Patriot Group Travel Medical Insurance
 
Patriot Group Travel Medical Insurance
  1. Quote-Apply On-line

  2. Rates (US Citizens Going Outside their Home Country)
  3. Rates (Non US Citizens Going Outside their home Country)
  4. Benefits
  5. Exclusions


Rates: Patriot Group Travel The following rates are on base of $250 deductible in all the policy maximum options
Options: Other lower and Higher deductible options available as following to improve the deductible or reduced the cost. please use this rate factors.
Deductible Rate Factors. Deductible Rate Factors.
US $ Zero 1.25 US $500 .90
US $100 1.10 US $1,000 .80
US $250 1.00 US $2,500 .70

Patriot International Group Travel provides coverage for U.S. citizens traveling abroad for a minimum of five days up to a maximum of two years.

All premium rates are in U.S. dollars.  Rates include surplus lines tax where applicable. A dependent child is a child shown on the Application Form over 14 days and under 18 years of age, traveling with the group as a dependent of a group member, and for whom premium has been paid.

On-line applications will receive discounted rates.  Please Click Quote / Buy Online
POLICY LIMIT Option 5
$50,000 		Option 6
$100,000 		Option 7
$500,000 		Option 8
$1,000,000 		Option 9
$2,000,000
 
AGE Monthly Rates
18-29 $23.00 $28.00 $33.00 $38.00 $49.00
30-39 $28.00 $33.00 $44.00 $51.00 $65.00
40-49 $50.00 $54.00 $61.00 $68.00 $89.00
50-59 $81.00 $92.00 $103.00 $108.00 $138.00
60-64 $98.00 $116.00 $138.00 $162.00 $181.00
65-69 $116.00 $124.00 $158.00 $170.00 $219.00
70-79 $170.00 N/A N/A N/A N/A
80+* $340.00 N/A N/A N/A N/A
DEP. CHILD $21.00 $25.00 $30.00 $33.00 $37.00
CHILD ALONE $23.00 $28.00 $33.00 $38.00 $47.00
 
AGE Daily Rates (Minimum length of coverage is 5 days)
18-29 $0.80 $0.95 $1.10 $1.30 $1.65
30-39 $0.95 $1.10 $1.50 $1.70 $2.20
40-49 $1.70 $1.80 $2.05 $2.30 $3.00
50-59 $2.70 $3.10 $3.45 $3.60 $4.60
60-64 $3.25 $3.90 $4.60 $5.40 $6.05
65-69 $3.90 $4.15 $4.80 $5.70 $7.30
70-79 $5.70 N/A N/A N/A N/A
80+* $11.35 N/A N/A N/A N/A
DEP. CHILD $0.70 $0.85 $1.00 $1.10 $1.25
CHILD ALONE $0.80 $0.95 $1.10 $1.30 $1.60

Rates: Patriot America Group Travel The following rates are on base of $250 deductible in all the policy maximum options
Options: Other lower and Higher deductible options available as following to improve the deductible or reduced the cost. please use this rate factors.
Deductible Rate Factors. Deductible Rate Factors.
US $ Zero 1.25 US $500 .90
US $100 1.10 US $1,000 .80
US $250 1.00 US $2,500 .70

Patriot America Group Travel provides coverage for non-US citizens traveling abroad for a minimum of five days up to a maximum of two years.

All premium rates are in U.S. dollars.  Rates include surplus lines tax where applicable. A dependent child is a child shown on the Application Form over 14 days and under 18 years of age, traveling with the group as a dependent of a group member, and for whom premium has been paid.
On-line applications will receive discounted rates.  Please Click Quote / Buy Online
POLICY LIMIT Option 1
$50,000 		Option 2
$100,000 		Option 3
$500,000 		Option 4
$1,000,000
 
AGE Monthly Rates
18-29 $35.00 $41.00 $53.00 $64.00
30-39 $47.00 $56.00 $70.00 $82.00
40-49 $70.00 $81.00 $107.00 $120.00
50-59 $102.00 $124.00 $152.00 $175.00
60-64 $128.00 $157.00 $186.00 $223.00
65-69 $146.00 $187.00 $203.00 $243.00
70-79 $197.00 N/A N/A N/A
80+* $343.00 N/A N/A N/A
DEP. CHILD $32.00 $37.00 $48.00 $53.00
CHILD ALONE $35.00 $41.00 $53.00 $59.00
 
  Daily Rates (Minimum length of coverage is 5 days)
18-29 $1.20 $1.40 $1.80 $2.15
30-39 $1.60 $1.90 $2.35 $2.75
40-49 $2.35 $2.70 $3.60 $4.00
50-59 $3.40 $4.15 $5.10 $5.85
60-64 $4.30 $5.25 $6.25 $7.50
65-69 $4.90 $6.30 $6.80 $8.10
70-79 $6.60 N/A N/A N/A
80+* $11.45 N/A N/A N/A
DEP. CHILD $1.10 $1.25 $1.60 $1.80
CHILD ALONE $1.20 $1.40 $1.80 $2.00

* $10,000 Maximum

* $10,000 Maximum

Quality Guarantee

The group's satisfaction is very important to IMG and the plan underwriter. If the sponsoring organization or group is not pleased with this product for any reason, a written request,prior to the effective date, for cancellation and refund of the premium. If the group does not have any claims filed with IMG, 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, IMG will only consider the two full months for a refund). If you have filed claims, your premium is non-refundable.

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 or e-mail: insurance@imglobal.com.



Benefits:
Schedule of Benefits (All amounts listed are in U.S. dollars)
MEDICAL BENEFITS Usual, reasonable and customary charges,subject to deductible and coinsurance
Hospital Room and Board Up to Policy Maximum for average semi-private room rate

Intensive Care Up to Policy Maximum

Medical Expenses Up to Policy Maximum

Outpatient Medical Up to Policy Maximum

Local Ambulance Up to Policy Maximum

Prescription Drugs Up to Policy Maximum

Emergency Room As described below
Charges incurred for the use of the Emergency Room due to an accident are covered up to the Policy Maximum.

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 admittance to the hospital.

Dental As described below
Injury due to an accident: Each Patriot Group plan covers the cost of emergency dental treatment and dental procedures necessary to restore sound natural teeth lost or damaged in an accident up to the Policy Maximum.

Sudden dental pain: Each plan will pay up to $100 for the necessary treatment of sudden, unexpected pain to sound natural teeth.

INTERNATIONAL EMERGENCY CARE (when coordinated through the Plan Administrator)
Emergency Evacuation Up to $500,000 lifetime maximum (independent of policy maximum)
Each Patriot Group plan includes coverage for Emergency Medical Evacuations to the nearest qualified medical facility; expenses for reasonable travel and accommodations resulting from the evacuation; and the cost of returning to either the home country or the country where the evacuation occurred, up to the $500,000.
Emergency Reunion Up to $50,000
Each Patriot Group plan also provides emergency reunion coverage, up to $50,000 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.
Return of Mortal Remains Up to $50,000
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.
Returning Minor Children Up to $50,000
If an insured person is hospitalized due to a covered illness/injury and is traveling alone with child(ren) 19 or under that otherwise would be left unattended, the Patriot Group plans will pay up to $50,000 for one way economy fare to their home country, including a chaperone, if necessary, for the safety of the child(ren).
Political Evacuation Up to $10,000
If the United States Department of State, Bureau of Consular Affairs issues a travel advisory that becomes effective on or after the Insured Person’s date of arrival in the Host Country, the Company will pay up to $10,000 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 issues the travel advisory;
  2. Political Evacuation and Repatriation is approved and coordinated by the Company.

To be eligible for the Evacuation, Reunion and Return benefits, these must be recommended by the attending physician in critical medical situations, and approved in advance and coordinated by IMG.
 
PLAN INFORMATION
Deductible Your choice of $0, $100, $250, $500, $1,000 or $2,500
On the Application Form, you will be asked to circle your choice of a deductible. Your premium rate is dependent on the deductible you choose. Please see the Application Form for more information.

Coinsurance As described below
For treatment received outside the U.S. & Canada: No coinsurance

For treatment received within the U.S. & Canada:
In the PPO Network: The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Policy Maximum

Outside the PPO Network: The plan pays 80% of eligible expenses up to $5,000, then 100% up to the Policy Maximum
Benefit Period Six months
If a covered injury or illness requires continuing treatment after the Period of Coverage expires, the six-month Benefit Period may provide continued coverage. 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 will continue subject to the Policy Limits and the other terms of the plan until there have been six months of continuous coverage for the covered injury or illness.

ADDITIONAL BENEFITS
Home Country Coverage As described below
Incidental 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: a. The insured person must have left their home country, b. The total Period of Coverage must be for a minimum of 30 days, and c. 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 five 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 two months. To purchase this special home country extension coverage, please check the appropriate box on the Application Form, and calculate your premium to include the additional month(s).
Trip Interruption Up to $5,000
If, during a covered trip, there is a 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 Patriot Group plan will pay to return the insured to the area of principal residence. The plan will pay 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.
Lost Luggage Up to $50 per item of personal property; maximum of $250 per Period of Coverage
This benefit will be paid in the event that the Common Carrier permanently loses an insured person’s checked luggage. This coverage is secondary to any other available coverage, including the Carrier’s.
Common Carrier Accidental Death $50,000 to Beneficiary; maximum of $250,000 per family of group
If accidental death should occur while traveling on a commercial Common Carrier, $50,000 will be paid to the designated beneficiary, to a maximum of $250,000 per family of group.
Natural Disaster $100 per day for five days
This benefit is available in the event an insured person is required depart his/her destination due to an evacuation order issued prevailing authorities in connection with a Natural Disaster. Natural Disaster is defined as widespread disruption of human lives disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe event resulting in migration of the population for its safety.
Sports and Activities Coverage  
Each Patriot Group plan covers injuries incurred during amateur athletic activities which are 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/motorscooter riding, scuba diving (to 10m), snorkeling, wakeboarding, and water skiing. However, activities not covered include 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 unless the Adventure Sports Rider is purchased: abseiling, BMX, bobsleigh, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, horseback riding, hot air ballooning, inline skating, jet skiing, kayaking, mountain biking, 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, snow boarding, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), and wildlife safaris. To be covered under the Adventure Sports Rider, these adventure activities must be engaged in solely for leisure, recreation, or entertainment purposes.

Injury sustained while participating in contact sports of any kind, racing of any kind, BASE jumping, kiteboarding, mountaineering or climbing or trekking above elevation 4500 meters above ground level or without proper ropes or guides; luge, motocross, Moto-X, rodeo activity, ski jumping, whitewater rafting exceeding Class V difficulty, scuba below 50 meters; and/or adventure sports not expressly covered hereunder are excluded regardless of which plan or rider is selected.
Accidental Death & Dismemberment $25,000 principal sum
Each Patriot Group plan includes $25,000 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.

Sudden Recurrence of a Pre-existing Condition
(U.S. citizens only) For those up to age 65 with a primary health plan, Patriot International Group will pay the Usual, Reasonable and Customary charges of a sudden and unexpected recurrence of a Pre-existing Condition (defined on page 16) up to the plan maximum. For those without a primary health plan, Patriot International Group will pay up to a $20,000 lifetime maximum. For those age 65 and older, with or without a primary health plan, Patriot International Group 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 Patriot Group plan, and the Pre-existing Condition must be covered under the primary health plan.

In addition, up to $25,000 will be paid 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.
Hospital Daily Indemnity
(U.S. citizens only) Patriot International Group will pay directly to the insured person $100 for each night of a required overnight stay in a hospital up to a maximum of 10 days. However, the hospital stay must be covered under this plan in order to receive this benefit.
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.

Description of Optional Riders
Adventure Sports Rider
The Adventure Sports Rider is available on both Patriot Group plans for those up to the age of 65. The following activities are covered to the lifetime maximum amounts listed on page four: abseiling, BMX, bobsleigh, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, horseback riding, hot air ballooning, inline skating, jet skiing, kayaking, mountain biking, 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, snow boarding, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), and wildlife safaris. These adventure activities must be engaged in solely for leisure, recreation, or entertainment purposes.
Chaperone/Faculty Leader Replacement Rider
In the event that an insured person who is designated as a Chaperone/Faculty Leader by the sponsoring organization has an unexpected death of a relative, a medical emergency, or the substantial destruction of the principal residence in his/her home country, which causes the insured person to have to cancel or interrupt travel, Patriot Group covers reimbursement up to $3,000 for the expense of a round trip economy airline ticket for a replacement Chaperone/Faculty Leader. For premium information, please see the Application Form.
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.


Exclusions:

Charges for the following services, treatments and/or conditions, among others, are excluded from coverage under the Patriot Group plans.
  1. 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.
  2. Treatment or surgeries which are elective, investigational, experimental or for research purposes.
  3. 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.
  4. Immunizations and routine physical exams.
  5. Treatment of Temporomandibular Joint or dental treatment, except as expressly provided for in the certificate of insurance.
  6. 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.
  7. Pregnancy, childbirth, birth control, artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
  8. 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 unless the Extreme Sports Rider is purchased: abseiling, aviation (except when traveling as a passenger in a commercial aircraft), BMX, bobsleigh, bungee jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning, inline skating, jet skiing, kayaking, mountain biking, paragliding, parascending, rappelling, rock climbing, sky diving, snow skiing, snowboarding, snowmobiling, spelunking, surfing, trekking, wind-surfing and whitewater rafting.

    Racing of any kind, BASE jumping, mountaineering, climbing or trekking above elevation 4500 meters above ground level or without proper ropes or guides; luge, motocross, Moto-X, rodeo activity, ski jumping, whitewater rafting exceeding Class V difficulty; and/or extreme sports not expressly coverd hereunder are excluded regardless of which plan or rider is selected.
  9. Vision 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, 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.
  13. Treatment for, and injuries and/or illnesses resulting or arising from, substance abuse or drug addiction.
  14. 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.
  15. Willful self-inflicted injury or illness.
  16. Treatment required as a result of or arising from complications from a treatment or condition not covered under the certificate.
  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 treatment or advice for such illness or injury, except as expressly provided for in the certificate of insurance.
  21. Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).
This web page contains only a consolidated and summary description of all current Patriot Group Travel Medical Insurance benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included with 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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