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LIAISON® International
Medical Insurance That Covers You
Outside Your Home Country
Brochure
and Application for the year 2005
5 DAYS TO
12 MONTHS (Renewable up to 3 years) OF COVERAGE FOR:
·
NON-CITIZENS
VISITING THE UNITED STATES.
·
UNITED
STATES CITIZENS TRAVELING OVERSEAS.
·
INTERNATIONAL
TRAVELERS REQUIRING CONTINUING COVERAGE
SCHEDULE OF COVERAGE
|
All
coverage’s and plan costs listed in this brochure are in U.S. Dollar amounts. |
|
|
Medical Maximum |
$50,000;
$100,000; $500,000; $1,000,000 (ages
80+, maximum limited to $15,000) |
|
Deductible: |
$0;
$100; $250; $500; $1000; $2500
Deductible is per person per policy period, maximum of 3 Policy Period
deductibles per family. The selected Deductible and Coinsurance amount must
be met for each 12-month period (see Continuing Coverage) |
|
Coinsurance: |
Inside the Outside the |
|
Hospital Indemnity: |
$100 /
night (traveling outside the |
|
Dental (Emergency): |
$100
(or $500 for accidents) Only available
to programs purchased for 1 month or more. |
|
Emergency Medical Evacuation/
Repatriation: |
$100,000
(in addition to the Medical Maximum) |
|
Home Country Coverage |
Incidental
Trips to The Home Country: $50,000 Follow
Me Home Coverage: $5,000 |
|
Return of Mortal Remains: |
$20,000 |
|
Emergency |
$10,000 |
|
Return of Minor Child(ren): |
$5,000 |
|
Interruption of Trip: |
$5,000 |
|
Loss of Checked Luggage: |
$250 |
|
Local Ambulance Expense: |
$2,500 |
|
Accidental Death &
Dismemberment (AD&D): |
$25,000
Principal Sum for Insured or Insured Spouse, $5,000 for Dependent Child. |
|
Common Carrier Accidental Death |
$50,000
per adult, $25,000 per children under age of 18; $250,000 Maximum per family |
|
Hospital Room & Board: |
Usual,
reasonable and customary to the selected Policy Maximum |
|
Intensive Care: |
Usual,
reasonable and customary to the selected Policy Maximum |
|
Outpatient Medical Expenses: |
Usual,
reasonable and customary to the selected Policy Maximum |
|
Terrorism |
Usual,
reasonable and customary to the selected Policy Maximum (not
covered in NY, OR, KS) |
|
Waiver of Pre-Existing Conditions: |
Up to
$15,000 for |
|
Benefit Period: |
Six
months |
WHY INTERNATIONAL MEDICAL INSURANCE?
Each year, millions of people travel outside of their Home
Country, beyond the boundaries of their medical insurance. If you are concerned
with the potential out-of-pocket expenses that could result from an injury or
illness while traveling, Liaisonâ International offers medical coverage
and emergency services to individuals and families traveling outside their Home
Country. This brochure is a brief description of Liaisonâ International. For a
full description, please visit our website at www.SpecialtyRisk.com. Once you
are approved for coverage a complete Program Summary will be mailed to you.
ELIGIBILITY
Liaisonâ International provides coverage as
outlined in this brochure for individuals and families (including unmarried
dependent children over 14 days and under 19 years of age) while traveling outside
of their home country.
Home
Country is defined as - The country where an insured person(s) has his/her
true, fixed and permanent home and principal establishment.
PERIOD OF COVERAGE
The
minimum period of coverage under Liaisonâ International is 5 days,
maximum is 12 months (see Continuing Coverage section). Coverage can be
purchased in a combination of monthly and/or daily periods by paying the
appropriate plan cost. If you are traveling for a long period of time, please
refer to "Continuing Coverage" section.
Effective Date
Your coverage will begin on the latest of the following: 1)
The moment you depart your Home Country; or 2) The date and time the
Application and full plan cost is received and accepted by SRI; or 3) The date
requested on the Application.
Expiration Date
Coverage will end on the earlier of the following: 1) Your
return to your Home Country *; or 2) The date shown on the ID Card, for which
plan cost has been paid; 3) The date you
are no longer eligible under this plan *See Home Country Coverage Section.
DESCRIPTION OF COVERAGE
Medical
When you
incur a covered Injury or Illness, the program will pay Usual, Reasonable and
Customary medical charges for Covered Expenses, excess of the chosen Deductible
and Coinsurance, up to the selected Policy Maximum. Only such expenses, incurred as the result of
a disablement, which are specifically enumerated in the following list of
charges, are incurred within six months from the onset of an Injury or Illness,
and which are not excluded in the Exclusions, shall be considered as Covered
Expenses:
1. Charges made by a Hospital for room and
board, floor nursing and other services inclusive of charges for professional
service and (with the exception of personal services of a non-medical nature);
charges made for an operating room.
2. Charges made for Intensive Care or Coronary
Care charges and nursing services.
3. Charges made for diagnosis, treatment and
Surgery by a Physician; charges made for the cost and administration of
anesthetics.
4. Charges made for Outpatient treatment, same
as any other treatment covered on an Inpatient basis. This includes ambulatory Surgical centers,
Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion
consultations.
5. Charges for medication, x-ray services,
laboratory tests and services, the use of radium and radioactive isotopes,
oxygen, blood transfusions, iron lungs, and medical treatment; dressings, drugs, and medicines that can only
be obtained upon a written prescription of a Physician or Surgeon.
6. Charges for physiotherapy, if recommended by
a Physician for the treatment of a specific Disablement and administered by a
licensed physiotherapist.
7. Ground ambulance (within the metropolitan
area) to and from the nearest Hospital with facilities for required
treatment. If the Insured Person is in a
rural area, then licensed air
ground ambulance transportation to the nearest metropolitan area shall
be considered a Covered Expense.
8. Hotel room charge, when the
Insured Person, otherwise necessarily confined in a Hospital, shall be under
the care of a duly qualified Physician in a hotel room owing to unavailability
of a Hospital room by reason of capacity or distance or to any other
circumstances beyond control of the Insured Person.
9. Charges made for artificial
limbs, eyes, larynx, and orthotic appliances, but not for replacement of such
items.
Dental - Emergency Only - The Emergency
Dental Benefit is available to you provided you have purchased 1 or more months
of coverage . Treatment necessary to
resolve acute, spontaneous and unexpected inception of pain to sound natural
teeth ($100) or Dental treatment necessary to restore or replace sound natural
teeth lost or damaged in an Accident which is covered under the program ($500).
This benefit is subject to the
Deductible and Coinsurance.
Emergency Medical
Evacuation/Repatriation - The program will pay Covered Expenses incurred if any covered Injury
or Illness commences during the Period of Coverage that results in the
Medically Necessary Emergency Medical Evacuation or Repatriation (your medical
condition warrants immediate transportation from the medical facility where you
are located to the nearest adequate medical facility where medical treatment
can be obtained). The benefit must be
ordered by the Assistance Company in consultation with the local attending
Physician.*
Return of Mortal Remains - The Program will pay the reasonable
Covered Expenses incurred up to a maximum of $20,000 to return your remains to
your Home Country, if you should die.*
Emergency Medical Reunion - When Emergency Medical Evacuation or
Repatriation is ordered and the attending Physician recommends that a family
member travel with you, the program will arrange and pay, up to $10,000, for a
round trip economy-class transportation for one individual of your choice, from
your Home Country, to be at your side while you are hospitalized and then
accompany you during your return to your Home Country.
Return of Minor Child(ren) - Should you be traveling alone with a
Minor Child(ren) and is hospitalized because of a covered Illness or Injury and
the Minor Child(ren), under age 19, is left unattended, the program will
arrange and pay up to $5,000 for one way economy fare to their Home Country
(including the cost of an attendant/escort, if necessary to insure the safety
and welfare of a Minor Child(ren)).*
Hospital Indemnity – If you are hospitalized while
traveling outside of the
Interruption of Trip - If you are unable to continue the Trip due to the
death of an Immediate Family member (parent, spouse, sibling or child) or due
to serious damage to your principal residence from fire, flood or similar
natural disaster (tornado, earthquake, hurricane, etc.). The program will reimburse you (up to $5,000)
for the cost of economy travel, less the value of applied credit from an unused
return travel ticket, to return you home to your area of principal residence. *
Loss of Checked Luggage - If your checked luggage is permanently lost by the
airline, the program will reimburse you for the replacement of clothing and
personal hygiene items lost to a maximum per bag limit of $50 (up to
$250). This benefit is secondary to any
other (including airline) coverage available.
You must furnish proof to the Company that full reimbursement has been
obtained from the airline. *
Assistance Services - Upon enrollment into Liaisonâ International, you are eligible to
use any of the assistance services provided by the Assistance Services
Provider. Additional information is
contained in the Program Summary. Open
24 hours / day, 365 days a year • Multilingual
personnel • Physicians / Nurses on
staff • Locate local
facilities • Help with emergency
situations.
Home Country Coverage – Incidental Trips to Your Home Country: This benefit covers you for incidental trips
to your Home Country (60 days per 12 months of purchased coverage or pro rata
thereof - example: approximately 5 days per month of purchased coverage). Maximum benefit is reduced to $50,000 for any
illness or injury occurring while on an incidental trip to your Home
Country. Follow Me Home Coverage: This plan shall pay for Covered Expenses
incurred in your Home Country up to $5,000 for conditions first diagnosed
outside Your Home Country (Does not apply for Emergency Evacuation or Repatriation).
* NOTE:
In the event of an Emergency Medical Evacuation, Repatriation, Return of Mortal
Remains, Emergency Reunion, Return of Minor Child(ren), Interruption of Trip,
Loss of Checked Luggage benefit is needed or utilized, arrangements must be
made by the Assistance Service Provider.
Complete details about the benefits and about the required notification
of the Assistance Service Provider are contained in the Program Summary.
OPTIONS
Continuing
Coverage
For those
who are intending longer international trips, an option is available to you. If
you choose this option on the application and enroll for at least three (3)
months of coverage, a notice will be sent to your address of correspondence,
allowing you to purchase an additional period of coverage (minimum of 1 month,
maximum of 12 months). If you purchase at least three months of coverage, SRI
will continue to send notices to your address of correspondence. If you choose
to purchase less than three months of coverage, SRI will assume that your
international trip is complete and will not send any further notices.
While a
new period of coverage will be issued, your original effective date will be
used with regards to calculating your deductible and coinsurance (for up to a
total of 12 months, then both will begin again), as well as determining any
pre-existing conditions. Since SRI's Benefit Period states that the program
will pay up to a total of 6 months for any one eligible condition, you can be
protected beyond your period of coverage.
The
maximum period of time SRI will offer this feature is three years (one year for
persons age 65 and over). It is important to note that rates and benefits may
change for each subsequent period of coverage. A $5.00 Administrative Fee will
be included on each notice. This option is not available if you allow coverage
to expire prior to reapplying. If this happens, an entirely new program must be
purchased (preexisting condition begins again).
Continuing
Coverage is available in periods as short as 5 days at a time when purchased
using SRI’s online system.
Hazardous Sport Coverage - To cover motorcycle/motor scooter
riding, mountaineering (4500 meter limit), hang gliding, parachuting, bungee
jumping, water skiing, snow skiing, snowmobiling, and snow boarding.
PRENOTIFICATION / REFERRAL
In order to ensure your claims are addressed as efficiently as
possible, you or the provider of service must contact the Assistance Company
for prenotification prior to any medical treatment in the US, as well as
hospital admissions and inpatient / outpatient surgeries incurred worldwide.
The Assistance Company has trained personnel available 24 hours a day, 7 days a
week throughout the year to answer your questions, provide assistance, and
guide you to an appropriate facility if necessary. In the case of an Emergency
Admission, the Assistance Company must be contacted within 48 hours, or as soon
as reasonably possible. Prenotification does not guarantee that benefits will
be paid. Failure to prenotify will result in a 20% reduction in Eligible
Benefits.
Please be aware that this is not a
general health insurance policy, but an interim, limited benefit period, travel
medical program intended for use while away from your Home Country. Liaisonâ International does
not guarantee payment to a facility or individual for medical expenses until
SRI determines that it is an eligible expense.
REFUND OF PREMIUM
SRI realizes that there is
uncertainty in international travel.
Refund of total plan cost will only be considered if written request is
received by SRI prior to the Effective Date of Coverage. If written request is received after the
Effective Date of coverage, the unused portion of the plan cost may be refunded
minus a cancellation fee, provided no claim has been submitted to SRI for
reimbursement.
CLAIM SUBMISSION
Filing a
claim with SRI is easy. You will receive
a Liaisonâ International identification card
and claim form once you are approved for insurance. When you receive treatment, send the
original, itemized bills to SRI within 90 days.
Eligible bills are automatically converted from local currencies to US
dollars. For payments of eligible
medical expenses, notify SRI of pending treatments and we can refer you to
approved health care providers worldwide.
You're only responsible for your deductible, coinsurance amounts and
non-eligible expenses. For more details,
consult the Program Summary that is provided with your insurance kit, or
contact the SRI Claim Department.
EXCLUSIONS
For
Medical benefits, this Insurance does not cover:
1. Any Injury or Illness which meets
the following criteria: a) condition(s)
that would have caused a person to seek medical advise, diagnosis, care or
treatment during the 36 months prior to the Effective Date of coverage under
this Policy; b) condition(s) for which
manifestation, medical advise, diagnosis, care or treatment was recommended,
received, or noticed during the 36 months prior to the Effective Date of
coverage under this Policy;
If you are traveling outside the
If you are a
2. Charges for treatment which exceed
Reasonable and Customary charges; or Charges incurred for Surgeries or
treatments which are Investigational, Experimental, or for research purposes;
expenses which are non-medical in nature; expenses for Vocational, Speech,
Recreational or Music Therapy.
3. Expenses which were not recommended, approved
and certified as Medically Necessary and reasonable by a Physician.
4. Suicide or any attempt there at, while sane
or self destruction or any attempt there at, while insane; intentionally
self-inflicted Injury or Illness; or expenses as a result or in connection with
the commission of a felony offense.
5. Any consequence, whether directly or
indirectly, proximately or remotely occasioned by, contributed to by, or
traceable to, or arising in connection with war, invasion, act of foreign enemy
hostilities, warlike operations (whether war be declared or not), or civil war.
6. Injury sustained while participating in
professional, sponsored and/or organized Amateur or Interscholastic Athletics.
7. Routine physicals, inoculations, or other
examinations where there are no objective indications or impairment in normal
health.
8. Treatment of the Temporomandibular joint.
9. Services or supplies performed or provided by
a Relative of yours, or anyone who lives with you.
10. Treatment and the provision of false teeth or
dentures, normal ear tests and the provision of hearing aids, cosmetic or
plastic Surgery (including deviated nasal septum), routine dental expenses, eye
care or eye related expenses, unless caused by Accidental bodily Injury
incurred while insured hereunder.
11. Treatment in connection with alcoholism and
drug addiction, or use of any drug or narcotic agent; any Mental and Nervous
disorders or rest cures; Injury sustained while under the influence of or
Disablement due to wholly or partly to the effects of intoxicating liquor or
drugs.
12. Congenital abnormalities and conditions
arising out of or resulting therefrom.
13. Expenses incurred during a hospital emergency
room visit which is not of an emergency nature.
14. Injury sustained while taking part in
mountaineering where ropes or guides are normally used, hang gliding,
parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle,
snowmobiling, motorcycle / motor scooter riding, scuba diving involving
underwater breathing apparatus (unless PADI or NAUI certified), water skiing,
snow skiing and snow boarding. *
15. Treatment paid for or furnished under any
other individual, government, or group policy or charges provided at no cost to
you.
16. Treatment of venereal or sexually transmitted
disease.
17. Pregnancy expenses or Illness resulting from
pregnancy, childbirth, or miscarriage; or for miscarriage resulting from an
Accident.
18. Drug, treatment or procedure that either
promotes or prevents conception, or prevents childbirth.
19. Expenses incurred while you are in your Home
Country (except as provided under the Home Country Coverage benefit).
20. Expenses incurred for which travel was
undertaken to seek medical treatment for a condition; or incurred after the
Insured Person’s physician has limited or restricted travel.
* Options are available to include all or part of these risks.
SRI
ASSIST
SRI Assist is a leading
provider of customized emergency assistance services to international
organizations, corporations, government entities, insurance companies, and
individual travelers. Regardless of the
location, SRI Assist provides valuable assistance in locating the best possible
medical treatment.
THE
INSURANCE COMPANY
Liaison International is
underwritten by Virginia Surety Company, Inc., rated A- “Excellent” by A.M.
Best and located in
THE
PROGRAM ADMINISTRATOR
Properly serving the needs
of the international traveler requires an understanding of the world in which
we live. Medical care is different
throughout the world and providing quality medical attention should be the ultimate
goal of any program. Most companies are
not prepared to meet the unique needs of these customers. An organization must
be equipped to address foreign currencies, international doctors and hospitals,
as well as unusual claim forms and documents. Liaison International is designed
and administered by Specialty Risk International, Inc (SRI). The claim and assistance professionals at SRI
have over 150 years of experience in claim processing and administration.
SPECIALTY
RISK INTERNATIONAL
Since 1993, Specialty Risk
International, Inc. (SRI) has provided international insurance plans to private
citizens, governments, missionaries, students, and corporations of various
nations around the globe. Each year,
thousands of insureds purchase coverage from SRI in order to obtain the most comprehensive
and reliable products in the international insurance industry.
SRI is an independent
underwriter and administrator, we are not owned by any insurance company or
other corporate organization. Thus, our
objective is to secure the best coverage and security for our insureds.
Our assistance professionals
are experienced in the complexity and importance of receiving medical care
internationally. As an insured of SRI,
you can feel confident that there is someone ready to assist you with a medical
situation 24 hours a day, 365 days a year.
INFORMATION
This
Insurance, under Policy HTP01158B is underwritten by: Virginia Surety Company,
Inc.
Policy
terms and conditions are briefly outlined in this brochure.
Complete
provisions pertaining to this insurance are contained in the Master Policy on
file with the trustee, American Consumer Insurance Trust, and Liaison
International. In the event of any conflict between this brochure and the
Master Policy, the Policy will govern. A Program Summary, listing more detailed
exclusions, will be mailed to you along with Your ID Card once coverage is
purchased.
Notice to
ENROLLING IN LIAISON®
INTERNATIONAL
1. Complete the entire Liaisonâ International Application. Payment for the entire period of coverage is
due at the time of application.
2. If paying by check or money order, make
payable to: “SRI” and enclose it
together with completed Application.
3. If paying by credit card, complete the
Application and mail or fax to ISA. Be
sure to sign the Method of Payment section.
4. Read the brochure and sign the application.
|
Return the Application with your
payment for the total premium to: Good Neighbor Insurance 620 S Fax 480-813-9930 (You may fax if paying by credit
card only. Originals are not required if application is faxed to SRI with
credit card payment.) |
MONTHLY AND DAILY RATES
Rates
based on a $250 Deductible
Effective
until December 31, 2005
|
Traveling to the (If the
applicant is traveling to, temporarily residing in, or visiting the |
Traveling Outside the (If the
applicant is traveling outside the |
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|
Policy Maximum Options |
|
Policy Maximum Options |
||||||
|
Age |
$50,000 |
$100,000 |
$500,000 |
$1,000,000 |
Age |
$50,000 |
$100,000 |
$500,000 |
$1,000,000 |
|
|
Monthly / Daily |
Monthly / Daily |
Monthly / Daily |
Monthly / Daily |
|
Monthly / Daily |
Monthly / Daily |
Monthly / Daily |
Monthly / Daily |
|
19 to
29 |
$48/1.60 |
$56/$1.87 |
$76/$2.53 |
$85/$2.83 |
19 to
29 |
$32/$1.07 |
$38/$1.26 |
$42/$1.41 |
$47/$1.57 |
|
30 to
39 |
$63/$2.10 |
$74/$2.47 |
$99/$3.30 |
$110/$3.67 |
30 to
39 |
$38/$1.26 |
$44/$1.45 |
$56/$1.86 |
$64/$2.12 |
|
40 to
49 |
$95/$3.17 |
$106/$3.53 |
$145/$4.83 |
$160/$5.33 |
40 to
49 |
$61/$2.02 |
$68/$2.28 |
$73/$2.43 |
$81/$2.69 |
|
50 to
59 |
$134/$4.47 |
$163/$5.43 |
$195/$6.50 |
$230/$7.67 |
50 to
59 |
$100/$3.33 |
$114/$3.80 |
$122/$4.05 |
$129/$4.30 |
|
60 to
64 |
$160/$5.33 |
$201/$6.70 |
$249/$8.30 |
$285/$9.50 |
60 to
64 |
$114/$3.80 |
$136/$4.53 |
$149/$4.95 |
$168/$5.59 |
|
65 to
69 |
$205/$6.83 |
$241/$8.03 |
$298/$9.93 |
$320/$10.67 |
65 to
69 |
$133/$4.44 |
$145/$4.85 |
$153/$5.10 |
$174/$5.79 |
|
70 to
79 |
$258/$8.60 |
N/A |
N/A |
N/A |
70 to
79 |
$199/$6.62 |
$280/$9.34 |
N/A |
N/A |
|
80 plus * |
$449/$14.97 |
N/A |
N/A |
N/A |
80 plus * |
$333/$11.09 |
N/A |
N/A |
N/A |
|
Each Dep. Child |
$28/$0.93 |
$32/$1.07 |
$42/$1.40 |
$45/$1.50 |
Each Dep. Child |
$20/$0.67 |
$25/$0.83 |
$27/$.90 |
$30/$1.01 |
|
Each Child Alone |
$46/$1.53 |
$54/$1.80 |
$68/$2.27 |
$76/$2.53 |
Each Child Alone | ||||