Patriot Multi-TripSM Group
All amounts shown are in U.S. dollars.
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 |
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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 |
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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 |
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Chiropractic Care Medical order or treatment plan required | Up to the maximum limit |
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Physical Therapy Medical order or treatment plan required | Up to the maximum limit |
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Extended Care Facility Upon direct transfer from an acute care facility | Up to the maximum limit |
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Home Nursing Care Upon direct transfer from an acute care facility | Up to the maximum limit |
| Prescription Drugs and Medication | |
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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 | |
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Emergency Local Ambulance Injury or illness resulting in an inpatient hospital admission | Up to the maximum limit. Subject to deductible and coinsurance. |
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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 |
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Emergency Reunion Must be approved in advance by the company | $100,000 maximum limit. Not subject to deductible. 15 day maximum. |
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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. |
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Natural Disaster Evacuation Must be approved in advance by the company | $25,000 maximum limit . |
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Political Evacuation & Repatriation Must be approved in advance by the company | $100,000 maximum limit. Not subject to deductible. |
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Return of Minor Children Must be approved in advance by the company | $100,000 maximum limit. Not subject to deductible. |
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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 | |
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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. |
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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. |
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Pet Return For a pet cat or dog traveling with the insured person | $1,000 maximum limit. Not subject to deductible or coinsurance. |
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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. |
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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. |
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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.