If accidental injury or emergency illness occurs during the Period of Coverage, the program will pay reasonable and customary charges for Covered Expenses resulting from such occurrence, up to the Medical Expense maximum selected ($200,000 for Global Learning Semesters students).
Only those expenses specifically described (see Covered Expenses) which are incurred within the Maximum Benefit Period (the first expense must be incurred by an insured within 30 days after the date of the accident or commencement of the sickness, and all expenses must be incurred by the insured person within 52 weeks from the date of the accident or commencement of the sickness) and which are not excluded (see exclusions) are considered Covered Expenses.
The Insured Person must remain continuously insured under the Policy for the duration of the treatment.
The charges enumerated herein shall in no event include any amount of such charges which are in excess of Reasonable and Customary charges. If the charge incurred is in excess of such average charge such excess amount shall not be recognized as a Covered Expense.
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; provided, however, that expenses do not exceed the hospital's average charge for a semi-private room and board accommodation
2. Charges made for Intensive Care of Coronary Care charges and nursing services
3. Charges made for diagnosis, treatment and surgery by a Physician
4. Charges made for an operating room
5. Charges made for Outpatient treatment, same as any other treatment covered on an Inpatient basis. This includes ambulatory surgical centers, Physician's Outpatient visits/examinations, clinic care, and surgical opinion consultations
6. Charges made for the cost and administration of anesthetics
7. Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood, transfusions, and medical treatment
8. Charges for physiotherapy, if recommended by a physician, for the treatment of a specific disablement and administered by a licensed physiotherapist
9. Dressings, drugs and medicines that can only be obtained upon the written prescription of a Physician or Surgeon
10. Charges made for artificial limps, eyes, larynx, and orthotic appliances, but not for replacement of such items
11. Local transportation to or from the nearest Hospital or to and from the nearest Hospital with facilities for required treatment. Such transportation shall be by licensed ground ambulance only, within the metropolitan area in which the insured person is located at at the time the service is used. If the insured person is in a rural area, then qualified licensed ground ambulance transportation to the nearest metropolitan area shall be considered a covered expense
12. Nervous or Mental Disorders: are payable, a) up to $2,500 for outpatient treatment or b) up to $5.000 on an inpatient basis. The company shall not be liable for more than one such inpatient or outpatient occurence per lifetime under the policy with respect to anyone insured
13.Chiropractic care and Therapeutic Services shall be limited to a total of $50 per visit, excluding x-ray and evaluation charges, with a maximum of 10 visits per injury or illness. The overall maximum coverage per injury or illness is $500 which includes x-ray and evaluation charges.
14. With respect to Accidental Dental, an eligible dental condition shall mean emergency dental repair or replacement to sound, natural teeth damaged as a result of a covered accident.
15. With respect to Palliative Dental, an eligible Dental condition shall mean emergency pain relief treatment to natural teeth ur to $500 ($250 maximum per tooth)
Not Covered Expenses
For all benefits listed in the Schedule of Benefits , this Insurance does not cover:
1. Pre-Existing Conditions, defined as any Condition for which a licensed Physician was consulted or for which treatment or medication was prescribed , or for which manifestations of symptoms would have caused a person to seek medical advice prior to the Effective Date of coverage under the Policy, except as specified:
a) If the Insured Person does not receive medical care or services , including prescription drugs or other medical supplies, and is not under the care of a Physician with respect to the Pre-Existing Condition or related condition(s), for a period of 12 consecutive months beginning on or after the first day of coverage, the preexisting condition exclusion will no longer apply and any eligible charges incurred after the treatment free period will be considered for reimbursement or
b) If the Injured is covered under the Policy for 12 consecutive months, the Pre-Existing Condition exclusion will no longer apply and any eligible expenses incurred thereafter will be considered for reimbursement or
c) Emergency Medical Evacuation and Repatriation/ Return of Mortal Remains
Note: This Policy does pay benefits to a maximum of $2,500 for loss due to Pre-Existing Condition,
2. Injury or illness which is not presented to the Company for payment within 12 months of receiving treatment
3. Charges for treatment which is not Medically Necessary
4. Charges for treatment which exceed Reasonable and Customary charges.
5. Charges incurred for Surgery or treatments which are Experimental/Investicational or for research purposes
6. Services, supplies or treatment including any period of Hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician.
7. A declared or undeclared war or any act thereof
8. Injury sustained while participating in professional athletics
9. Routine physicals, immunizations or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a Disablement established by a prior call or attendance of a Physician
10. Treatment of the Temporomandibular joint
11. Vocational, speech, recreational or music therapy
12. Services or supplies performed or provided by a Relative of the Insured Person or anyone who lives with the Insured Person
13. Travel arrangements that were neither coordinated by nor approved by the Assistance Company in advance, unless otherwise specified
14. Cosmetic or Plastic Surgery, except as the result of a covered Accident; for the purposes of this Policy, treatment of a deviated nasal septum shall be considered a cosmetic condition
15. Elective Surgery or Elective Treatment which can be postponed until the Insured Person returns to his/her Home Country, where the objective of the trip is to seek medical advise , treatment or Surgery
16. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids
17. Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye glasses or for the fitting thereof, unless caused by Accidental bodily incurred while insured here under
18. Any Mental and Nervous disorders or rest cures, unless otherwise covered under this Policy
19. Congenital abnormalities and conditions arising out of or resulting therefrom
20. Expenses as a result or in connection with the commission of a felony offense
21. Injury sustained while taking part in mountaineering where ropes or guides are normally used , hang gliding, parachuting , bungee jumping, racing by horse, motor vehicle or motorcycle, para sailing
22. Treatment paid for or furnished under any other individual or group policy (including no-fault automobile) or other service or medical pre-payment plan arranged through the employer to the extend so furnished or paid or under any mandatory government program or facility set up for treatment without cost to any individual
23. Dental care , except as the result of injury to natural teeth caused by Accident, unless otherwise covered under this Policy
24. Routine Dental Treatment
25. Drug treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion
26. Treatment for human organ tissue transplants or bone marrow transplants and their related treatment
27. Expenses incurred within the Insured Person's home country, unless otherwise covered under this Policy
28. Weak, strained or flat feet, corns, calluses or toenails
29. Diagnosis and treatment of acne
30. Sex change operations, or for treatment of sexual dysfunction or sexual inadequacy
31. Weight reduction programs or the surgical treatment of obesity
In addition to the exclusions listed above, the following exclusions apply to Accidental Death and Dismemberment Insurance only:
1. Disease of any kind; sickness of any kind
2. Suicide or any attempt thereof, while sane or self destruction or any attempt thereof, while sane
3. Bacterial infections except pyogenic infection which shall occur though an accidental cut or wound
4. Service in the military, naval or air service of any country
4. While riding or driving in any kind of competition
5. Injury sustained while the Insured Person is riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting from, any type of aircraft
6. 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; mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power
7. Injury sustained while the insured person is riding as a passenger in any aircraft a) not having a current and valid Airworthy Certificate and b) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft
8. Injury occasioned or occurring while the insured person is committing or attempting to commit a felony or to which the contributing cause was the insured person being engaged in an illegal occupation
