|IMG Visitor Medical Program - Platinum Comprehensive Plan|
|IMG Platinum Insurance Enrollment|
|Program Eligibility||Pre-Existing Condition Coverage|
|Insurance Enrollment||Medical Evacuation And Repatriation|
|Periods Of Coverage & Premium Rates||Accidental Death Dismemberment|
|Medical Expense Benefits - Accident and Sickness||Return of Mortal Remains / Cremation|
|Trip Interruption Coverage||Return of Minor Children|
|Assistance Services||Emergency Medical Reunion|
|Exclusions||Baggage Loss Coverage|
|Claims Procedure||Home Country Coverage|
|24x7 Assistance Services (Insured Members Only)||Cancellation Policy|
To enroll in the India Network Platinum Comprehensive Network Insurance Program, you may enroll online by completing the insurance form as below
the online Platinum Insurance Enrollment Form and
submit the payment information on the secure server site. You will receive
certificate of coverage and ID card by email and regular mail by our fulfillment
Plan Administrator normally processes Application Forms within 24 hours of receipt. Once processing is complete, Plan Administrator will mail a fulfillment kit to the mailing address listed on the application form. The fulfillment kit will include an Plan Administrator Identification Card, Plan Administrator contact numbers, claim forms and your insurance certificate providing a complete description of your coverage under the contract. Please note: If you require express mail delivery, there is an additional charge listed on the Application Form.
ONLINE FULFILLMENT KIT: For convenience, approved applicants may choose to communicate electronically and download their fulfillment kit from the Plan Administrator website for immediate access. To do this, you must check the appropriate box listed in Section 2 of the application form. We must have your correct email address to complete this process. If Plan Administrator has processed and approved your application form, you will receive an email from Plan Administrator that contains all of the hyper-links to easily obtain the fulfillment information through the Internet.
PERIODS OF COVERAGE & PREMIUM RATES
CONDITIONS OF COVERAGE
1. Coverage and benefits are subject to the deductible and coinsurance, and all terms of the Certificate of Insurance and Master Policy.
2. Coverage under a Platinum plan is secondary to any other coverage.
3. Coverage and benefits are for medically necessary, usual, reasonable and customary charges only.
4. Charges must be administered or ordered by a physician.
5. Charges must be incurred during the Period of Coverage or the Benefit Period.
6. Claims must be presented to Plan Administrator for payment within ninety (90) days from the date the claim was incurred.
The following conditions apply to all persons applying for and/or enrolling in Platinum Travel Medical Insurance.
- Platinum Travel Medical Insurance is travel insurance for U.S. citizens traveling outside the United States with coverage for brief returns to the U.S., and for non-U.S. citizens traveling outside their home country.
- For those under 65 years of age and visiting the U.S., your initial Period of Coverage must begin within six months of arrival in the U.S. For those 65 years of age and older, it must begin within 30 days of arrival. These requirements will be waived with proof of previous valid international travel insurance. Prior U.S. domestic health care coverage does not meet this eligibility requirement. Please provide the name of your international insurance carrier on the Application Form. If you are not in the U.S. at the time of application, please indicate your expected date of arrival on your Application Form.
RENEWAL OF COVERAGE
If your Platinum plan is purchased for a minimum of one month, coverage may be renewed (unless there is a break in coverage) for a total of up to three years. Renewals are available in whole month or daily increments and may be completed online or by using a paper application, however, renewals of less than one month are available only online. For each renewal of less than one month completed online, you will be charged an additional $5 processing fee. Each insured person must only satisfy one deductible and coinsurance within each 12 month coverage period. Please note: Renewal rates may differ from initial rates.
Effective Date of Coverage begins on the latest of the following:
You, your spouse and unmarried dependent children (over 14 days and under 18 years of age) listed on the Application Form and for whom premiums have been paid will be covered from the latest of the following dates:
1. the date Fulfilment Center receives your completed Application Form and the appropriate premium;
2. the date you depart from your home country; or
3. date requested on your Application Form.
4. Expiration Date of Coverage terminates on the earlier of the following:
Travel Medical Insurance coverage ends on the earliest of the following dates:
a.the end of the period for which premium has been paid;
b. the date requested on your Application Form; or
c. the date you return to your home country (however, see End of Trip Home Country Coverage)
MEDICAL EXPENSE BENEFITS - ACCIDENT AND SICKNESS
The following is a summary of benefits and terms that are available to eligible insureds on the Platinum plans.
Charges incurred for the use of the Emergency Room due to an accident or illness are covered up to the Maximum Limit.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: Injury due to an accident
Each Platinum plan 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.
Each plan will pay up to $250 for the necessary treatment of sudden, unexpected pain to sound natural teeth.
Each Platinum plan provides upfront, additional protection for unexpected injuries. This benefit provides up to $300 of first-dollar benefits for treatment of an injury.
HOSPITAL DAILY INDEMNITY:
Each plan pays $250 directly to the insured person for each night of a required overnight stay in a hospital up to a maximum of 10 days. The hospital stay must be covered under this plan in order to receive this benefit.
If a covered injury or illness requires continuing treatment after the Period of Coverage expires, the twelve-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 six months before the Period of Coverage 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 six months of continuous coverage for the covered injury or illness.
TRIP INTERRUPTION COVERAGE:
If, during a covered trip, there is an unexpected 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, each Platinum plan pays to return the insured to the area of principal residence. The plan pays 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.
24x7 ASSISTANCE SERVICES (INSURED MEMBERS ONLY)
Service at your fingertips anytime, anywhere - that’s what My Plan Administrator provides. My Plan Administrator is our proprietary online service that allows you to access information and manage accounts, 24 hours a day, seven days a week, from anywhere in the world. Our service centers in the U.S. and Europe are always available to help or handle emergencies 24 hours a day, but through My Plan Administrator you have immediate access to a wealth of information about your account and can manage routine areas to help you save time when you may need it most. Some features include:
As a Platinum member, you may seek treatment with the hospital or doctor of your choice. When seeking treatment in the U.S., you can reduce your out-of-pocket costs by using the independent Preferred Provider Organization (PPO), a separately organized network of hundreds of thousands of established, highly qualified health care physicians and many well-recognized hospitals in the U.S. contracted by Plan Administrator . You can quickly search the network through My Plan Administrator . Additionally, to help you locate health care providers outside the U.S., Plan Administrator provides its online International Provider Access (IPA), a database of over 17,000 providers.
As a registered user of My Plan Administrator, you can access eDocAmerica and communicate with experienced health care professionals 24 hours a day, regardless of your location.
eDocAmerica allows you to consult with board-certified physicians, licensed psychologists, pharmacists, dentists, dietitians and fitness trainers to assist you with any routine health related questions you have. It is not meant to replace your family physician; instead eDocAmerica focuses on addressing your concerns in a convenient manner and providing you with support to make informed decisions. eDocAmerica professionals will quickly respond to your questions, suggest treatment alternatives, and get you the information you need – saving you time and possibly preventing unnecessary office visits. Email responses are normally received within two to four hours and guaranteed within 24 hours.Universal Rx Pharmacy Discount Savings
This is a discount savings program available to every certificate holder of the Platinum plans. This program allows card members to purchase prescriptions at one of over 35,000 participating pharmacies in the U.S. and receive the lower of 1) Universal Rx contract price or 2) the pharmacy regular retail price.
This discount program is not insurance coverage. It is purely a discount program to purchasers of the Platinum plans. Use of the discount card does not guarantee that prescribed medication is covered under the insurance benefit plan.Global Concierge & Assistance Services
Platinum provides clients more than insurance protection. Plan Administrator ’s Global Concierge and Assistance Services offers the knowledge and information needed to keep you healthy and safe. Below is a list of services handled by a dedicated service team that is available 24 hours a day, seven days a week, exclusively for our Platinum members.*Dedicated Service Line n Emergency Travel Arrangements n Dedicated Claims Team n Legal Referrals n Bag Tracking n Drug Translation Services n Embassy & Consulate Referrals n Pre-trip Health & Safety Advisories n Emergency Cash Transfers n Emergency Message Relay n Security Updates & Country Profiles Lost Passport/Travel Documents Assistance Prescription Drug Replacement Assistance
* You will be provided information on how to access the Global Concierge and Assistance Services. Please note: these are additional services offered under Platinum Travel Medical Insurance. They are not insurance benefits.
Akeso Care Management® (ACM®)
The ability to access quality health care is of paramount importance when a medical emergency arises abroad. To coordinate care and provide U.S. and internationally based medical management services, Plan Administrator formed ACM, an on-site specialized division devoted entirely to medical management.
The clinical staff consists of qualified physicians and registered nurses who are experts at assessing the need for services and ensuring those services are delivered in a timely, cost-effective manner. ACM has international medical experience, providing services in more than 170 countries worldwide.
ACM is accredited by URAC, an independent, nonprofit organization that is internationally recognized for promoting continuous improvement in the quality and efficiency of health care management. Through a rigorous and comprehensive review that ensures ongoing compliance, ACM earned its URAC accreditation in Health Utilization Management.
From routine medical care to complex case management, from checkups to emergency medical evacuations, ACM is there for you. They are committed to consumer protection and empowerment, quality operations and regulatory compliance. This translates into better care for you around the world, around the clock.
Charges for certain services, treatments and/or conditions, among others, are excluded from coverage under the Platinum plans and include but are not limited to:
This contains only a brief summary of current Platinum Medical Insurance benefits, conditions, limitations and exclusions, and is subject to all the terms and conditions of the full Certificate of Insurance. The complete Certificate of Insurance with all terms, conditions and exclusions will be included in the fulfillment kit sent to approved applicants. The Travel Medical Insurance plans are amended, modified or replaced from time to time, and Plan Administrator reserves the right to issue the most current Certificate of Insurance for this insurance plan in the event this application and/or brochure has expired, is modified, or is replaced with a newer version. Samples of current Certificate wordings are available upon request.
IMPORTANT NOTICE REGARDING PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA): This insurance is not subject to, and does not provide benefits required by, PPACA. On January 1, 2014, PPACA will require U.S. citizens and certain U.S. residents to obtain PPACA compliant insurance coverage unless they are exempt from PPACA. Penalties may be imposed on U.S. citizens and U.S. residents who are required to maintain PPACA compliant coverage but do not do so. Please note that it is solely your responsibility to determine if PPACA is applicable to you.
Each proposed hospital admission, inpatient or outpatient surgery, and other procedures as noted in the Certificate of Insurance must be Precertified for medical necessity, which means the insured person or their attending physician must communicate with an Plan Administrator representative at the number listed on the Plan Administrator identification card prior to admission to a hospital or performance of a surgery. In case of an emergency admission, the Precertification call must be made within 48 hours of the admission, or as soon as reasonably possible. If a hospital admission or a surgery is not Precertified, eligible claims and expenses will be reduced by 50%. It is important to note that Precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits or a guarantee of payment. All medical expenses eligible for reimbursement must be medically necessary and will be paid or reimbursed at usual, reasonable, and customary rates. Please refer to the Certificate of Insurance for full details of the Precertification requirements.
For Precertification, emergency evacuation, and return of mortal remains, please call: Plan Administrator in the U.S.: 1.800.628.4664 (toll free) or 1.317.655.4500. Call Plan Administrator outside the U.S.: 001.317.655.4500 (collect if necessary). This information will also be provided on your ID card.
Note: An insured person may begin the Precertification process through MyPlan Administrator or the Client Resources section of our website, www.imglobal.com. Simply look for the Precertification option. You will be asked to provide the required information, which can then be submitted electronically to Plan Administrator . Once we have confirmed receipt of your request, our utilization management and review team will review the information provided and respond to the insured person or the provider within two business days. Please note that this online service will only initiate the Precertification process, and it should not be used to Precertify emergency admissions, procedures, or evacuations.
All benefits payable under Platinum Travel Medical Insurance are subject to the terms and conditions in the Certificate of Insurance. To make claim processing efficient, claims may be paid in two ways:
1. Eligible expenses that have been paid by or on behalf of the insured person may be reimbursed by check directly to the insured person.
2. Eligible expenses that have not yet been paid by the insured person may, at the option of Plan Administrator , be paid either to the insured person or directly to the provider.
Claim forms can be accessed at www.imglobal.com and mailed to International Medical Group, P.O. Box 88500, Indianapolis, IN 46208- 0500 USA. All Plan Administrator contact numbers, claim forms and the Certificate of Insurance are included in the fulfillment kit. Plan Administrator may also be contacted by fax: 1.317.655.4505 or email: firstname.lastname@example.org.
RETURN OF MINOR CHILDREN
If a covered illness/injury results in a hospitalization and/or death of the insured person, and he/she is traveling alone with child(ren) 19 or under that otherwise would be left unattended, the Platinum plans will pay up to $100,000 for one way economy fare to their home country, including a chaperone, if necessary, for the safety of the child(ren). To be eligible for the Remote Transportation, Evacuation, Reunion and Return benefits, these must be recommended by the attending physician in life-threatening medical situations, and approved in advance and coordinated by Plan Administrator.
PRE-EXISTING CONDITION COVERAGE
SUDDEN AND UNEXPECTED RECURRENCE OF A PRE-EXISTING CONDITION:
citizens only Traveling Abroad
For those up to age 65 with a primary health plan, Platinum International will pay the Usual, Reasonable and Customary charges of a sudden and unexpected recurrence of a Pre-existing Condition up to the plan maximum. For those without a primary health plan, Platinum International will pay up to a $20,000 lifetime maximum. For those age 65 and older, with or without a primary health plan, Platinum International will pay up to a $2,500 lifetime maximum. The primary health plan must have existed prior to the effective date and during coverage of the Platinum plan, and the Pre-existing Condition must be covered under the primary health plan.
Non-U.S. citizens Traveling to the United States
The Platinum Insurance will pay Usual, Reasonable, and Customery charges of a sudden and unexpected recurrence of a pre-existing condition as follows: For those under age 65, Platinum Plan will pay up to a $50,000 lifetime maximum for eligible medical expenses. For those age 65 and older, Platinum Plan will pay up to $2,500 lifetime maximum.
MEDICAL EVACUATION AND REPATRIATION
In addition, up to $25,000 will be paid to U.S. and non-U.S. citizens 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.
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 $100,000 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: 1. The insured person contacts the Company within 10 days of the United States Department of State, Bureau of Consular Affairs, or similar government organization of the insured person’s home country, issuance of the evacuation order; and 2. The evacuation order pertains to persons from the same home country
as the insured person; and 3. Political Evacuation and Repatriation is approved and coordinated by the Company; In no event will the Company pay for a political evacuation if there is a travel warning in effect on or within six (6) months prior to the insured person’s date of arrival in the host country.
In the event of a diagnosis of a critical medical condition which is not necessarily immediately life-threatening, but severe enough to result in death or a permanent disability if not treated right away, Remote Transportation provides for eligible charges arising out of the transportation of an insured person to a qualified facility for further treatment (if the current facility is unable to provide such treatment).
The Platinum plans offer coverage for Emergency Medical Evacuation 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.
ACCIDENTAL DEATH DISMEMBERMENT
Each Platinum plan offers a $50,000 principal sum benefit for Accidental Death and Dismemberment occurring during the Period of Coverage: • Accidental Loss of life - principal sum • Accidental Loss of two Members - principal sum • Accidental Loss of one Member - 50% of principal sum. “Member means hand, foot or eye.
COMMON CARRIER ACCIDENTAL DEATH:
If accidental death should occur while traveling on a commercial Common Carrier, $100,000 per adult and $25,000 per child is payable to the designated beneficiary, to a maximum of $250,000 per family.
This benefit is available in the event an insured person is required to depart his/her destination due to an evacuation order issued by prevailing authorities in connection with a Natural Disaster. Natural Disaster is defined as widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe or event resulting in migration of the population for its safety.TERRORISM COVERAGE:
Each Platinum plan provides coverage for injuries and illness incurred as a result of an act of Terrorism, limited in amount and by circumstances. If an insured person is injured as a result of an act of Terrorism, and the insured person has no direct or indirect participation in the act, the plan reimburses eligible medical claims up to the maximum limit. Terrorism includes criminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provide
a state of terror in the general public or in a group of persons or particular persons, intimidate a population, or compel a government of international organization to do or to abstain from doing an act. However, this benefit does not cover an act of Terrorism in any country or location where the United States government has issued a travel advisory that has been in effect within the six months prior to the insured person’s date of arrival. In addition, claims incurred as a result of radiological, nuclear, chemical or biological weapons or events are not covered.
This benefit also does not cover an act of Terrorism in the event that an advisory to leave a certain country or location is issued by the United States government after the insured person’s arrival date, and the insured person unreasonably fails or refuses to to heed such warning or depart the country or location.
IDENTITY THEFT ASSISTANCE:
If an impostor obtains key personal information such as a Social Security or Driver’s License number, or other method of identifying an insured person in order to impersonate or obtain credit, merchandise or services in the insured person’s name, the Platinum plans provide coverage for up to $500 for the reasonable, customary and necessary costs incurred by the insured for: re-filing a loan or other credit application that is rejected solely as a result of the stolen identity event; notarization of legal documents, long distance telephone calls, and postage that has resulted solely as a result of reporting, amending and/or rectifying records as a result of the stolen identity event; up to three credit reports obtained within one year of the insured person’s knowledge of the stolen identity event; and stop payment orders placed on missing or unauthorized checks as a result of the stolen identity event.
The identity theft event must occur during the Period of Coverage.
If you are Injured as a result of a Felonious Assault while traveling outside of your home country, each plan pays up to $10,000. This benefit is in addition to any other benefit available under Platinum.
SMALL PET COMMON AIR CARRIER ACCIDENTAL DEATH:
A benefit of up to $500 is payable in the event of loss of life to a small pet while traveling with a covered insured on a common air carrier. This covers the pet while on the insured’s originating flight from his/her home country, and returning flight to the insured’s home country only. A small pet is a cat or dog up to 30 pounds in weight.
RETURN OF MORTAL REMAINS / CREMATION
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 $50,000; or up to $5,000 for the preparation, local burial or cremation of your mortal remains at the place of death.
EMERGENCY MEDICAL REUNION
Each Platinum plan also offers Emergency Reunion coverage, up to $100,000 for a maximum of 15 days, for the reasonable travel and lodging expenses of a relative or friend during an Emergency Medical Evacuation: either the cost of accompanying the insured during the evacuation or traveling from the home country to be reunited with the insured.
BAGGAGE LOSS COVERAGE
A benefit of up to $500 is payable in the event that there is damage to, loss of, or theft of your checked or stored baggage or personal items by a common carrier or while stored with your hotel. It will also include coverage for the replacement costs of travel documents.
HOME COUNTRY COVERAGE
During the Period of Coverage an insured person may return to their home country for incidental visits up to a cumulative two weeks total, subject to: 1. The insured person must have left their home country, 2. The total Period of Coverage must be for a minimum of 30 days, and 3. The return to the home country may not be taken to receive treatment for an illness or injury incurred while traveling.
END OF TRIP HOME COUNTRY COVERAGE: For every four months of continuous coverage you purchase, you can purchase one additional month of home country coverage as an accommodation and supplemental travel benefit up to a maximum of three months. To purchase this special home country extension coverage, calculate your premium on the Application Form, and include the additional month(s).
SPORTS AND ACTIVITIES COVERAGE:
Each Platinum plan covers injuries incurred during athletic activities which are non-organized, non-contact and engaged in by the insured person solely for leisure, recreation, entertainment or fitness purposes. Some of these sports and activities include, but are not limited to, motor cycle/motor scooter riding, recreational downhill and/or cross country snow skiing, horseback riding, sub-aquatic activities (to 10m), wake boarding, and water skiing. However, 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, and or Adventure Sports. Please note this is only a summary of sports and activities and exclusions. For additional information, please refer to the Certificate of Insurance.
Your satisfaction is very important to Plan Administrator . If you are not pleased with this product for any reason, you may submit a written request, prior to your effective date, for cancellation and refund of your premium. If you do not have any claims filed with Plan Administrator , you may cancel your plan after your effective date, however, the following conditions will apply:
1. You will be required to pay a $50 cancellation fee and
2. only full month premiums will be considered for refunds (e.g., if you choose to cancel your coverage two months and two weeks prior to the date your coverage ends, Plan Administrator will only consider the two full months for a refund). If you have filed claims, your premium is non-refundable.
DESCRIPTION OF OPTIONAL RIDERS
ADVENTURE SPORTS RIDER:
The Adventure Sports Rider is available on both Platinum plans for those up to the age of 65. The following activities are covered to the lifetime maximum amounts listed on page four as long as they are engaged solely for leisure, recreation, or entertainment purposes: abseiling, BMX, bobsledding, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, hot air ballooning, in-line 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), and 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. Certain sports activities are never covered, regardless of whether or not you purchase the Adventure Sports Rider. Please see page 16, exclusion 8. Please note this is only a summary of Adventure Sports and exclusions. For additional information, please refer to the Certificate of Insurance.
ENHANCED AD&D RIDER:
This optional coverage is available for the primary insured person only. This coverage is in addition to the Accidental Death and Dismemberment already included in the Platinum plans. This rider is available with a minimum purchase of three months of medical and AD&D rider coverage.
CITIZENSHIP RETURN RIDER:
When purchased at the time of application, the Citizenship Return Rider provides temporary medical coverage for non-U.S. citizens returning to their country of citizenship. For U.S. citizens, the rider provides up to 60 days of coverage for brief returns to the U.S. provided you have a current health plan in force and have resided outside the U.S. continuously for the past six months. Coverage for sudden recurrence of pre-existing conditions is excluded if the rider is selected. For premium information, please see the back of the Application Form.
PERSONAL LIABILITY RIDER:
This optional coverage provides for the reimbursement of legal costs associated with a personal liability event by a covered insured. This includes legal costs incurred arising from the determination and/or settlement of such legal liability associated with the injury of a third person or damage to a third person’s property during the period of coverage.
EVACUATION PLUS RIDER:
This optional rider is available to insureds up to age 65. It offers coverage for medical evacuations for sudden and unexpected medical conditions that are non life threatening and where hospitalization is medically necessary. It also offers coverage for evacuations as a result of a natural disaster. This rider must be purchased for a minimum of three months regardless of the minimum number of days being traveled.Plan Administrator: