All the deductible and all the policy maximum plan options available
Rates: Patriot International 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 provides coverage for U.S. citizens traveling abroad for a minimum of five days up to a maximum of two years.
If the plan is purchased for a minimum of three months, coverage may be renewed (without break in coverage) for a total of up to
two years.
All premium rates are in U.S. dollars. Rates include 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.
The following rates are on base of $250 deductible in all the policy maximum options.
The following rates are discounted rates for on-line purchase.
|
|
| 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 |
$26.00 |
$31.00 |
$37.00 |
$42.00 |
$54.00 |
| 30-39 |
$31.00 |
$37.00 |
$49.00 |
$57.00 |
$72.00 |
| 40-49 |
$55.00 |
$60.00 |
$68.00 |
$75.00 |
$99.00 |
| 50-59 |
$90.00 |
$102.00 |
$114.00 |
$120.00 |
$153.00 |
| 60-64 |
$109.00 |
$129.00 |
$153.00 |
$180.00 |
$201.00 |
| 65-69 |
$129.00 |
$138.00 |
$158.00 |
$189.00 |
$243.00 |
| 70-79 |
$189.00 |
N/A |
N/A |
N/A |
N/A |
| 80+* |
$378.00 |
N/A |
N/A |
N/A |
N/A |
| DEP. CHILD |
$29.00 |
$33.00 |
$39.00 |
$43.00 |
$49.00 |
| CHILD ALONE |
$26.00 |
$31.00 |
$37.00 |
$42.00 |
$52.00 |
| |
| AGE |
Daily Rates (Minimum length of coverage is 5 days) |
| 18-29 |
$0.90 |
$1.05 |
$1.25 |
$1.40 |
$1.85 |
| 30-39 |
$1.05 |
$1.25 |
$1.65 |
$1.90 |
$2.45 |
| 40-49 |
$1.85 |
$2.00 |
$2.30 |
$2.50 |
$3.35 |
| 50-59 |
$3.00 |
$3.40 |
$3.80 |
$4.00 |
$5.15 |
| 60-64 |
$3.65 |
$4.35 |
$5.15 |
$6.05 |
$6.75 |
| 65-69 |
$4.35 |
$4.65 |
$5.35 |
$6.35 |
$8.15 |
| 70-79 |
$6.35 |
N/A |
N/A |
N/A |
N/A |
| 80+* |
$12.65 |
N/A |
N/A |
N/A |
N/A |
| DEP. CHILD |
$1.00 |
$1.10 |
$1.30 |
$1.45 |
$1.65 |
| CHILD ALONE |
$0.90 |
$1.05 |
$1.25 |
$1.40 |
$1.80 |
* $10,000 Maximum
Quality Guarantee
Your satisfaction is very important to IMG and the plan underwriter. 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. In order to be considered for a full refund, your request for cancellation must be received by
IMG prior to your effective date. If you do 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 Return of Mortal Remains
For precertification, emergency evacuation and return of mortal remains, 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 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 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 $500,000. |
| Emergency Reunion |
Up to $50,000 |
| Each Patriot 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 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: |
- The Insured Person contacts the Company within 10 days of the United States Department of State, Bureau of Consular
affairs issues the travel advisory;
- 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). |
| Natural Disaster |
$100 per day for five days |
| 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. |
| 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 |
| 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. |
| 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 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. |
| Terrorism Coverage |
Up to $50,000 lifetime maximum |
| Each Patriot 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 will reimburse eligible medical claims subject to a $50,000
lifetime maximum. However, claims incurred as a result of radiological, nuclear, chemical or
biological weapons or events are not covered.
Terrorism is defined as the systematic or planned use of violence, fear, or threat of
violence in order to intimidate a population or government, especially as a means of coercion
or to obtain a granting of any demand. 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 6 months prior to the insured person's date of arrival.
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 depart the country or location. |
| Identity Theft Assistance |
Up to $500 per Period of Coverage |
| If an imposter 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 Patriot plans will provide
coverage 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 and must be reported within 6
months of the termination of coverage date. |
|
| Sudden and Unexpected 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 Preexisting
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.
|
| |
|
Description of Optional Riders::
ADVENTURE SPORTS RIDER:
The Adventure Sports Rider is
available on both Patriot 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 noncommercial
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.
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 Patriot plans.
Coverage must be purchased for a minimum of three months.
This rider is
available with a minimum purchase of three months of medical
and AD&D rider coverage.
| Up to US$100,000 additional coverage |
US$8 |
| Up to US$200,000 additional coverage |
US$16 |
| Up to US$300,000 additional coverage |
US$24 |
| Up to US$400,000 additional coverage |
US$32 |
EVACUATION PLUS RIDER
This optional rider is available to insureds up to age 65 and it provides
coverage for medical evacuations for medical conditions that are non
life-threatening and 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.
|
Exclusions:
Charges for the following services, treatments
and/or conditions, among others, are excluded from coverage under the Patriot plans.
- 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 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.
- 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).
This web page contains only a consolidated and summary description of all current Patriot Travel Medical Insurance 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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