|
COMPLETE BROCHURE & RATES
FOR
 atriot  mericaSM
Underwritten
by SIRIUS International Insurance Corporation
Short-Term Travel Medical Insurance for non-US
Citizens
traveling outside their home country.
Rates &
Application at the bottom of this page.
Please read the Benefits & Exclusions of this plan carefully before submitting your application.
Click here for Instant Quotes & Online Purchase
Patriot America
provides coverage for non-US citizens
traveling abroad for a minimum of 5 days up to a maximum of two years. Although the
Patriot International Plan is not renewable, it can be rewritten for succeeding or
subsequent coverage periods. New Deductible, Coinsurance, Eligibility, Conditions of
Coverage and Pre-Existing Condition Exclusions apply to any succeeding or subsequent
Period of Coverage. A new application also must be completed. If you or other family
members applying for coverage are age 65 or older, please see the Eligibility section of
the Patriot brochure for additional information.
SCHEDULE OF BENEFITS
& LIMITS |
MEDICAL BENEFITS |
Usual reasonable and customary charges, subject to deductible and
coinsurance |
| Hospital Room and Board |
To Policy Maximum for average semi-private room rate |
| Intensive Care |
To Policy Maximum |
| Medical Expenses |
To Policy Maximum |
| Outpatient Medical |
To Policy Maximum |
| Local Ambulance |
To Policy Maximum |
| Emergency Room |
As described below |
Charges incurred for the use of the Emergency Room due to an
accident are covered up to the Policy Maximum.
Charges incurred for the use of the Emergency Room for treatment of an illness are subject
to an additional (extra) US$250 deductible if treatment does not require admittance to the
hospital. |
| Dental |
As described below |
Injury due to an accident: Each Patriot plan
covers the cost of emergency dental treatment and dental procedures necessary to restore
sound natural teeth lost or damaged in an accident up to the Policy Maximum.
Sudden dental pain: Each plan will pay up to US$100 for the necessary
treatment of sudden, unexpected pain to sound natural teeth. |
| INTERNATIONAL EMERGENCY CARE |
| Emergency Evacuation |
To Policy Maximum when coordinated through the Plan
Administrator |
| Each Patriot Travel Medical Insurance® plan includes
coverage for Emergency Medical Evacuations to the nearest qualified medical facility;
expenses for reasonable travel and accommodations resulting from the evacuation; and the
cost of returning to either the home country or the country where the evacuation occurred,
up to the policy limit. |
| Emergency Reunion |
To US$15,000 when coordinated through the Plan
Administrator |
Each Patriot plan also provides emergency reunion coverage,
up to US$15,000 for a maximum of 15 days, for the reasonable travel and lodging expenses
of a relative or friend during an Emergency Medical
Evacuation: either the cost of accompanying the insured during the evacuation or traveling
from the home country to be reunited with the insured. |
|
Political Evacuation |
Up to US$10,000 when coordinated through the
Plan Administrator
If the United States
Department of State, Bureau of Consular Affairs issues a travel advisory
that becomes effective on or after the Insured Person’s date of arrival
in the Host Country, the Company will pay up to US$10,000 for
transportation to the nearest place of safety or for repatriation to the
Insured Person’s home country or country of residence provided that:
- The Insured Person contacts the
Company within 10 days of the United States Department of State,
Bureau of Consular affairs issues the travel advisory;
- Political Evacuation and
Repatriation is approved and coordinated by the Company.
|
| Return of Mortal Remains |
To US$25,000 when coordinated through the Plan
Administrator |
| If a covered illness/injury results in death, expenses for
Repatriation of bodily remains or ashes to the home country will be covered up to a
maximum of US$25,000. |
| Returning Minor Children |
To US$5,000 when coordinated through the Plan
Administrator |
| If an insured person is hospitalized due to a covered
illness/injury and is traveling alone with child(ren) 19 or under that otherwise would be
left unattended, the Patriot plans will pay up to US$5,000 for one way economy fare to
their home country, including a chaperone, if necessary, for the safety of the child(ren).
|
| PLAN INFORMATION |
| Deductible |
Your choice of US$0, $100, $250, $500, $1,000 or $2,5000 |
| On the Application Form, you will be asked to circle your
choice of a deductible. Your premium rate is dependent on the deductible you choose.
Please see the Application Form for more information. |
| Coinsurance |
As described below |
For treatment received outside the U.S. &
Canada: No coinsurance
For treatment received within the U.S. & Canada:
In the PPO Network: The plan pays 90% of eligible expenses up to
US$5,000, then 100% up to the Policy Maximum
Outside the PPO Network: The plan pays 80% of eligible expenses up to
US$5,000, then 100% up to the Policy Maximum |
| Benefit Period |
Six months |
| If a covered injury or illness requires continuing treatment
after the Period of Coverage expires, the six-month Benefit Period may provide continued
coverage. When the certificate expires, the Company will review the date of initial
treatment for the covered injury or illness. If treatment began less than six months
before the Period of Coverage expired, benefits for the covered injury or illness will
continue subject to the Policy Limits and the other terms of the plan until there have
been six months of continuous coverage for the covered injury or illness. |
SPECIAL COVERAGES |
| Home Country Coverage |
As described below |
Incidental Home Country Coverage - During
the Period of Coverage an insured person may return to their home country for incidental
visits up to a cumulative two weeks total, subject to: a. The insured
person must have left their home country, b. The total Period of Coverage
must be for a minimum of 30 days, and c. The return to the home country
may not be taken to receive treatment for an illness or injury incurred while traveling.
End of Trip Home Country Coverage - For every five months of continuous
coverage you purchase, you can purchase one additional month of home country coverage as
an accommodation and supplemental travel benefit, up to a maximum of two months. To
purchase this special home country extension coverage, please check the appropriate box on
the Application Form, and calculate your premium to include the additional month(s). |
| Trip Interruption |
To US$5,000 |
| If, during a covered trip, there is a death of an immediate
family member (spouse, child, parent or sibling) or the substantial destruction of the
insured’s principal residence, each Patriot plan will pay to return the insured to
the area of principal residence. The plan will pay for a one way air or ground
transportation ticket of the same class as the unused travel ticket, less the value of the
unused return ticket. |
| Lost Luggage |
To US$50 per item or personal property; maximum of US$250
per Period of Coverage |
| This benefit will be paid in the event that the Common
Carrier permanently loses an insured person’s checked luggage. This coverage is
secondary to any other available coverage, including the Carrier’s. |
| Common Carrier Accidental Death |
US$50,000 to Beneficiary; maximum of US$250,000 per
family |
| If accidental death should occur while traveling on a
commercial Common Carrier, US$50,000 will be paid to the designated beneficiary, to a
maximum of US$250,000 per family. |
| Sports & Activities Coverage |
To Policy Maximum for basic sports Coverage as described
below |
Each Patriot plan covers injuries incurred during amateur
athletic activities which are non-contact and engaged in by the insured person solely for
leisure, recreation, entertainment or fitness purposes. However, activities not covered
include amateur or professional sports or other athletic activity which is organized
and/or sanctioned, or which involves regular or scheduled practices, games or competition.
The following hazardous activities are excluded: racing of any kind, aviation (except when
traveling as a passenger in a commercial aircraft), BMX, BASE jumping, bobsleigh, bungee
jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning,
inline skating, jet skiing, kayaking, luge, motocross (moto-x), mountain biking,
mountaineering, parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping,
sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling, surfing,
wakeboarding, water skiing, windsurfing and whitewater rafting.
Optional Leisure or Extreme
Sports Riders: Please
contact us at 877-211-3654 or
info@worldwidemedicalplans.com for more
information. |
| Accidental Death & Dismemberment |
US$25,000 principal sum |
| Each Patriot plan includes US$25,000 principal sum benefit
for Accidental Death and Dismemberment occurring during the Period of Coverage: •
Accidental Loss of life - principal sum; • Accidental Loss of two Members - principal
sum; • Accidental Loss of one Member - 50% of principal sum. “Member” means
hand, foot or eye. For more information, see the Conditions of Coverage section in the
Patriot Travel Medical Insurance brochure. |
| Terrorism Coverage |
Up to US$50,000 lifetime maximum |
| Each Patriot Plan provides coverage for injuries and illness
incurred as a result of an act of Terrorism, limited in amount and by circumstances. If an
insured person is injured as a result of an act of Terrorism, and the insured person has
no direct or indirect participation in the act, the plan will reimburse eligible medical
claims subject to a US$50,000 lifetime maximum. However, claims incurred as a result of
radiological, nuclear, chemical or biological weapons or events are not covered. Terrorism is defined as the systematic or planned use of
violence, fear, or threat of violence in order to intimidate a population or government,
especially as a means of coercion or to obtain a granting of any demand. However, this
benefit does not cover an act of Terrorism in any country or location where the United
States government has issued a travel advisory that has been in effect within the 6 months
prior to the insured person's date of arrival.
This benefit also does not cover an act of Terrorism
in the event that an advisory to leave a certain country or location is issued by the
United States government after the insured person's arrival date, and the insured person
unreasonably fails or refuses to depart the country or location. |
| Identity Theft Assistance |
Up to US$500 per Period of Coverage |
| If an imposter obtains key personal information such as a
Social Security or Driver's License number, or other method of identifying an insured
person in order to impersonate or obtain credit, merchandise or services in the insured
person’s name, the Patriot plans will provide coverage for the reasonable, customary
and necessary costs incurred by the insured for: re-filing a loan or other credit
application that is rejected solely as a result of the stolen identity event; notarization
of legal documents, long-distance telephone calls, and postage that has resulted solely as
a result of reporting, amending and/or rectifying records as a result of the stolen
identity event; up to three credit reports obtained within one year of the insured
person’s knowledge of the stolen identity event; and stop payment orders placed on
missing or unauthorized checks as a result of the stolen identity event. The identity theft event must occur during the Period of
Coverage and must be reported within 6 months of the termination of coverage date. |
| This web page contains only a consolidated and summary description of all
current Patriot Travel Medical Insurance benefits, conditions, limitations and exclusions.
A certificate containing the complete Policy Wording with all terms, conditions and
exclusions will be included with the fulfillment kit. The Plan Administrator reserves the
right to issue the most current Policy Wording for this insurance plan in the event this
application and/or brochure has expired, is modified, or is replaced with a newer version.
Current Policy Wordings are available upon request. |
Exclusions:
Charges for the following services,
treatments and/or conditions are excluded from coverage under the Patriot plans.
Pre-existing Conditions. A
pre-existing condition is defined as any injury, illness, sickness, disease, or other
physical, medical, mental or nervous condition, disorder or ailment that existed at the
time of application or at any time during the three years prior to the effective date of
the insurance, whether or not previously manifested or symptomatic, diagnosed, treated, or
disclosed prior to the effective date, including any subsequent, chronic or recurring
complications or consequences related thereto or arising therefrom.
Treatment or surgeries which are
elective, investigational, experimental or for research purposes.
War, military action, terrorism,
political insurrection, protest, or any act thereof.
Immunizations and routine physical
exams.
Treatment of Temporomandibular Joint
or dental treatment, except as expressly provided for in the certificate of insurance.
Venereal disease, AIDS virus,
AIDS related illness, ARC Syndrome, or AIDS, and the cost of testing for these conditions, and charges for treatment or surgeries which are incurred by
any Insured who was HIV+ at time of enrollment into this insurance.
Pregnancy, childbirth, birth control,
artificial insemination, treatment for infertility or impotency, sterilization or reversal
thereof, or abortion.
Injury sustained while participating
in amateur or professional sports or other athletic activity which is organized and/or
sanctioned, or which involves regular or scheduled practices, games or competition. The
following hazardous activities are excluded: racing of any kind, aviation (except when
traveling as a passenger in a commercial aircraft), BMX, BASE jumping, bob sleigh, bungee
jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning,
inline skating, jet skiing, kayaking, luge, motocross (moto-x), mountain biking,
mountaineering, parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping,
sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling, surfing,
wakeboarding, water skiing, windsurfing and whitewater rafting.
Vision or ear tests and the provision
of visual or hearing aids.
Vocational, recreational, speech or
music therapy.
Treatment while confined primarily to
receive custodial care, educational or rehabilitative care, or nursing services.
Charges, injuries and/or illnesses
resulting or arising from or occurring during the commission or continuing perpetration of
a violation of law by the insured, including without limitation, the engaging in an
illegal occupation or act, but excluding minor traffic violations.
Treatment for, and injuries and/or
illnesses resulting or arising from, substance abuse or drug addiction.
Injury and/or illness resulting or
arising from or sustained while under the influence of or disablement of drugs or alcohol.
-
Willfull self-inflicted injury or
illness.
Treatment required as a result of or
arising from complications from a treatment or condition not covered under the
certificate.
Any services or supplies performed
or provided by a relative of the Insured or provided at no cost to Insured.
Treatment for mental and nervous
disorders.
Organ or tissue transplants or
related services.
Illness or injury where the trip to
the host country is undertaken for treatment or advice for such Illness or injury, except
as expressly provided for in the certificate of insurance.
-
Treatment incurred as a result of
or arising from exposure to nuclear radiation, and/or radioactive material(s).
PATRIOT AMERICA
RATES
for Non-U.S. Citizens
Displayed Rates are for $250 Deductible
Option (in USD)
Effective through 3/31/2008
|
| ANNUAL
DEDUCTIBLE |
|
| POLICY
LIMIT |
$50,000 |
$100,000 |
$500,000 |
$1,000,000 |
| AGE
|
Monthly Rates |
| 18-29
|
$43.00 |
$50.00 |
$64.00 |
$76.00 |
| 30-39
|
$56.00 |
$67.00 |
$84.00 |
$97.00 |
| 40-49
|
$84.00 |
$96.00 |
$126.00 |
$142.00 |
| 50-59
|
$120.00 |
$147.00 |
$178.00 |
$206.00 |
| 60-64
|
$142.00 |
$174.00 |
$207.00 |
$248.00 |
| 65-69
|
$162.00 |
$208.00 |
$226.00 |
$270.00 |
| 70-79
|
$219.00 |
N/A |
N/A |
N/A |
| 80+*
|
$381.00 |
N/A |
N/A |
N/A |
| DEP.
CHILD |
$26.00 |
$28.00 |
$36.00 |
$39.00 |
| CHILD
ALONE |
$39.00 |
$46.00 |
$59.00 |
$66.00 |
|
AGE |
Daily Rates
(Minimum length of coverage is 5 days) |
| 18-29
|
$1.45
|
$1.75
|
$2.20
|
$2.55
|
| 30-39
|
$1.90
|
$2.25
|
$2.85
|
$3.25
|
| 40-49
|
$2.85
|
$3.25
|
$4.25
|
$4.80
|
| 50-59
|
$4.05
|
$4.95
|
$6.00
|
$6.90
|
| 60-64 |
$4.80
|
$5.85
|
$6.95
|
$8.35
|
| 65-69 |
$5.45
|
$7.00
|
$7.60
|
$9.05
|
| 70-79 |
$7.35
|
N/A |
N/A |
N/A |
| 80+* |
$12.75
|
N/A |
N/A |
N/A |
| DEP. CHILD |
$0.90
|
$1.00
|
$1.25
|
$1.35
|
| CHILD ALONE |
$1.35
|
$1.60
|
$2.00
|
$2.25
|
*
US$10,000 Maximum
Optional Leisure or Extreme
Sports Riders: Please contact
us at 877-211-3654 or
info@worldwidemedicalplans.com for more
information.
Refund of Premium
Only if a written request is received prior to the policy's effective date. The premium is
non-refundable after that date.
Click here for Online Application
Back to
Brochure of Patriot Travel Medical Insurance
Bon Voyage!
Haben Sie eine sichere
Reise! Abbia un viaggio sicuro!
¡Tenga un viaje seguro! Ayez un
voyage sûr! Have a safe trip!
|
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