sales@gooseinsurance.com
www.gooseinsurance.com
Patriot Multi-TripSM
Patriot Multi-TripSM

All amounts shown are in U.S. dollars.
PLAN INFORMATION
Maximum Limits Up to age 69: $1,000,000
Age 70-79: $50,000
Deductible $250
Extensions Up to 36 continuous months
Coinsurance

For treatment received outside the U.S.: 100% up to the maximum limit

For treatment received within the U.S.:

In the PPO Network: 100% up to the maximum limit

Outside the PPO Network: 80% up to $1,000, then 100%

Sudden and Unexpected Recurrence of Pre-existing Conditions $5,000 maximum limit
Inpatient or Outpatient Services
Eligible Medical Expenses Up to the maximum limit
Physician Visits / Services Up to the maximum limit
Urgent Care Clinic $25 copayment. Copayment is not applicable if the declaration states a $0 deductible. Not subject to deductible
Walk-in Clinic $25 copayment. Copayment is not applicable if the declaration states a $0 deductible. Not subject to deductible
Hospital Emergency Room:
Inside the U.S.
Injury: Not subject to emergency room deductible.
Illness: Subject to a $250 deductible for each emergency room visit for treatment that does not result in direct inpatient hospital admission. Up to the maximum limit.
Hospital Emergency Room:
Outside the U.S.
Up to the maximum limit
Hospitalization / Room & Board Average semi-private room rate up to the maximum limit, includes Nursing services, miscellaneous and Ancillary services
Intensive Care Up to the maximum limit
Bedside Visit
Hospitalized in an Intensive Care Unit
$1,500 maximum limit. Not subject to deductible.
Outpatient Surgical / Hospital Facility Up to the maximum limit
Laboratory Up to the maximum limit
Radiology / X-ray Up to the maximum limit
Chemotherapy / Radiation Therapy Up to the maximum limit
Pre-Admission Testing Up to the maximum limit
Surgery Up to the maximum limit
Reconstructive Surgery
Surgery is incidental to and follows surgery that was covered under the plan
Up to the maximum limit
Assistant Surgeon 20% of the primary surgeon’s eligible fee
Anesthesia Up to the maximum limit
Durable Medical Equipment Up to the maximum limit
Chiropractic Care
Medical order or treatment plan required
Up to the maximum limit
Physical Therapy
Medical order or treatment plan required
Up to the maximum limit
Extended Care Facility
Upon direct transfer from an acute care facility
Up to the maximum limit
Home Nursing Care
Upon direct transfer from an acute care facility
Up to the maximum limit
Prescription Drugs and Medication
Prescription Drugs and Medication
Obtained through Retail Pharmacy, Inpatient and Outpatient Surgery, Emergency Room and Outpatient Office Visits Dispensing maximum for Retail Pharmacy: 90 days per prescription
Through age 65 Maximum Limit: $250,000 per period of insurance Ages 66 to 79 Maximum Limit: Up to the period of coverage limit
Emergency Services
Emergency Local Ambulance
Injury or illness resulting in an inpatient hospital admission
Up to the maximum limit. Subject to deductible and coinsurance.
Emergency Medical Evacuation
Must be approved in advance and coordinated by the company
Through age 65 maximum limit: Up to the period of coverage limit Ages 66 to 79 maximum limit: $50,000 Not subject to deductible
Emergency Reunion
Must be approved in advance by the company
$100,000 maximum limit. Not subject to deductible. 15 day maximum.
Interfacility Ambulance Transfer
Transfer from one licensed health care facility to another licensed health care facility resulting in an inpatient hospital admission
Company pays 100%. Not subject to deductible.
Natural Disaster Evacuation
Must be approved in advance by the company
$25,000 maximum limit .
Political Evacuation & Repatriation
Must be approved in advance by the company
$100,000 maximum limit. Not subject to deductible.
Return of Minor Children
Must be approved in advance by the company
$100,000 maximum limit. Not subject to deductible.
Remote Transportation
Must be approved in advance by the company
$20,000 maximum limit
Return of Mortal Remains or Cremation/Burial
Must be approved in advance by the company
Up to the maximum limit
Other Services
Accidental Death & Dismemberment (AD&D)
Death must occur within 90 days of the accident
$50,000 principal sum. Not subject to deductible.
Common Carrier Accidental Death $25,000 per insured child, $100,000 per insured adult, $250,000 maximum limit per family. Not subject to deductible or coinsurance.
Identity Theft $500 maximum limit. Not subject to deductible or coinsurance.
Personal Liability
Secondary to any other insurance
$25,000 combined maximum limit. Injury to a third person: $100 per injury deductible. Damage to a third person’s property: $100 per damage deductible. No coverage for injury to a related third party or damage to related third person’s property.
Pet Return
For a pet cat or dog traveling with the insured person
$1,000 maximum limit. Not subject to deductible or coinsurance.
Small Pet Common Air Carrier
Accidental Death Benefit
For a pet cat or dog up to 30 pounds traveling with the insured person
$500 maximum limit. Not subject to deductible or coinsurance.
Return Travel $10,000 maximum limit. Not subject to deductible or coinsurance.
Dental Treatment $300 maximum limit due to dental accident or unexpected pain to sound natural teeth. Subject to deductible and coinsurance.
Traumatic Dental Injury
Treatment at a hospital due to an accident
Up to the maximum limit. Additional treatment for the same injury rendered by a dental provider will be paid at 100%. Subject to deductible and coinsurance.
Emergency Eye Examination
Loss or damage to prescription corrective lenses due to an accident
$150 maximum limit. $50 deductible per occurrence.
Hospital Indemnity $250 per overnight inpatient confinement, maximum limit of 10 overnights. Not subject to deductible or coinsurance.
Natural Disaster $250 per day and maximum limit of five days for accommodations. Not subject to deductible or coinsurance.
Terrorism $50,000 maximum limit. Not subject to deductible or coinsurance.
Lost Luggage Maximum Limit per item $150, $500 maximum limit. Not subject to deductible or coinsurance.

* 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.