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COMPLETE BROCHURE & RATES
FOR
 atriot  xecutiveSM
Underwritten
by SIRIUS International Insurance Corp.
Annual Global
Medical, Evacuation and Accident Insurance for
Executives or Individuals Who Travel Frequently Outside of 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
Executive is designed for:
U.S. citizens who:
- are under the age of 76,
- are covered by an individual or group medical plan,
and
- travel outside of the United States frequently
throughout the year.
Non-US citizens who:
- are under the age of 76,
- are covered by an individual or group medical plan,
and
- travel outside your country of citizenship frequently
throughout the year.
Although the Patriot Executive plan is not
renewable, it can be rewritten for succeeding or subsequent coverage periods. New
Deductible, 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.
|
Schedule of Benefits
& Limits |
INTERNATIONAL EMERGENCY
CARE |
| Emergency
Evacuation |
Up to US$25,000
for pre-existing conditions; up to policy maximum for covered incidents for insured
persons under age 66; up to US$50,000 for covered incidents for insured persons from ages
66 to 75 |
| The Patriot Executive® plan includes coverage for emergency
medical evacuation 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. The plan pays up to US$25,000 for evacuations resulting from a pre-existing
condition; up to the policy maximum for covered incidents for insured persons under age
66; and up to US$50,000 for covered incidents for insured persons from ages 66 to 75. |
| Emergency
Reunion |
To US$15,000
when coordinated through the Plan Administrator |
| The Patriot Executive® 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 of the insured
person: either the cost of accompanying the insured during the evacuation or traveling
from the home country to be reunited with the insured. |
| 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 Executive plan will reimburse 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). |
SPECIAL COVERAGES |
| 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, the Patriot Executive plan will reimburse the insured
up to US$5,000 for the cost of returning the insured to the area of principal residence.
The plan will cover reimbursement 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 of luggage; maximum of US$250 |
| 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.* |
| MEDICAL BENEFITS |
usual, reasonable and customary charges, subject to
deductible |
| 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: The 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: The plan will pay up to US$100 for the necessary
treatment of sudden, unexpected pain to sound natural teeth. |
| Pre-existing Conditions |
To US$5,000 per period of coverage |
| The plan will cover up to US$5,000 maximum, per insured
person, per period of coverage (not per trip), for the sudden and unexpected recurrence of
a pre-existing condition, as defined in the certificate wording. |
| Sports & Activities Coverage |
To Policy Maximum for basic sports as described below |
| The Patriot Executive 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. |
| Accidental Death & Dismemberment |
US$25,000 principal sum |
The Patriot Executive 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 life which
occurred during a hijacking, kidnapping or attempted kidnapping - two times the 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 on panel 9 of the Patriot Executive brochure.* |
BASIC PLAN INFORMATION |
| Deductible |
US$250 per each covered Illness; deductible waived
for claims incurred as a result of a covered accident |
| Coinsurance |
None |
| Policy Maximum |
US$1,000,000; US$50,000 for travelers who are 70-75
years old |
| 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. |
| * Notwithstanding separate benefits, limits and sublimits for
Common Carrier Accidental Death benefit and Accidental Death & Dismemberment benefits
(above), no more than US$50,000 dollars per individual will be paid to a beneficiary in
the event of any death that occurs while covered by the Patriot Executive plan. |
| This web page contains only a consolidated and summary
description of all current Patriot Executive benefits, conditions, limitations and
exclusions, and is subject to all of the terms and conditions of the full Policy Wording.
A certificate containing the complete Policy Wording with all terms, conditions and
exclusions will be included with the fulfillment kit. The Company 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, among others, are excluded from coverage under the Patriot Executive plan.
- Treatment for pre-existing conditions in excess of
US$5000, per Insured Person, per Period of Coverage (not per trip). A pre-existing
condition is defined as any injury, illness, sickness, disease, or other physical,
medical, mental or nervous condition, disorder or ailment that with reasonable medical
certainty existed at the time of application or at any time prior thereto, including any
subsequent, chronic or recurring complications or consequences relating thereto or arising
there-from, whether or not previously manifested or known, diagnosed, treated, or
disclosed.
- 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 provided for in the Certificate of Coverage.
- Venereal disease, AIDS virus, AIDS related illness,
ARC Syndrome, or AIDS, 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, 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, wind-surfing 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
being under the influence of alcohol or drugs; and injury or illness resulting from
operating any type of vehicle after consuming any alcohol or drugs.
- Willful self-inflicted injury or illness.
- Treatment required as a result of or arising from
complications from a treatment or condition not covered hereunder.
- . 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.
- . Treatment for Illness or Injury where the trip is
undertaken for the purpose of obtaining such treatment or advice for a pre-existing
condition.
- .Treatment incurred as a result of or arising from
exposure to nuclear radiation, and/or radioactive material(s).
Pre-Certification
All proposed hospital admissions and surgeries, whether inpatient or outpatient, will be
subject to Pre-certification. You or your attending physician must call the number listed
on your Confirmation of Coverage prior to admittance to a hospital or performance of a
surgery. In the event of an Emergency Admission, the Pre-certification call must be made
within 48 hours after the admission, or as soon as reasonably possible. In the event an
admission or surgery is not pre-certified, eligible expenses will be reduced by 50%.
Benefit Period
The Benefit Period is the period of time specified in the Policy Limits. It begins once an
eligible incident occurs to the insured. While coverage is in effect under this policy,
the Benefit Period does not apply. When coverage under this policy terminates as defined,
Patriot Executive InsuranceSM will pay eligible expenses for covered Injuries
or Illnesses which commenced during the period of coverage for up to, but not exceeding
the Benefit Period, subject to the Policy Limits.
Premiums
Patriot Executive Travel
Medical Insurance
Through age 75*
|
Maximum Trip
Duration** |
30 Days |
U.S. CITIZENS |
| Annual Premium |
US$200 |
| Spouse & 2 children |
US$100 |
| Each additional child |
US$40 |
NON-U.S.
CITIZENS |
| Annual Premium |
US$236 |
| Spouse & 2 children |
US$118 |
| Each additional child |
US$47 |
* The plan pays a policy maximum of
US$50,000 for travelers who are 70-75 years old. Otherwise, the policy maximum is
US$1,000,000.
** The maximum duration of any one trip is 30 days. |
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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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