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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.
Obtaining coverage is as simple as:
- Filling out the Enrollment Form with the information
requested.
- Mailing or faxing the above information to your
independent agent or IMG.
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Benefits:
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 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 the premium.
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.
SCHEDULE OF BENEFITS All amounts listed are in U.S.
dollars
| BASIC PLAN
INFORMATION & HIGHLIGHTS |
| Plan Maximum |
$10,000 per illness or injury with a
Lifetime Maximum of $5,000,000. |
| Coinsurance |
No Coinsurance |
| Deductible |
$100 per Illness or Injury |
| Treatment Period |
60 days per chronic illness |
| MyIMG SM |
24 hour secure access from anywhere in the world to
manage your account at anytime |
| International Emergency Care |
A wide range of international emergency benefits
available including emergency evacuation, emergency reunion,
and return of mortal remains |
| Dependent Coverage |
Coverage not only provided for dependents, but for
faculty, scholars, students and exchange participants as
well |
| Optional Add-on Plan |
Additional coverage is available for high school sports,
personal liability and legal assistance |
SCHEDULE OF BENEFITS BASIC
SHORT-TERM TRAVEL PLAN |
MEDICAL BENEFITS
*Usual, Reasonable and Customary
(URC) charges for eligible expenses in the area where you
receive treatment. |
| Hospital Room and Board |
Up to semi-private room rate |
| Hospital Intensive Care |
URC* |
| Physical Therapy |
URC* - 1 visit per day |
| Physician Visit |
URC* |
| Student Health Center |
$5 co-pay per visit |
| Prescription Drugs |
Up to Policy Maximum |
| Eligible Medical Expenses |
URC* |
| Emergency Room |
URC* |
| Emergency Room Illness with In-patient Admission |
URC* |
| Emergency Room Illness without In-patient Admission |
Additional $250 deductible |
INTERNATIONAL EMERGENCY
CARE When coordinated through
the Plan Administrator |
| Emergency Medical Evacuation |
$25,000 Lifetime Maximum |
| Emergency Reunion |
$5,000 Lifetime Maximum |
| Return of Mortal Remains |
$7,500 |
| Political Evacuation |
Up to $10,000 |
| ADDITIONAL BENEFITS |
| Accidental Death |
$5,000 |
| Dismemberment |
$5,000 two limbs; $2,500 one limb |
| Terrorism Coverage |
Up to $50,000 Lifetime Maximum |
Sudden Recurrence of a Pre- existing
Condition (U.S. citizens) |
| Medical |
Up to $5,000 of eligible expenses |
| Emergency Medical Evacuation |
Up to $25,000 of eligible costs and expenses |
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Pre-existing Conditions
(For U.S. Citizens, this benefit will begin when the Sudden Recurrence benefit is exhaused.)
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$500 per year; $50,000 lifetime maximum - after 12 months of continuous coverage |
Incidental Home Country Coverage
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Up to a cumulative two weeks |
| OPTIONAL ADD-ON PLAN |
| Baggage |
| Loss/theft of Baggage |
$250 |
| Loss/theft of Valuables |
$250 |
| Loss/theft of Personal Papers |
$250 |
| Legal Assistance |
| Binder Fee |
$500 when served with summons |
| Personal Liability |
| Injury to third party |
$2,000 limit after $100 deductible |
| Damage to third person property |
$500 limit after $100 deductible. Secondary to any other
insurance in force |
| Limited High School Sports Coverage |
URC* |
| OPTIONAL RIDER |
| Applies to all
individuals listed on the Application Form |
Adventure Sports Rider
(available to insured up to age 65 - apply 1.20 rate factor)
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Age Lifetime Maximum
0 - 49 $50,000
50 - 49 $30,000
60 - 64 $15,000
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*Usual, Reasonable and Customary (URC) charges for eligible
expenses in the area where you receive treatment.
| STANDARD PLAN
INFORMATION & HIGHLIGHTS |
| Plan Maximum |
Choice of $50,000, $250,000 or $500,000 per
illness or injury with a Lifetime Maximum of $5,000,000.
|
| Coinsurance |
No Coinsurance |
| Deductible |
$100 per Illness or Injury |
| Treatment Period |
60 days per chronic illness |
| MyIMG SM |
24 hour secure access from anywhere in the world to
manage your account at anytime |
| International Emergency Care |
A wide range of international emergency benefits
available including emergency evacuation, emergency reunion,
and return of mortal remains |
| Dependent Coverage |
Coverage not only provided for dependents, but for
faculty, scholars, students and exchange participants as
well |
| Optional Add-on Plan |
Additional coverage is available for high school sports,
personal liability and legal assistance |
SCHEDULE OF BENEFITS STANDARD
SHORT-TERM TRAVEL PLAN |
| All coverages, benefits
and premium amounts shown are in U.S. dollars |
MEDICAL BENEFITS
*Usual, Reasonable and Customary
(URC) charges for eligible expenses in the area where you
receive treatment. |
| Hospital Room and Board |
Up to semi-private room rate |
| Hospital Intensive Care |
URC* |
| Physical Therapy |
URC* - 1 visit per day |
| Physician Visit |
URC* |
| Student Health Center |
$5 co-pay per visit |
| Prescription Drugs |
Up to Policy Maximum |
| Eligible Medical Expenses |
URC* |
| Emergency Room |
URC* |
| Emergency Room Illness with In-patient Admission |
URC* |
| Emergency Room Illness without In-patient Admission |
Additional $250 deductible |
| Dental |
| Injury Due to Accident |
$500 |
| Sudden and Unexpected Pain |
$350 |
INTERNATIONAL EMERGENCY
CARE When coordinated through
the Plan Administrator |
| Emergency Medical Evacuation |
$50,000 Lifetime Maximum |
| Emergency Reunion |
$15,000 |
| Return of Mortal Remains |
$25,000 |
| Political Evacuation |
Up to $10,000 |
| ADDITIONAL BENEFITS |
| Accidental Death |
$25,000 |
| Dismemberment |
$25,000 two limbs; $12,500 one limb |
| Terrorism Coverage |
Up to $50,000 Lifetime Maximum |
Sudden Recurrence of a Pre- existing
Condition (U.S. citizens) |
| Medical |
Up to $5,000 of eligible expenses |
| Emergency Medical Evacuation |
Up to $25,000 of eligible costs and expenses |
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Pre-existing Conditions
(For U.S. Citizens, this benefit will begin when the Sudden Recurrence benefit is exhaused.)
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$500 per year; $50,000 lifetime maximum - after 12 months of continuous coverage |
Incidental Home Country Coverage
|
Up to a cumulative two weeks |
| OPTIONAL ADD-ON PLAN |
| Baggage |
| Loss/theft of Baggage |
$250 |
| Loss/theft of Valuables |
$250 |
| Loss/theft of Personal Papers |
$250 |
| Legal Assistance |
| Binder Fee |
$500 when served with summons |
| Personal Liability |
| Injury to third party |
$2,000 limit after $100 deductible |
| Damage to third person property |
$500 limit after $100 deductible. Secondary to any other
insurance in force |
| Limited High School Sports Coverage |
URC* |
| OPTIONAL RIDER |
| Applies to all
individuals listed on the Application Form |
Adventure Sports Rider
(available to insured up to age 65 - apply 1.20 rate factor)
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Age Lifetime Maximum
0 - 49 $50,000
50 - 49 $30,000
60 - 64 $15,000
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Exclusions:
Charges for the following services, treatments and/or conditions, among others, are excluded from coverage under the Patriot Exchange Program 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: 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.
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