Insurance Adams & Associates INTERNATIONAL This insurance plan has been specifically designed to meet your needs during your overseas assignment and available for; Orphanage Outreach Personnel on active service. The policy provides Accidental Death & Dismemberment, Permanent Total Disability, Emergency Evacuation, Repatriation, Baggage and Emergency Assistance Services. This plan is intended to be supplemental insurance to an approved overseas major medical insurance policy. This meets the Orphanage Outreach requirements for overseas service, as briefly described below;
SUMMARY OF COVERAGE FOR PERSONS AGES 13 - 69 Accidental Death and Dismemberment, Principal Sum $100,000.00 per month for 4th - 54th months, Sickness $250.00 Medical, Legal, Passport, Baggage and Assistance See Separate "AIG" Assist Info Sheet Emergency Medical Transportation $50,000.00 Repatriation of Mortal Remains $7,500.00 Property (baggage) Insurance, $100 deductible, per occurrence $2,500.00 SUMMARY OF COVERAGE FOR PERSONS AGES 70 & OVER & CHILDREN AGES 12 & UNDER Accidental Death and Dismemberment, Principal Sum $10,000.00
NOTE: THIS IS A SUMMARY OF COVERAGE AND NOT A CONTRACT OF INSURANCE. FOR DETAILS OF COVERAGE, PLEASE CONSULT THE MASTER POLICY NUMBER: XXXXXXX AND OTHERS, OR SUBSEQUENT POLICIES ON FILE WITH THE POLICYHOLDER.
AMONG THE MAJOR EXCLUSIONS IN THE POLICY ARE WAR, SUICIDE AND SERVICE IN THE ARMED FORCES OF ANY COUNTRY AND CERTAIN FLYING IN NON-SCHEDULED AIRCRAFT.
ENROLLMENT FORM:
To enroll in the Master Policy, please fully complete the attached enrollment form and return to Orphanage Outreach.
CLAIMS
Claim forms are attached to this insert to be carried with you when traveling overseas. In the event of a claim, please complete the appropriate form and return to Adams & Associates International. Please identify yourself as Orphanage Outreach, the country in which you are serving, and your dates of service so we may verify coverage.
Orphanage Outreach BENEFIT OVERVIEW SHORT TERM VOLUNTEER MEDICAL Page 1 of 2OUTREACH INTERNATIONAL - Group # OGT 00000 38497 Effective March 1, 2001
Eligibility
All participants and their dependents, who are approved by Orphanage Outreach for Volunteer Service are eligible. Eligible dependents include the Volunteer or Volunteer's Spouse and unmarried children from birth to Age 19 (23 if attending school and the Parents are providing sole support). Purpose of the Plan
This plan is designed to reimburse for eligible expenses incurred by the insured and covered dependents for medical care and treatment as a result of serving overseas and non-occupational injury or illness incurred while in the U.S. This plan will pay a percentage of such covered medical expenses as outlined in the plan, less the deductible and coinsurance, but not more than the Maximum Lifetime Benefit.
Maximum Medical Benefit $100,000 Lifetime, Per Insured. Deductible $100 per year Overseas or on Furlough. $1,000 USA/Canada or Non furlough. Coinsurance After the deductible the plan will pay 80% of the next $5,000 (then 100 %) of eligible expenses per insured, per policy period. Reasonable & Customary All charges will be reimbursed based on the R & C Charges where service is rendered or based on negotiated rate within the PPO network. Hospital Room & Board Average Semi-Private Room Rate. Accidental Death & US$25,000 principal sum Dismemberment (AD&D also provided on Travel Insurance.)
Pre-Certification All proposed Hospital admissions and Surgeries overseas or in the United States, whether In-Patient or Out-Patient, will be subject to Pre-Certification. The Insured or the Attending Physician must call the number listed below prior to admittance to a Hospital or performance of a Surgery.
The information given by the Physician will be reviewed by the Company. If the Company agrees with the Physician, the Company will confirm to the Physician. In the event of an Emergency Admission, the Pre-Certification call must be made within 48 hours after the admission, or as soon as is reasonably possible. In the event a Hospital Admission or Surgery is not Pre-Certified, Eligible Medical Expenses will be reduced by 50%.
PLEASE NOTE: This is a summary of Coverage and not a Contract of insurance. For Specific details of the policy limits and exclusions, please refer to the complete Summary Plan Description.
Major Exclusions
NOTE: This is only a brief listing of the major exclusions. For a complete description of the Policy exclusions, please refer to the complete Summary Plan Description..
Orphanage Outreach BENEFIT OVERVIEW SHORT TERM VOLUNTEER MEDICAL OUTREACH INTERNATIONAL – Group # OGT 00000 38497 Page 2 of 2 Special Coverage's Outreach International Travel Medical InsuranceSM includes the following special provisions:
1) Incidental Home Country Coverage: During the period of coverage an insured person may return to their country of citizenship for incidental visits up to two weeks total. The following conditions apply to this coverage: Ø The insured person must have left their country of citizenship. Ø The total Period of Coverage must be for a minimum of 30 days. Ø The return to the country of citizenship may not be taken to receive treatment for a condition incurred while traveling.
2) End of Trip - Home Country Coverage: You will be covered for up to one additional months for Home Country Coverage at the end of your trip, if you have paid a premium for this at the time of your enrollment.
3) Benefit Period: If a covered injury or illness has continuing treatment after the policy expires, the Benefit Period may provide continued coverage. When the policy expires, IMG will review the date of initial treatment for the covered injury or illness. If treatment began less than six months before the policy expired, benefits for the covered injury or illness will continue subject to the Policy Limits until there has been six months of coverage. The Benefit Period serves as an extension of benefits and does not limit the treatment time during the Policy Period.
Emergency Reunion During a medical emergency having a family member near by brings comfort and peace of mind. Outreach Travel Medical InsuranceSM includes coverage for the travel and lodging expenses of a relative or friend during an Emergency Medical Evacuation. The travel expenses for the relative or friend may be either the cost of accompanying during the evacuation or traveling from the country of citizenship. The reunion expenses are covered up to US$15,000 for a maximum of 15 days. To make scheduling easier, all arrangements must be approved and coordinated by IMG.
Claim Payment To make claim processing efficient, claims are paid two ways. All benefits are subject to the provisions described in this brochure and the Policy Wording. Eligible claims are made by the insured person will be reimbursed directly to the insured person. Payment will be sent by check or directly deposited to a US bank account.
Eligible expense that have not yet been paid by the insured person will be made to either the insured person or directly to the provider.
Conditions of Coverage Ø Coverage is subject to the deductible and coinsurance. Ø Charges must be administered or ordered by a physician Ø Coverage under this program is secondary to any other insurance Ø Coverage is for medically necessary, usual, reasonable and Ø Charges must incurred during the Policy Period or the Benefit Period customary charges only Claims must be presented to IMG for payment within the Policy Period, Benefit Period or three months immediately following the Policy Period
Exclusions 1) Pre-Existing Conditions, defined as an injury or illness which was contracted or which first manifested itself; or for which manifestations of symptoms would have caused a prudent person to seek medical advice or treatment or for which a licensed physician was consulted; or for which treatment or medication was prescribed within the three years prior to the effective date of the Insured Person's coverage. 2) Treatment or surgeries which are elective, investigational, experimental, or for research purposes. 3) War; political insurrection, protest; or any act thereof. 4) Immunizations and routine physical exams. 5) Treatment of Temporomandibular Joint or dental treatment, except as provided for herein. 6) Venereal disease, AIDS virus, AIDS related illness, ARC Syndrome, AIDS or the cost of testing for these conditions and charges for treatment or surgeries which are Incurred by the Insured who was HIV+ at time of enrollment into this insurance. 7) Pregnancy, childbirth, birth control, artificial insemination, treatment of infertility or impotency, sterilization or reversal thereof, or abortion. 8) Injury sustained while participating in a professional, club, interscholastic, or intercollegiate sport. 9) Visual or ear tests and the provision of visual or hearing aids. 10) Vocational, recreational, speech or music therapy. 11) Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services. 12) Charges resulting from or occurring during the commission of a violation of law by the insured, including without limitation, the engaging in an illegal occupation or at, but excluding minor traffic violations. 13) Treatment for substance abuse or drug addiction. 14) Injury sustained while under the influence of or disablement of drugs or alcohol. 15) Willfully self-inflicted injury or illness. 16) Treatment required as a result of complications for treatment or condition not covered hereunder. 17) Any services or supplies performed or provided by a relative of the insured or provided at no cost to Insured. 18) Treatment for mental and nervous disorders.19) Organ or tissue transplants or related services. 20) Illness or injury where the trip to the host country is undertaken for the treatment or advice for such illness or injury, except as provided for herein. 21) Treatment incurred as a result of exposure to nuclear radiation, and/or radioactive material(s).
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