returning to either the home country or the country where the evacuation occurred, up to the Maximum Limit.|
|Emergency Reunion||Up to $10,000|
|Patriot Adventure also provides emergency reunion coverage, up to $10,000 for a maximum of 15 days, for the reasonable travel and lodging expenses of a relative or friend during an emergency medical evacuation of the insured person: 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 or Cremation/Burial||Up to $15,000 for Return of Mortal Remains or $5,000 for Cremation/Burial|
|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 $15,000; or up to $5,000 for the preparation, local burial or
cremation of your mortal remains at the place of death. |
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.
|Political Evacuation||Up to $10,000|
|If the United States Department of State, Bureau of Consular Affairs, or
similar government organization of the insured person’s home country,
orders the evacuation of all non-emergency government personnel
from the host country, due to political unrest, that becomes effective
on or after the insured person’s date of arrival in the host country,
the Company pays up to a $10,000 lifetime maximum for transportation
to the nearest place of safety or for repatriation to the insured person’s
home country or country of residence provided that:
|Benefit Period||Three months|
|If a covered injury or illness requires continuing treatment after the certificate expires, the 3-month Benefit Period may offer continued coverage for that injury or illness. When the Certificate expires, the Company will review the date of initial treatment for the covered injury or illness. If treatment began less than three months before the certificate expired, benefits for the covered injury or illness continues. This is subject to the Maximum Limits and the other terms of the plan until there have been three months of continuous coverage for the covered injury or illness.|
|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 is payable to the designated beneficiary, to a maximum of $250,000 per family.|
|Sports & Activities||Up to the Maximum Limit for basic and Adventure sports as described below|
Each Patriot Adventure plan covers injuries incurred during athletic activities which are non-organized, non-contact and engaged solely for leisure, recreation, entertainment or fitness purposes. Some of these sports include, but are not limited to, motor cycle/motorscooter riding, recreational downhill and/cross country snow skiing, horseback riding, wakeboarding, and water skiing. In addition some Adventure sports are covered:abseiling, BMX, bobsledding, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, hot air ballooning, inline skating, jet skiing, jungle zip lining, kayaking, mountain biking, parachuting, 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, snorkeling, snowboarding, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), wildlife safaris, and windsurfing. All such activities must be carried out in strict accordance with the rules, regulations and guidelines of the applicable Governing Body or Authority of each such activity. Also, activities not covered include amateur or professional sports or other athletic activity which is organized and/or sanctioned by the National Collegiate Athletic Association (and/or any other collegiate sanctioning or government body), or the International Olympic Committee.
Please note this is only a summary of sports and activities and exclusions. For additional information, please refer to the Certificate of Insurance.
|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, the 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; maximum of $250|
|A benefit of $50 per luggage item, up to a maximum of $250, is payable in the event that the Common Carrier permanently loses an insured person’s checked luggage while in transit. This coverage is secondary to any other available reimbursement, including the Carrier’s.|
|Additional Benefits for U.S. Citizens|
|Indemnity||Click for more information|
Patriot Adventure 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.
|Sudden Recurrence of a Pre-existing Condition||Click for more information|
Up to $1,000 will be reimbursed for the eligible medical expenses of a sudden and unexpected recurrence of a Preexisting Condition (defined on page 10) while traveling outside of the U.S. In addition, up to $25,000 will be reimbursed 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 the Exclusions page.
* This Web page contains only a consolidated and summary description of all current 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 Web page, application, and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.