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Overseas Travel
Medical Plan
 
Short
Term Medical Protection Benefits for Individuals
Traveling Outside of Their Home Country
Pre-certification (notification to HPA) is required prior to
all hospital admissions and inpatient/outpatient surgeries.
In the case of an Emergency Admission, notification to HPA
must be within 24 hours, or as soon as reasonably possible.
This does not guarantee that benefits will be paid. Failure
to notify HPA of an admission or surgery will result in a
40% reduction of Benefit payments. HPA does not guarantee
payment to a facility or individual for medical expenses
until HPA determines that it is an Eligible Expense.
Notice of Claim:
Written notice of claim must be given to HPA within 30 days after the
occurrence or commencement of any Disablement provided by
the Plan, or as soon thereafter as is reasonably possible.
Notice given by or on behalf of the claimant to HPA, or to
any authorized agent of HPA, with information sufficient to
Your identity shall be deemed notice to HPA.
Claim Forms:
Upon receipt of a notice of claim, claim forms shall be
furnished to You as are usually furnished for filing Proofs
of Loss.
Payment of Claims:
Indemnity for loss of life will be payable in
accordance with the beneficiary designation and the
provisions respecting such payment which may be prescribed
herein and effective at the time of payment.
If no such
designation or provision is then effective, such indemnity
shall be payable to You. Any other accrued benefits unpaid
at the time of Your death may be paid to Your estate. All
other indemnities will be payable to You. If any indemnity
of the Plan shall be payable to You or to an Eligible
Dependent or otherwise not competent to give a valid
release, HPA may pay such indemnity, up to an amount not
exceeding $1,000, to any Relative by blood or connection by
marriage to You who is deemed to be equitably entitled
thereto. Any payment made in good faith pursuant to this
provision shall fully discharge the Plan to the extent of
such payment. Subject to Your written direction
all or a
portion of any benefits provided by this Plan on account of
Hospital, nursing, medical or surgical service may, unless
You request otherwise in writing not later than the time for
filing proof of such loss, be paid directly to the Hospital
or person rendering such services, but is not required the
service be rendered by a particular Hospital or person.
Physical Examination and
Autopsy:
At its own expense, HPA shall have the right to examine the
person of any individual whose Injury or Illness is the
basis of claim when and as often as it may reasonably
require during the pendency of a claim hereunder and to make
an autopsy in case of death, where it is not forbidden by
law.
Legal Actions:
No actions at law or in equity shall be brought to recover
on the Plan prior to the expiration of sixty days after
written proof of loss has been furnished in accordance with
requirements of this Plan. No such action shall be brought
after expiration of three years after that time written
Proof of Loss is required to be furnished.
Monetary Limits:
The monetary limits stated in this Plan and the Plan Cost
shall be in U.S. Dollars. For service outside of the
territorial limits of the United States, the exchange rate
date used to determine the amount of U.S. dollars to be paid
is the exchange rate effective for the date the claims
expense was incurred.
Benefits will not be paid for
losses caused by or resulting from:
For Accidental Death and Dismemberment, Medical Benefits,
Dental, Emergency Medical Evacuation/Repatriation, Return of
Mortal Remains, Return of Minor Child, Emergency Medical
Reunion, Trip Interruption (continue below for additional
exclusions for these benefits):
Suicide or attempt thereof
while sane or self destruction or any attempt thereof while
insane; 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.
- any act
of any person acting on behalf of or in connection with
any organization with activities directed towards the
overthrow by force of the Government de jure or de facto
or to the influencing of it by terrorism or violence.
- martial
law or state of siege or any events or causes which
determine the proclamation or maintenance of marital law
or state of siege (hereinafter for the purposes of this
Exclusion called the Occurrences). Any consequence
happening or arising during the existence of abnormal
conditions (whether physical or otherwise), whether
directly or indirectly, proximately or remotely
occasioned by, or contributed to by, traceable to, or
arising in connection with, any of the said Occurrences
shall be deemed to be consequences not liable under this
Plan except to the extent that You shall prove that such
consequence happened independently of the existence of
such abnormal conditions.
For Accidental
Death and Dismemberment:
Disease of any kind; Bacterial infections except pyogenic
infection which shall occur through an accidental cut or
wound; Hernia of any kind; Injury sustained while You are
riding as a pilot, student pilot, operator or crew member,
in or on, boarding or alighting from, any type of aircraft;
Injury sustained while You are 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; Service in the military, naval or air service
of any country; Flying in any aircraft being used for or in
connection with acrobatic or stunt flying, racing or
endurance tests; Flying in any rocket-propelled aircraft;
Flying in any aircraft being used for or in connection with
crop dusting or seeding or spraying, fire fighting,
exploration, pipe or power line inspection, any form of
hunting or herding, aerial photography, banner towing or any
experimental purpose; Flying in any aircraft which is
engaged in any flight which requires a special permit or
waiver from the authority having jurisdiction over civil
aviation, even though granted; Sickness of any kind; Being
under the influence of alcohol or having taken drugs or
narcotics unless prescribed by a legally qualified Physician
or surgeon; Injury occasioned or occurring while You are
committing or attempting to commit a felony or to which a
contributing cause was Your being engaged in an illegal
occupation; While riding or driving in any kind of
competition; Pregnancy, childbirth, miscarriage or abortion;
Injury arising out of a Pre-Existing Condition, however, an
Injury for which the treatment has not been rendered or
treatment medically recommended for the past thirty
consecutive months shall not be considered a Pre-Existing
Condition unless otherwise specifically excluded; Neuroses,
psychoneuroses, psychopathies, psychoses or mental or
emotional diseases or disorders of any type.
For Medical
Benefits, Dental, Emergency Medical Evacuation/Repatriation,
Return of Mortal Remains, Return of Minor Child, Emergency
Medical Reunion, Trip Interruption:
Any Injury or Illness which meets the following criteria:
1) a condition that would have caused a person to seek
medical advice, diagnosis, care or treatment during the 36
months prior to the Effective Date of Benefits under this
Plan; or 2) a condition for which medical advice, diagnosis,
care or treatment was recommended or received during the 36
months prior to the Effective Date of Your Plan. Injury or
Illness which is not presented to HPA for payment within 3
months of receiving treatment; Charges for treatment which
is not Medically Necessary; Charges provided at no cost to
You; Charges for treatment which exceed Reasonable and
Customary charges; Charges incurred for surgery or
treatments which are, experimental / investigational, or for
research purposes; 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; Injury sustained while
participating in professional athletics; Injury sustained
while participating in Amateur or Interscholastic Athletics;
Routine physicals 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 unless otherwise covered under
this Plan; Treatment of the Temporomandibular joint;
Vocational, speech, recreational or music therapy; Services
or supplies performed or provided by a Relative of You, or
anyone who lives with You; The refusal of a Physician or
Hospital to make all medical reports and records available
to HPA will cause an otherwise valid claim to be denied;
Medical reports and records or history of treatment provided
free-of-charge, by a Relative, or a friend of Yours may
cause an otherwise valid claim to be denied; Cosmetic or
plastic Surgery, except as the result of an Accident; for
the purposes of this Plan, treatment of a deviated nasal
septum shall be considered a cosmetic condition; Elective
Surgery which can be postponed until You return to Your Home
County, where the objective of the trip is to seek medical
advice, treatment or surgery; Treatment and the provision of
false teeth or dentures, normal ear tests and the provision
of hearing aids; 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
Injury incurred while under this Plan; Treatment in
connection with alcoholism and drug addiction, or use of any
drug or narcotic agent; Injury sustained while under the
influence of or Disablement due to wholly or partly to the
effects of intoxicating liquor or drugs other than drugs
taken in accordance with treatment prescribed and directed
by a Physician for a condition which is provided hereunder
but not for the treatment of drug addiction; Any Mental and
Nervous disorders or rest cures; Telephone consultations or
failure to keep a scheduled appointment; Treatment while
confined primarily to receive custodial care, educational or
rehabilitative care, or nursing services; Congenital
abnormalities and conditions arising out of or resulting
there/from; Expenses which are non-medical in nature; The
cost of Your unused airline ticket for the transportation
back to Your Home Country, where an Emergency Medical
Evacuation or Repatriation and/or Return of Mortal Remains
benefit is provided; Expenses as a result or in connection
with intentionally self-inflicted Injury or Illness;
Expenses as a result or in connection with the commission of
a felony offense; 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, snowmobiling, motorcycle/motor
scooter riding, scuba diving, involving underwater breathing
apparatus, unless PADI certified, snorkeling, water skiing,
snow skiing, spelunking, and snow boarding; Treatment paid
for or furnished under any other individual or group policy
or other service or medical pre-payment plan arranged
through the employer to the extent so furnished or paid, or
under any mandatory government program or facility set up
for treatment without cost to any individual; Injuries for
which benefits are payable under any no-fault automobile
Insurance Policy; Treatment of venereal disease; Dental
care, except as the result of Injury to natural teeth caused
by Accident, unless otherwise provided under this Plan;
Routine Dental Treatment; For Pregnancy or Illness resulting
from Pregnancy, childbirth, or miscarriage; For miscarriage
resulting from Accident; 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; Treatment for human organ
tissue transplants and their related treatment;
Exclusions
continued:
Expenses incurred while You are in Your Home Country; Weak,
strained or flat feet, corns, calluses, or toenails;
Duplicate services actually provided by both a certified
nurse-midwife and a Physician; Expenses incurred during a
Hospital emergency visit which is not of an emergency
nature; Injury sustained as the result of the Injured Person
operating a motor vehicle while not properly licensed to do
so in the jurisdiction in which the motor vehicle accident
takes place; Expenses incurred for which the trip to the
Host Country was undertaken to seek medical treatment for a
condition; Expenses incurred during a trip after Your
Physician has limited or restricted travel.
For Interruption
of Trip:
Your making changes to personal plans; Having business or
contractual obligations; Being unable to obtain necessary
travel documents (passports, visas, etc.); Being detained or
having property confiscated by customs authorities; Carrier
caused delays (including bad weather); Prohibition or
regulatory by any government; Default of yacht charter
companies; Default of the organization from which You
purchased Your trip arrangements.
For Loss of
Checked Luggage:
Aircraft, automobiles, automobile equipment, motors,
motorcycles, bicycles (except bicycles when checked as
baggage with a common carrier,) boats or other conveyances
or their accessories; Animals; Artificial teeth or limbs,
hearing aids; Sunglasses, contact lenses or eyeglasses;
Documents of any kind, including but not limited to
documents, bills, currency, deeds, evidences of debt,
letters of credit, stamps, credit cards, money, notes,
securities, transportation or other tickets; Keys, household
furniture or furnishings, rugs or carpets of any type;
Perishable items, Medicines, perfumes, cosmetics, and
consumables; Physicians and Surgeons instruments; Theatrical
property, or professional or business property; Property
shipped as freight or shipped prior to the trip departure
date; All jewelry, watches, gems, furs, cameras and camera
equipment, camcorders, sporting equipment, computers,
radios, and other electronic items unless otherwise provided
in this Plan; Wear and tear or gradual deterioration; Insect
or vermin damage; Damage from being worked upon; Breakage of
articles of a brittle nature unless caused by thieves, fire
or Accident to conveyances; Destruction or seizure under
quarantine or customs rules or by order of a government;
Illegal transportation or trade; War, including undeclared
war, civil war insurrection, rebellion, revolution, warlike
act by a military force or military personnel, destruction
or seizure of use for a military purpose, and including any
consequence of any of these; Nuclear hazard meaning any
nuclear reaction, radiation or radioactive contamination,
all whether controlled or uncontrolled or however caused or
any consequence of any of these. Loss caused by the nuclear
hazard will not be considered Loss caused by fire, explosion
or smoke; however, direct Loss by fire resulting from
nuclear hazard is eligible.
Benefits under this Plan (form TP-401/TP-402) are provided
by the American Consumer Insurance Trust. The Trust is
insured by TIG Insurance Company/TIG Premier Insurance
Company.
Notice to residents of
Florida:
The
benefits of this Plan are provided by the American Consumer
Insurance Trust. The Trust is insured by TIG Premier
Insurance Company and is governed by the law of a state
other than Florida. Your homeowner’s policy, if any, may
provide coverage for loss of personal effects provided by
the baggage and personal effects benefits. For U.S.
Residents: This insurance is not required in connection with
the purchase of Your travel arrangements.
Notice to residents of
California:
This plan contains disability benefits or health benefits,
or both, that only apply during Your trip. You may have
coverage from other sources that already provide You with
these benefits. You should review Your existing policies.
If You have any questions about Your current coverage, call
Your insurer or health plan administrator. Note, in
California, the pre-existing condition limitation is waived
for medical expenses.
Refund of Plan Cost will be considered only if You send a
written request to HPA and it is received by HPA
prior to Your Effective Date
of Protection. After Your Effective Date of
Protection the Plan Cost is considered fully earned and
nonrefundable.
Accident or Accidental
shall mean an event, independent of Illness or self
inflicted means, which is the direct cause of bodily Injury
to You.
Coinsurance shall mean
the percentage amount of Eligible Expenses, after the
Deductible, which are Your responsibilities and must be paid
by You. The Coinsurance amount is stated in the Schedule of
Benefits.
Deductible shall mean
the amount of Eligible Expenses which are Your
responsibility and must be paid by You before benefits under
the Plan are payable. The Deductible amount is stated in
the Schedule of Benefits.
Disablement as used
with respect to Eligible Expenses under the Medical Benefit
section shall mean an Illness or an Accidental bodily Injury
necessitating medical treatment by a Physician as defined in
this Plan.
Family Member shall
mean Your spouse, parent, sibling or Child.
Home Country shall
mean the country where You have Your true, fixed and
permanent home and principal establishment and for which You
hold a current and valid passport.
Hospital shall mean a
Hospital (other than an institution for the aged,
chronically ill or convalescent, resting or nursing homes)
operated pursuant to law for care and treatment of sick or
Injured persons with organized facilities for diagnosis and
Surgery and having 24-hour nursing service and medical
supervision.
Illness shall mean
sickness or disease of any kind contracted and commencing
after the Effective Date of Your Plan and eligible under
this Plan.
Injury shall mean
bodily Injury caused solely and directly by violent,
Accidental, external, and visible means occurring while this
Plan is in force and resulting directly and independently of
all other causes under this Plan.
Medically Necessary or
Medical Necessity
shall mean services and supplies received during the Term of
Protection which are determined to be: 1) appropriate and
necessary for the symptoms, diagnosis, or direct care and
treatment of Your medical conditions; 2) within the
standards the organized medical community deems good medical
practice for Your condition; 3) not primarily for You, Your
Physician’s or another Service Provider’s or person’s
convenience; 4) not Experimental/Investigational or
unproven, as recognized by the organized medical community,
or which are used for any type of research program or
protocol; and 5) not excessive in scope, duration, or
intensity to provide safe and adequate, and appropriate
treatment. For Hospital stays, this means that acute care
as an Inpatient is necessary due to the kinds of services
You are receiving or the severity of Your condition, in that
safe and adequate care cannot be received as an Outpatient
or in a less intensified medical setting. The fact that any
particular Physician may prescribe, order, recommend, or
approve a service, supply, or level of care does not, of
itself, make such treatment Medically Necessary or make the
charge of an Eligible Expense under this Plan.
Physician as used in
this Plan shall mean a doctor of medicine or a doctor of
osteopathy licensed to render medical services or perform
Surgery in accordance with the laws of the jurisdiction
where such professional services are performed, however,
such definition will exclude chiropractors and
physiotherapists.
Reasonable and Customary
shall mean the maximum amount that the Company determines is
Reasonable and Customary for eligible Expenses You receive,
up to but not to exceed charges actually billed. The
Company’s determination considers: 1) amounts charged by
other Service Providers for the same or similar service in
the locality were received, considering the nature and
severity of the bodily Injury or Illness in connection with
which such services and supplies are received; 2) any usual
medical circumstances requiring additional time, skill or
experience; and 3) other factors the Company determines are
relevant, including but not limited to, a resource based
relative value scale. For a Service Provider who has a
reimbursement agreement, the Reasonable and Customary charge
is equal to the amount that constitutes payment in full
under any reimbursement agreement with the Company. If a
Service Provider accepts as full payment an amount less than
the negotiated rate under a reimbursement agreement, the
lesser amount will be the maximum Reasonable and Customary
charge. The Reasonable and Customary charge is reduced by
any penalties for which a Service Provider is responsible as
a result of its agreement with the Company.
You, Your, Yours, or Yourself
means the Eligible Person or Eligible Dependents.
In all cases, please be
prepared to state Your passport number. Customer Service
and Claims Administration:
Direct all related customer service inquiries, benefits
verification requests, Plan payments, and Claims to be made
to HPA at the address and numbers listed below.
Health Plan Administrators, Inc. (HPA)
P.O. Box 15250
Rockford, IL 61132-5250
1-800-397-5800 (in the U.S.)
1-815-633-5800 (outside the U.S.)
In the event of
an emergency or difficulty during Your trip, telephone
access to assistance operators is available 24 hours a day,
seven days a week, from anywhere in the world. Travel
assistance is available for, but not limited to: locating
medical providers and services; consultative and advisory
services; coordinating emergency medical evacuation or
repatriations; assisting in the replacement of lost
passports; locating legal assistance and local interpreters;
and other incidental aid that may be required. The
Assistance Company operators may be accessed by calling the
numbers listed below:
1-800-666-3192 (in the U.S.)
1-603-898-8752 (outside the U.S., call collect)
This Description of Benefits contains the Overseas Travel
Medical Plan benefit descriptions, definitions and
exclusions. Please cut out the ID CARD, write Your passport
number, Plan dates and sign.
Health Plan Administrators, Inc. (HPA) is a fully licensed,
full service Third Party Administrator transacting business
worldwide. HPA is a third generation company dating back to
1939. Industry leading services include: professional
customer service, prompt claims payment, state of the art
premium accounting and reporting.
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