International Major Medical

Choice of Deductible

Age 0-69   : $100, $250, $500, $1,000, $2,500 or $5,000
Age 70-79 : $1,000, $2,500 or $5,000
Age 80-84 : $2,500 or $5,000

(Deductibles listed are per policy period.)
One policy will be issued for each person.

Maximum Benefit

$1,000,000

Age 70-74 : up to $500,000
Age 75-79 : up to $250,000
Age 80-84 : up to $100,000

(Benefits listed are per policy period)
One policy will be issued for each person.

The insurance being described is a temporary major medical insurance plan designed to cover foreign nationals/resident aliens while they are residing in or visiting the USA. The International Major Medical plan covers eligible expenses incurred by the insured as the result of an illness or injury. The insured has the flexibility to see any doctor or any hospital within the USA.

Eligible Expenses

Hospital Expenses

All medically necessary expenses while hospitalized.

Physician Services

All medically necessary expenses for treatment.

Skilled Nursing Facilities

All medically necessary expenses if confinement begins following a medically necessary hospital confinement of 3 days or longer.

Home Health Care

All medically necessary expenses if hospitalization would have been required if Home Health Care was not provided and the care is provided in accordance with a written plan established, approved and followed by a physician.

Medical Evacuation

All medically necessary expenses for stabilization and transportation to the facility nearest your home, which can provide the appropriate care up to $250,000.

$25,000 Accidental Death

$50,000 if accidental death occurs while riding as a passenger of a common carrier.

Ambulance Services Expenses

To and from a hospital within 100 miles in the same geographic area.

Prescription Drugs

Outpatient prescription medications covered up to a maximum of $500.

Emergency Return Home

If, after you have departed, you learn of the death of an Immediate Family Member, or you learn of the substantial destruction of your home by fire, wind, flood, or earthquake, Underwriters shall cover the cost of an economy one way air or ground transportation ticket for you to your home, up to a maximum of $5,000.

Trip Cancellation Benefit

If within two weeks prior to your pre-paid ticketed or vouchered initial trip departure your entire trip must be cancelled due to 1) your death, illness or injury causing hospitalization or outpatient surgery, or 2) the death of an Immediate Family member, or 3) the substantial destruction of your home due to fire, wind, flood, or earthquake, any unused and nonrefundable portion of expenses shall be reimbursed up to a maximum of $2,500, excess of $100 each and every loss and excess of all other valid Insurances.

Repatriation of Remains

In the event of death, Underwriters will reimburse the cost of delivery of your remains to a mortuary nearest your home up to $250,000.

Lost Luggage

In the event that your checked on luggage is completely and totally lost, Underwriters shall reimburse you to a maximum of $500, excess of any and all other valid and collectible coverages.

War & Terrorism Coverage

Underwriters will pay for Eligible Expenses which are incurred as a result of Injuries or Illnesses sustained due to war/terrorism or act of war/terrorism. Injuries or Illnesses due to war/terrorism or act of war/terrorism involving the use or release of any nuclear weapon or device or chemical or biological agent, regardless of any contributory cause(s) are not covered with this benefit.

The First Health Network has providers in all 50 states. The network has more than 5,000 hospitals, over 90,000 ancillary facilities, and over 1 million health care professional service locations in the network. To locate a provider please use the following information: First Health PPO Network

You may receive diagnosis and treatment of your Sickness or Injury from a Provider within the PPO Network, at your option. To find a Provider within the PPO Network please review the information on Your identification card. By utilizing the PPO network You may receive discounts and savings for any incurred Eligible Expenses. Utilizing the PPO network is not required and it does not guarantee that benefits will be payable or that the Provider will bill Us directly. You have the option to see any Provider whether they are in network or out of network.

We allow the insured to see any provider even if they are outside of the PPO Network. PPO Network discounts do not apply for treatment received out of network and expenses will be reimbursed up to Usual, Customary, and Reasonable (UCR) charges.

Sports or Activities included in Your coverage. Participation in the following sports or activities are covered at no additional premium and without the need for prior declaration, when participating on a recreational and non professional basis during the term of insurance. Any involvement in these sports and/or activities is subject to your compliance with local laws and regulations and the use of recommended safety equipment (including but not limited to helmet, harness, knee and/or elbow pads).

• Aerobics
• Archery
• Baseball
• Basketball
• Badminton
• Banana boating
• Body boarding (boogie boarding) up to 10 foot waves
• Canoeing/kayaking/rafting (grade 1 only)
• Cross country running
• Curling
• Cycling (street)
• Deep sea fishing
• Elephant riding
• Fencing
• Fishing
• Go karting
• Golf
• Hot air ballooning (organized pleasure rides only)
• Indoor climbing (on climbing wall)
• Jet boating
• Paint balling/war games (wearing eye protection)
• Parasailing (over water)
• Rowing
• Running (non-competitive and not marathon)
• Sailing/yachting (if qualified or accompanied by a qualified person and no racing)
• Snorkeling
• Soccer
• Spear fishing up to 30 feet (without tanks)
• Swimming
• Swimming with dolphins
• Table tennis
• Tennis
• Trampolining
• Trap shooting
• Trekking/hiking (without the need for climbing equipment) up to 10,000 feet above sea level
• Tug of war
• Volleyball
• Zorbing/hydro zorbing/sphering

Included Sports or Activities Does Not Include

• Any sport and/or activity not listed above, or
• Any activity you do as a high school athlete, college athlete, semi-professional athlete, professional athlete, or in a race, or
• Any activity carried out against local warnings or advice, or
• Any activity if it is not carried out in a safe way, or
• Any activity if you act irresponsibly or put yourself in needless danger.

Hazardous Sports or Activities are the following list of activities which are considered to be more than a standard risk. This optional rider will provide up to $250,000 for eligible expenses incurred by participation in the following:

• Bungee Jumping
• Driving/Riding a motor scooter
• Hang Gliding
• Horseback Riding (no jumping)
• Hiking/Trekking (without the need for climbing equipment) up to 20,000 feet above sea level
• Jet Skiing
• Mountaineering up to 10,000 feet
• Paragliding
• Roller skating/inline skating
• Scuba diving (up to depth of 60 feet if PADI or equivalent qualified or accompanied by qualified instructor and not diving alone)
• Skydiving with an instructor
• Snow Skiing/ Snowboarding
(excluding back country and helicopter skiing/boarding)
• Snowmobiling (trail riding only)
• Surfing up to 10 foot waves
• Tree canopy tours / Zip lining / repelling
• Wake Boarding
• Waterskiing
• White Water Rafting / canoeing / kayaking (grades 2-4 only).
• Windsurfing

Optional Hazardous Sports or Activities Does Not Include

• Any sport and/or activity not listed in the Optional Hazardous Sports and Activities Rider description, or
• Any activity you do as a high school athlete, college athlete, semi-professional athlete, professional athlete, or in a race, or
• Any activity carried out against local warnings or advice, or
• Any activity if it is not carried out in a safe way, or
• Any activity if you act irresponsibly or put yourself in needless danger.

Covers medically necessary treatment of COVID-19 up to the maximum benefit of the policy. For individuals ages 65 and above, the rider covers up to $100,000 or the maximum policy benefit, whichever is less.

1. This insurance is not subject to, and does not provide certain of the insurance benefits required by, the United States’ Patient Protection and Affordable Care Act (‘ACA’). This insurance does not provide, and Insurers do not intend to provide, minimum essential coverage under ACA. In no event will benefits be provided in excess of those specified in the contract documents. This insurance is not subject to guaranteed issuance or renewability other than as specified in the policy. ACA requires certain US citizens and US residents to obtain ACA compliant health insurance coverage. In some circumstances penalties maybe imposed on persons who do not maintain ACA-compliant coverage. You should consult your attorney or tax professional to determine if ACA’s requirements are applicable to you.
2. No benefits will be payable if the Insured is a US citizen at the time of loss.
3. Individuals over age fifty-nine (59), services and supplies for Cardiac Related Conditions and Cancer Related Conditions are limited to either (i) the medical costs of stabilizing Your condition and the transportation costs of returning You to Your home in Your home country or (ii) a maximum reimbursement for Eligible Expenses of $25,000.00, at Our option.
4. The maximum Eligible Expense for Repatriation of Remains or Global Medical Transportation is $250,000 in the aggregate.
5. The maximum Eligible Expense for room and board charges for an intensive care unit is three times the Provider’s semi-private room.
6. The maximum Eligible Expense for outpatient prescription medication(s) is $500.00 in the aggregate and for a maximum prescribed period of ninety (90) days for any one prescription.

Pre-existing Condition means a condition caused or contributed to by a Sickness or Injury for which medical advice, diagnosis, care or treatment, including the use of prescription medication including but not limited to ongoing conditions(s), was recommended by or received from a licensed health care practitioner, and/or any symptom(s) and/or any condition(s) which would have caused a reasonably prudent person to seek medical attention during the twelve (12) months immediately preceding the Effective Date of the insurance described in this Certificate, whether disclosed or not on Your application or online enrollment.

• Any expense which You are not legally obligated to pay.
• Services which are not Medically Necessary or are not furnished by and under supervision of a Physician.
• Expenses for services and supplies for which You are entitled to benefits, services or reimbursement through the Veterans' Administration, Workers' Compensation insurance, any private health plan or from any other source except Medicaid.
• Expenses in excess of UCR.
• Intentional self-inflicted injuries while sane or insane.
• Treatment for alcoholism, drug addiction, allergies, and/or Mental or Nervous Disorders and all related symptoms and side effects.
• Rest cures, quarantine or isolation.
• Cosmetic surgery unless necessitated by an accidental Injury.
• Dental exams, dental x-rays and general dental care except as a result of an accidental Injury.
• Eye glasses or eye examinations.
• Hearing aids or hearing examinations.
• General or routine examinations.
• Injuries sustained from participation in Hazardous Sports or Activities.*
• Pregnancy and pregnancy-related conditions including but not limited to fertility, pre-natal care, childbirth, miscarriage, abortion or postpartum conditions.
• Injuries or Illnesses due to War or any act of War whether declared or undeclared.*
• Injuries or Illnesses due to Terrorism or an Act of Terrorism whether declared or undeclared.
• Injuries or Illnesses due to an Act of Terrorism involving the use or release of any nuclear weapon or device or chemical or biological agent, regardless of any contributory cause(s).
• Injuries or Illnesses sustained while committing a criminal or felonious act.
• Expenses incurred for or resulting from pain which is not supported by medical diagnosis.
• Cataract surgery.
• Any elective surgery, including but not limited to complications of previous elective or cosmetic surgeries.
• Custodial Care.
• Expenses for supplies and services that were not incurred with in the specified Geographic Area.
• Pre-existing conditions.

*This exclusion can be removed if the appropriate additional premium has been paid and the optional benefit is indicated on the Schedule or attached by an endorsement.

This insurance is not subject to, and does not provide certain of the insurance benefits required by, the United States’ Patient Protection and Affordable Care Act (‘ACA’). This insurance does not provide, and Insurers do not intend to provide, minimum essential coverage under ACA. In no event will benefits be provided in excess of those specified in the contract documents. This insurance is not subject to guaranteed issuance or renewability other than as specified in the policy. ACA requires certain US citizens and US residents to obtain ACA compliant health insurance coverage. In some circumstances penalties maybe imposed on persons who do not maintain ACA compliant coverage. You should consult your attorney or tax professional to determine if ACA’s requirements are applicable to you.

The insurance described in this Certificate will terminate upon the Expiry Date of this Certificate or the date US citizenship obtained, whichever occurs first. If on the Expiry Date, You are a patient confined in a Hospital in the specified Geographic Area, benefits will continue until (i) the date You are discharged from the Hospital, or (ii) thirty (30) days beyond the Expiry Date. or (iii) the date US citizenship is obtained, whichever occurs first.

This plan is not compliant with the Affordable Care Act

This is not intended to be a complete outline of coverage. Actual wording may change without notice.
Underwriters reserve the right to modify terms and benefits at time of underwriting.

FOR ADDITIONAL INFORMATION

Phone: 312-627-9100
Fax: 312-627-1902
Website: seyfarth.brokersnexus.com

Version: 03/2023