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Benefits | Benefit Description | | Plan Maximum | US$10,000 per illness or injury with a lifetime maximum of US$500,000 | | Coinsurance | 100% | | Deductible | US$100 per illness or injury | | Treatment Period | 60 days per chronic illness | | Hospital Room & Board | Up to semi-private room rate | | Hospital Intensive Care | URC* | | Physical Therapy | URC*, 1 visit per day | | Physician Visit | URC* | | Student Health Center | US$5 co-pay per visit | | Eligible Medical Expenses | URC* | Emergency Room | URC* | | Emergency Illness-with in-patient admission | URC* | | Emergency Illness-without in-patient admission | Additional US$250 deductible | | Emergency Medical Evacuation | US$25,000 lifetime maximum | | Emergency Reunion | US$5,000 lifetime maximum | | Return of Mortal Remains | US$7,500 | | Political Evacuation | Up to US$10,000 | | Accidental Death | US$5,000 | | Dismemberment | US$5,000 two limbs; US$2,500 one limb | | Terrorism Coverage | Up to US$50,000 lifetime maximum | | Sudden Recurrence of a Pre-existing Condition (U.S. citizens) | | | •Medical | Up to US$5,000 of eligible expenses | | •Emergency Medical Evacuation | Up to US$25,000 of eligible costs and expenses | | Benefit Description | | Baggage | | | •Loss/theft of Baggage | US$250 | | •Loss/theft of Valuables | US$250 | | •Loss/theft of Personal Papers | US$250 | | Legal Assistance | | | •Binder Fee | US$500 when served with summons | | Personal liability | | | •Injury to third party | US$2,000 limit after US$100 deductible | | •Damage to third person property | US$500 limit after US$100 deductible. Secondary to any other insurance in force | | Limited high school sports coverage | | *Usual, Reasonable and Customary (URC) charges for eligible expenses in the area where you receive treatment. Exclusions Charges for the following services, treatments and/or conditions, among others, are excluded from coverage under the Patriot Exchange Program. - Pre-existing Conditions. A pre-existing condition is defined as any injury, illness, sickness, disease, or other physical, medical, mental or nervous condition, disorder or ailment that, with reasonable medical certainty, existed at the time of application or at any time during the three years prior to the effective date of the insurance, whether or not previously manifested or symptomatic, diagnosed, treated, or disclosed prior to the effective date, including any subsequent, chronic or recurring complications or consequences related thereto or arising therefrom.
- Treatment or surgeries which are elective, investigational, experimental or for research purposes.
- War, military action, terrorism, political insurrection, protest, or any act thereof. The Company will not pay for a Political Evacuation if there is a travel advisory in effect on or within six (6) months prior to the Insured Person’s date of arrival in the Host Country.
- Immunizations and routine physical exams.
- Treatment of Temporomandibular Joint or dental treatment, except as expressly provided for in the certificate of insurance.
- Venereal disease, AIDS virus, AIDS related illness, ARC Syndrome, or AIDS, and the cost of testing for these conditions, and charges for treatment or surgeries which are incurred by any Insured who was HIV+ at time of enrollment into this insurance.
- Pregnancy, childbirth, birth control, artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
- Injury sustained while participating in amateur or professional sports or other athletic activity which is organized and/or sanctioned, or which involves regular or scheduled practices, games or competition. The following hazardous activities are excluded: racing of any kind, aviation (except when traveling as a passenger in a commercial aircraft), BMX, BASE jumping, bobsleigh, bungee jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning, inline skating, jet skiing, kayaking, luge, motocross (moto-x), mountain biking, mountaineering, parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping, sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling, surfing, wakeboarding, water skiing, wind-surfing and whitewater rafting.
- Vision or ear tests and the provision of visual or hearing aids.
- Vocational, recreational, speech or music therapy.
- Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services.
- Charges, injuries and/or illnesses resulting or arising from or occurring during the commission or continuing perpetration of a violation of law by the insured, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
- Treatment for, and injuries and/or illnesses resulting or arising from, substance abuse or drug addiction.
- Injury and/or illness resulting or arising from being under the influence of alcohol or drugs; and injury or illness resulting from operating any type of vehicle after consuming any alcohol or drugs.
- Willful self-inflicted injury or illness.
- Treatment required as a result of or arising from complications from a treatment or condition not covered under the certificate.
- Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured.
- Treatment for mental and nervous disorders.
- Organ or tissue transplants or related services.
- Illness or injury where the trip to the host country is undertaken for treatment or advice for such Illness or injury, except as expressly provided for in the certificate of insurance.
- Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).
- Charges for Treatment of a Chronic Illness incurred beyond sixty (60) days from the date of initial Treatment thereof.
This web page contains only a consolidated and summary description of all current Patriot Exchange Program 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 application and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request. Premiums
Patriot Exchange Program The Patriot Exchange Program is designed for those who are: - actively engaged or participating in an educational or cultural exchange program in the country of assignment.
- traveling to a destination that is not their home country.
All premium rates are in US dollars and are effective through 31-Oct-2008. Rates include 2.5% surplus lines tax where applicable. A dependent child is your child shown on the Application Form over 14 days and under 18 years of age, traveling with you, and for whom premium has been paid. | US$10,000 per illness/injury | | US$25.55 | | US$28.10 | | | | | US$10,000 per illness/injury | | US$18.95 | | US$20.95 | | | | | US$10,000 per illness/injury | | US$15.85 | | US$17.45 | | | A. US$50,000 per illness/injury | | US$41.10 | | US$43.15 | | | B. US$250,000 per illness/injury | | US$51.10 | | US$53.65 | | | C. US$500,000 per illness/injury | | US$53.90 | | US$56.55 | | | | | A. US$50,000 per illness/injury | | US$30.55 | | US$32.05 | | | B. US$250,000 per illness/injury | | US$37.80 | | US$39.65 | | | C. US$500,000 per illness/injury | | US$40.00 | | US$42.00 | | | | | A. US$50,000 per illness/injury | | US$25.55 | | US$26.85 | | | B. US$250,000 per illness/injury | | US$31.10 | | US$32.65 | | | C. US$500,000 per illness/injury | | US$33.35 | | US$35.00 | | A long-term plan is also available. For more information, please contact your independent insurance agent or International Medical Group at 1-800-628-4664. Quality Guarantee
Your satisfaction is very important to the plan underwriter. If, for any reason, you are not pleased with this product, you may submit a written request for cancellation and refund of the premium may be submitted. The request must be received by IMG prior to the effective date of coverage.
Precertification, Emergency Evacuation and Repatriation
For precertification, emergency evacuation and repatriation, please call: IMG in the US: 1-800-628-4664 (toll free) or 1-317-655-4500. Call IMG outside the US: 001-317-655-4500 (collect if necessary). This information will also be provided on your ID card. IMG must be notified prior to treatment or within 48 hours of an emergency.
To Report Claims
Please mail completed claim forms to International Medical Group, P.O. Box 88500, Indianapolis, IN 46208-0500 USA. All IMG contact numbers, claim forms and Certificate Wordings will be included in the fulfillment kit. IMG may also be contacted by fax: 317-655-4505. This web page contains only a consolidated and summary description of all current Patriot Exchange Program 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 application and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.
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