7 DAYS TO 3 YEARS OF COVERAGE FOR:
 |
NON-CITIZENS
VISITING THE UNITED STATES
|
|
UNITED STATES
CITIZENS TRAVELING OVERSEAS.
|
|
INTERNATIONAL
TRAVELERS REQUIRING CONTINUING 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: |
$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 United States and Canada: After the Insured pays
the deductible, the program pays 80% of the next $5,000 of eligible
expenses, then 100% to the selected Maximum.
Outside the
United States and Canada:
After the Insured pays the deductible, the program pays 100% to the
selected Maximum. |
|
Hospital Indemnity: |
$100 / night (traveling outside the U.S. and Canada) In addition to any
other Covered Expense. |
|
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) |
|
Return of Mortal Remains: |
$20,000 |
|
Emergency
Reunion: |
$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. |
|
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 |
|
Waiver of Pre-Existing
Conditions: |
Up
to $15,000 for
U.S.
citizens traveling outside the United States and Canada (refer to
exclusion #1 for details) |
|
Benefit Period: |
Six months |
SCHEDULE
OF COVERAGE
WHY
INTERNATIONAL MEDICAL INSURANCE?
Each year, millions of people travel outside of their Home
Countries, beyond the boundaries of their medical insurance. They're concerned
with the potential out-of-pocket expenses that could result from an injury or
sickness abroad. Liaisonâ International
offers medical coverage and emergency services to individuals and families
traveling outside their Home Countries. This brochure is a brief description
of Liaisonâ International. For a full description, see the Program Summary,
which will be mailed to you once you are approved for coverage.
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 7 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)
Moment of departure from 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) The arrival
of the Insured Person back in their Home Country *; or 2) The date shown
on the ID Card, for which plan cost has been paid; *See Home Country
Coverage Section.
DESCRIPTION
OF COVERAGE
Medical
When the Insured
incurs 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
|
|
7.
|
Charges for
physiotherapy, if recommended by a Physician for the treatment
of a specific Disablement and administered by a licensed physiotherapist
|
|
8.
|
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 ground ambulance transportation
to the nearest metropolitan area shall be considered a Covered
Expense
|
Dental
- Emergency Only - The Emergency Dental Benefit is available to programs
purchased for 1 month or more. Treatment necessary to resolve
acute, spontaneous and unexpected inception of pain to 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 commencing during the Period of Coverage results in the Medically
Necessary Emergency Medical Evacuation or Repatriation of the Insured
Person (the Insured Person's medical condition warrants immediate transportation
from the medical facility where the Insured Person is 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 Insured Person’s 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 the Insured Person's remains to his/her Home Country,
if he or she dies.*
Emergency
Medical Reunion - When
Emergency Medical Evacuation or Repatriation is ordered and the attending
Physician recommends that a family member travel with the Insured, the
program will arrange and pay, up to $10,000, for round trip economy-class
transportation for one individual selected by the Insured Person, from
the Insured Person’s Home Country to the location where the Insured
Person is hospitalized and return to the Home Country.
Return
of Minor Child(ren) - Should
the Insured Person 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 United States
or Canada, and the hospitalization is considered a Covered Expense,
the program will indemnify the Insured $100 for each night spent in
the hospital (this benefit is in addition to any other covered expenses
of the program).
Interruption
of Trip - If the Insured
is 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
the Insured’s principal residence from fire, flood or similar natural
disaster (tornado, earthquake, hurricane, etc.). The program will
reimburse (up to $5,000) the Insured for the cost of economy travel,
less the value of applied credit from an unused return travel ticket,
to return home to their area of principal residence. *
Loss
of Checked Luggage -
If the Insured's checked luggage is permanently lost by the airline,
the program will reimburse the Insured 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. The Insured 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
- 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). Maximum benefit is reduced to
$50,000 while in your Home Country. Coverage will be limited 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 in at least three (3) months,
a notice will be sent to your address of correspondence, allowing you
to purchase another period of coverage (minimum of 1 month, maximum
of 12 months). If you purchase at least an additional three months,
SRI will continue to send notices to your address of correspondence.
If you choose to purchase less than three months, 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 70 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 7 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,
the Insured 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 PLAN COST
Refund of plan cost
will be considered only if written request is received by SRI prior
to the Effective Date of Coverage. After the Effective Date of
Coverage, the plan cost is considered fully earned and non-refundable.
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
For Insured Persons traveling outside the United
States and Canada, the period is 12 months instead of 36 months
If the Insured Person is a United
States citizen, this exclusion is waived for the first $15,000
in eligible medical expenses incurred outside the United States
and Canada (for persons age 65 and over, the amount is $2500).
This waiver does not include coverage for known, scheduled, required,
or expected medical care, drugs, or treatments existent or necessary
prior to the effective date of this program
|
|
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 the Insured Person,
or anyone who lives with the Insured Person
|
|
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 the Insured
Person.
|
|
16.
|
Treatment of
venereal or sexually transmitted disease
|
|
17.
|
Pregnancy expenses
or Illness resulting from pregnancy, childbirth, or miscarriage;
or for miscarriage resulting from Accident
|
|
18.
|
Drug, treatment
or procedure that either promotes or prevents conception, or prevents
childbirth
|
|
19.
|
Expenses incurred
while the Insured Person is in their Home Country (except after
approved Emergency Evacuation / Repatriation or if treatment is
a follow-up to a covered disablement during coverage or if the
expenses pertain to 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 |
ABOUT
SRI
Since 1993, Specialty
Risk International has provided medical insurance to corporations, international
travelers, expatriates, students, overseas visitors, immigrants and
global citizens. With expertise and efficiency we’ve served clients
in more than a hundred countries.
INFORMATION
This
Insurance, under Policy HTP01158 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 Florida residents: the benefits of this policy providing Your coverage
are governed by the law of a state other than Florida. Your Homeowners
policy, if any, may provide coverage for loss of personal effects provided
by the Loss of Checked Luggage coverage. This insurance is not required
in connection with the purchase of Your travel arrangements.
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 SRI.
Be sure to sign the Method of Payment section |
|
4.
|
Read the brochure
and sign the application |
MONTHLY
AND DAILY RATES
Rates based
on a $250 Deductible
Effective until December 31, 2004
|
Traveling
to the United States
(If the applicant
is traveling to, temporarily residing in, or visiting the United
States, please use these rates.
|
|
|
Policy
Maximum Options
|
|
Age
|
$50,000
|
$100,000
|
$500,000
|
$1,000,000
|
|
|
Monthly / Daily
|
Monthly / Daily
|
Monthly / Daily
|
Monthly / Daily
|
|
19
to 29
|
$51/$1.70
|
$60/$2.00
|
$76/$2.53
|
$85/$2.83
|
|
30
to 39
|
$66/$2.20
|
$78/$2.60
|
$99/$3.30
|
$110/$3.67
|
|
40
to 49
|
$97/$3.23
|
$110/$3.67
|
$145/$4.83
|
$160/$5.33
|
|
50
to 59
|
$134/$4.47
|
$163/$5.43
|
$195/$6.50
|
$230/$7.67
|
|
60
to 64
|
$160/$5.33
|
$199/$6.63
|
$249/$8.30
|
$285/$9.50
|
|
65
to 69
|
$201/$6.70
|
$239/$7.97
|
$298/$9.93
|
$320/$10.67
|
|
70
to 79
|
$255/$8.50
|
N/A
|
N/A
|
N/A
|
|
80
plus *
|
$425/$14.17
|
N/A
|
N/A
|
N/A
|
|
Each Dep. Child
|
$28/$0.93
|
$32/$1.07
|
$42/$1.40
|
$45/$1.50
|
|
Each Child Alone
|
$46/$1.53
|
$54/$1.80
|
$68/$2.27
|
$76/$2.53
|
|
*
Ages 80+ limited to $15,000. Dep. Child rate is applicable
when at least one parent will also be covered under Liaison International.
Child Alone rate is used when a child will be insured by themselves.
|
|
Traveling Outside the U.S.
(If the applicant
is traveling outside the United States, use these rates.
This includes US citizens traveling overseas as well as persons
traveling between countries. ie. a Brazilian traveling to
Spain
|
|
|
Policy
Maximum Options
|
|
Age
|
$50,000
|
$100,000
|
$500,000
|
$1,000,000
|
|
|
Monthly / Daily
|
Monthly / Daily
|
Monthly / Daily
|
Monthly / Daily
|
|
19
to 29
|
$34/$1.13
|
$40/$1.33
|
$47/$1.57
|
$55/$1.83
|
|
30
to 39
|
$40/$1.33
|
$46/$1.53
|
$62/$2.07
|
$74/$2.47
|
|
40
to 49
|
$64/$2.13
|
$72/$2.40
|
$81/$2.70
|
$94/$3.13
|
|
50
to 59
|
$105/$3.50
|
$120/$4.00
|
$135/$4.50
|
$150/$5.00
|
|
60
to 64
|
$120/$4.00
|
$143/$4.77
|
$165/$5.50
|
$195/$6.50
|
|
65
to 69
|
$140/$4.67
|
$153/$5.10
|
$170/$5.67
|
$202/$6.73
|
|
70
to 79
|
$209/$6.97
|
$295/$9.83
|
N/A
|
N/A
|
|
80
plus *
|
$350/$11.67
|
N/A
|
N/A
|
N/A
|
|
Each Dep. Child
|
$21/$0.70
|
$26/$0.87
|
$30/$1.00
|
$35/$1.17
|
|
Each Child Alone
|
$34/$1.13
|
$38/$1.27
|
$44/$1.47
|
$50/$1.67
|
|
*
Ages 80+ limited to $15,000. Dep. Child rate is applicable
when at least one parent will also be covered under Liaison International.
Child Alone rate is used when a child will be insured by themselves.
|
Premium:
35-year-old U.S.
citizen traveling to Spain, from March 15th to April 19th
Example:
$250 deductible and $50,000 maximum
March 15th
through April 14th equals 1 month (calendar month) -
$40.00
April 15th
through April 19th equals 5 days $1.33 x 5 - $
6.65
Total Premium Submitted = $46.65
