Medical Insurance That Covers You Outside Your Home Country
Brochure and Application for the year 2002
15 DAYS TO 3 YEARS OF COVERAGE FOR:
All coverages and plan costs listed in this brochure are in U.S. dollar amounts
|Policy 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)|
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
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 US 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|
|Return of Mortal Remains:||$20,000|
|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:||$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 Expense:||Usual, reasonable and customary to the selected Policy Maximum.|
|Unexpected Recurrence:||Up to $1000 for those traveling outside the United States and Canada (see exclusion #1).|
|Benefit Period:||Six months|
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. Liaison International offers medical coverage and emergency services to individuals and families traveling outside their Home Countries. This brochure is a brief description of Liaison International. For a full description, see the Program Summary, which will be mailed to you once you are approved for coverage.
Liaison 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.
The minimum period of coverage under Liaison International is 15 days, maximum is 12 months (see Continuing Coverage section). Coverage can be purchased in a combination of monthly and 15 day periods by paying the appropriate plan cost. If you are traveling for a long period of time, please refer to "Continuing Coverage" section.
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
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:
- Emergency Only
The Emergency Dental Benefit is only 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
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 Persons 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 Persons 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 the Minor Child(ren)). *
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).
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 the Insured (up to $5,000) 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.*
Upon enrollment into Liaison International, you are eligible to use any of the assistance services provided by the Assistance Service Provider. Additional information is contained in the Program Summary.
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 that 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.
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 continue with 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 they 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 option 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).
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. Liaison International does not guarantee payment to a facility or individual for medical expenses until SRI determines that it is an eligible expense.
OF PLAN COSTS
Refund of plan costs 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 nonrefundable.
Filing a claim with SRI is easy. You will receive a Liaison 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 payment 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.
For Medical benefits, this Insurance does not cover:
* Options are available to include all or part of these risks.
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.
This Insurance, under Policy HTP01158 is underwritten by: Virginia Surety Company, Inc. Executive Offices: 1000 Milwaukee Avenue, Glenview, IL 60025.
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.
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Liaison® is a registered
Trademark of Specialty Risk International, Inc.
In Florida, Florida Resident - Agent No. A10702