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BROCHURE
Short-Term
 mmigrant nsurance
Underwritten by The
Insurance Company of the State of Pennsylvania
Medical
Insurance for Visitors, New Immigrants
to the United States from 3 months to 24 months of
coverage.
$500,000 in Coverage Available for Accident & Sickness Medical.
 Also see Long-Term Immigrant Insurance,
Medical Insurance for
Visitors
Medical Insurance for New
Immigrants and Returning Expatriates to the United States - three
months to a total of 24 months of Coverage. Short Term Immigrant
Insurance is underwritten by The Insurance Company of the State of Pennsylvania, a member of the AIG group of
companies and rated A++ "Superior" by
AM Best.
Please contact us at
877-211-3654
regarding this plan.
WHY YOU NEED THIS INSURANCE
Unfortunately, as a new resident of the United States, you are not
eligible for many domestic medical insurance programs. The majority of insurance companies
require that you be a resident of the United States for 6 to 12 months before they allow
you to purchase their coverage. In the interim, you may be exposed to financial
burden if an unforeseen medical event should occur.
Short Term Immigrant Insurance is designed to offer medical coverage and emergency
services to new immigrants and returning expatriates to the United States for at least
three months.
This brochure is a brief
description of Short Term Immigrant Insurance. A complete description is contained in the
Program Summary, which will be mailed to you together with you Insurance Confirmation Card
after the Plan Administrator receives your completed application and correct premium.
ELIGIBILITY
Short Term Immigrant Insurance was designed by SRI to
protect the recent immigrant. If your Country of Residence was a country other than
the United States of America or one of its territories, and you plan to make the United
States your new Country of Residence, you are eligible to insure yourself, your
spouse, and your unmarried dependent children (over 14 days and under 18 years of age).
Maximum age of coverage is 79.
Home Country or Country of Residence is defined as - The country where an eligible
person(s) has his/her true, fixed and permanent home and principal establishment.
You must purchase this program within the first 12 months upon your arrival in the
United States.
PERIOD OF COVERAGE
As you wait until a
domestic insurance company will allow you to apply for coverage under their insurance
plan, you need flexibility. You must initially enroll into Short Term Immigrant
Insurance for between 3 and 12 months. After that, you may continue to renew coverage,
minimum 3 months at a time, at the premium rate in force at the time of renewal.
Total period of coverage for Short Term Immigrant Insurance can not exceed 24 months. See
"Renewal" section for more information.
Effective Date - Your coverage will begin on the latest of the following:
1. Your arrival in the United States; or
2. The date your Application and premium are received by
the Plan Administrator, SRI; or
3. The date you request on the Application.
Expiration Date - Your coverage will end on the earlier of the following:
1. The date shown on the Insurance Confirmation Card, for which
premium has been paid; or
2. The date you leave the United States (except for the
International Travel Coverage benefit - see below).
Renewal
Short Term Immigrant Insurance must
initially be purchased for at least three months. One month before the expiration
date, the Plan
Administrator, SRI will send a renewal
notice to the Address of Correspondence listed on the application. Coverage may then be
renewed for a period of time, depending upon your specific need. If you renew the
coverage for 3 or more months (up to 12 months at a time), SRI will continue to send
renewal notices to you. If you renew the coverage for only 1 or 2 months, SRI will
assume that you no longer require the coverage and will not send another renewal notice.
SCHEDULE OF BENEFITS
All coverages, benefits and premiums listed in this brochure are
in US Dollar Amounts
| Policy
Maximum |
Option A |
$50,000 |
| |
Option B |
$100,000 |
| |
Option C |
$250,000 (ages
70 to 79, not available) |
| |
Option D |
$500,000 (ages
70 to 79, not available) |
| Deductible
Options |
|
(per person per
policy period) |
| |
Option 1 |
$100 |
| |
Option 2 |
$500 (10%
discount) |
| |
Option 3 |
$1000 (20%
discount) |
| |
Option 4 |
$2500 (30%
discount) |
| |
Option 5 |
$5000 (40%
discount) |
| Coinsurance |
Traditional Program: After you pay your
selected deductible, the program pays 80% of the next $5000of eligible expenses, then 100%
to the selected Policy Maximum.
Cost Saver Program: After you pay your selected deductible, the
program pays 70% of eligible expenses to the selected Policy Maximum. |
|
Emergency Medical Evacuation |
$100,000 |
|
Repatriation of Mortal Remains |
$20,000 |
|
Local Ambulance Expense |
$2,500 |
|
Accidental Death and Dismemberment |
$25,000 Principal Sum for Insured or Insured Spouse, $5,000 for
Dependent Child |
|
Hospital Room and Board |
Average semi-private room rate up to the selected Policy Maximum |
|
Intensive Care |
Average semi-private room rate up to the selected Policy Maximum |
|
Outpatient Medical Expense |
Usual, reasonable and customary to the selected Policy Maximum |
|
Benefit Period |
six months |
DESCRIPTION OF MEDICAL BENEFITS
If you or your insured dependent become sick or injured
during the period of coverage and require medical treatment, Short Term Immigrant
Insurance will pay, subject to the selected deductible and coinsurance, reasonable and
customary charges for Covered Expenses resulting from such occurrence, up to the medical
benefit amount selected.
| |
Covered Expenses |
1 |
Charges made by a hospital for room and board, floor
nursing and other services, inclusive of charges for professional services 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 semiprivate room and board accommodation,
or intensive care when medically necessary. |
| 2 |
Charges made for diagnosis, treatment and surgery by a physician. |
| 3 |
Charges made for the cost of administration of anesthetics. |
| 4 |
Charges for medication, X-ray services, laboratory tests and
services, the use of radium and radioactive isotopes, oxygen, blood transfusions, iron
lungs, and medical treatment. |
| 5 |
Charges for physiotherapy, if recommended by a physician for the
treatment of a specific disablement and administered by a licensed physiotherapist. |
| 6 |
Dressings, drugs and medicines that can be obtained upon a
written prescription of a physician or surgeon. |
| 7 |
Hotel room charge, when you, otherwise necessarily confined in a
hospital, shall be under the care of a duly qualified physician in a hotel room owing to
the unavailability of a hospital room by reason of capacity or distance or to any other
circumstances beyond your control. |
Benefit Period
Only those expenses
specifically described above which are incurred within six months from the onset of an
Injury or Sickness and which are not excluded (see "Exclusions") are considered
Covered Expenses. Initial treatment of an Injury must occur within 60 days of the
accident.
International Travel Coverage
While the purpose of Short Term Immigrant Insurance is to cover new residents to
the U.S., coverage is also valid worldwide. International Travel Coverage is limited to 60
days per 12 months of coverage, or pro rata thereof. Insured must be in the United
States for at least 6 months before International Travel Coverage is available. Covered
Expenses described in (1-7) above which are incurred outside of the United States are
limited to a maximum of $50,000, subject to the selected deductible and coinsurance. The
Insured may not travel for the purpose of seeking medical treatment.
Emergency Medical Evacuation Expenses
If you or any covered dependents become sick or injured during the period of coverage and
it has been determined that an Emergency Medical Evacuation is required to either the
nearest medical facility, where appropriate medical treatment can be obtained, or to your
Country of Residence, all eligible expenses incurred are covered up to $100,000. An
Emergency Medical Evacuation must be recommended by a legally licensed physician who
certifies that the severity of the Injury or Sickness necessitates such Emergency Medical
Evacuation, and agreed to by you or your representative. All arrangements are to be
coordinated by the Assistance Provider.
Repatriation of Mortal Remains Expenses
If Injury or Sickness commencing during the Period of Coverage results in death, all
reasonable expenses incurred for preparation and return of the remains to the Country of
Residence are covered up to a maximum of $20,000 provided that all arrangements are
coordinated by the Assistance Provider.
Accidental Death and Dismemberment (AD&D)
Short Term Immigrant Insurance includes $25,000 coverage for each Insured
Person and Insured Spouse and $5,000 for each Dependent Child. If an Injury occurs
during your Period of Coverage and results in one of the following losses within 365 days
after an accident, the insurance company will pay for loss as follows:
Loss of
Life............................................Principal Sum
Loss of two Members..........................Principal Sum
Loss of one Member............................50% Principal Sum
"Member" means
hand, foot or eye. Only one amount, the largest to which you are
entitled, is paid for all losses resulting from one accident. "Loss" means
with regard to hands and feet, actual severance through or above wrist or
ankle joints, and with regard to eyes, entire irrecoverable loss of sight.
In the event of a loss, benefits will be paid according to the Principal
Sum. "Injury wherever used in the policy shall mean bodily injury
caused solely and directly by accidental, violent, external, and visible
means occurring while the policy is in force and resulting directly and
independently of all causes in loss covered by the policy. Accidental Death
& Dismemberment Indemnity loss schedule will be extended to include the following:
Quadriplegia (total
paralysis of both upper and lower limbs).....Principal
Sum.
Paraplegia
(total paralysis of both lower limbs)....Three-Quarters
of the Principal Sum.
Hemiplegia (total paralysis of both upper and lower limbs of one side of the body).....
One Half
the Principal Sum.
Uniplegia
(total paralysis of one limb)... One Quarter the
Principal Sum.
"Loss" shall mean the
complete and irreversible paralysis of such limbs.
EXCLUSIONS |
| For
Medical Expense Benefits, this insurance does not cover: |
| 1 |
Pre-Existing Conditions, defined as any Injury or Illness which
was contracted or which manifested itself, or for which treatment or medication was
prescribed within three (3) years prior to the Effective Date of this
insurance; |
| 2 |
For services, supplies or treatment, including any period of Hospital
confinement, which were not recommended, approved and certified and necessary and
reasonable by a Physician; |
| 3 |
For suicide or any attempt thereat while sane or self destruction or any attempt
thereat while insane; |
| 4 |
Declared or undeclared war or any act thereof; |
| 5 |
For Injury sustained while participating in professional athletics; |
| 6 |
For sickness resulting from pregnancy, childbirth, or miscarriage; |
| 7 |
For miscarriage resulting from accident; |
| 8 |
For 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 Disability established by a prior call or
attendance of a Physician; |
| 9 |
For cosmetic or plastic surgery, except as a result of an accident; |
| 10 |
For elective surgery which can be postponed until the insured returns to his/her
Country of Residence; |
| 11 |
For any mental and nervous disorders or rest cures; |
| 12 |
For dental care, except as the result of Injury to natural teeth caused by
accident; |
| 13 |
For eye infractions 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 insured thereunder; |
14 |
In connection with alcoholism
and drug addiction, or use of any drug or narcotic agent; |
| 15 |
For congenital anomalies and
conditions arising out or resulting from thereof; |
| 16 |
For expenses which are
non-medical in nature; |
17 |
For the ordinary cost of a
one-way airplane ticket used in the transportation back to the Insured Person's Home
Country where an air ambulance benefit is provided; |
| 18 |
For expenses as a result of or
in connection with intentionally self-inflicted Injury; |
| 19 |
For expenses as a result if or
in connection with the commission of a felony offense; |
| 20 |
For specific named hazards:
motorcycle driving, scuba diving, skiing, mountain climbing, ski diving, professional and
amateur racing, and piloting an aircraft; |
| 21 |
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. |
| For Accidental Death and Dismemberment, Emergency
Medical Evacuation, and Repatriation of Mortal Remains, this insurance does not cover the
following: |
| 1 |
Suicide or attempt thereof by the Insured Person while sane or self destruction
or any attempt thereof by the Insured Person while insane; |
| 2 |
Disease of any kind; |
| 3 |
Bacterial infections except pyogenic infection which shall occur through an
accidental cut or wound; |
| 4 |
Hernia of any kind; |
| 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 |
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; |
| 7 |
Declared or undeclared war or any act thereof; |
| 8 |
Service in the military, naval or air service of any country; |
| 9 |
Flying in any aircraft being used for or in connection with acrobatic or stunt
flying, racing or endurance tests; |
| 10 |
Flying in any rocket-propelled aircraft; |
| 11 |
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; |
| 12 |
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. |
| |
With regard to Emergency
Medical Evacuation and Repatriation of Mortal Remains, exclusions 2,3 & 4 shall not
apply.
|
The Insurance Company
The value of your insurance coverage depends upon the security behind the
policy. Short Term Immigrant Insurance is underwritten by The Insurance Company of
the State of Pennsylvania, a member company of the American International Group of
Companies (AIG) and is rated A++ "Superior" by the A.M. Best Company.
Monthly Premiums
Effective March 1, 2002
|
Base Deductible of
$100 |
Traditional Program |
Program pays 80% of the first $5,000, then 100% to selected
maximum. |
| |
Option A |
Option B |
Option C |
Option D |
Age |
$50,000 |
$100,000 |
$250,000 |
$500,000 |
15 days to 20 |
$40 |
$50 |
$61 |
$81 |
21 - 29 |
$46 |
$58 |
$73 |
$90 |
30 - 39 |
$76 |
$87 |
$103 |
$130 |
40 - 49 |
$119 |
$134 |
$150 |
$186 |
50 - 59 |
$163 |
$182 |
$216 |
$252 |
60 - 69 |
$210 |
$236 |
$272 |
$306 |
70 - 79 |
$420 |
$525 |
N/A |
N/A |
Dep. Child* |
$29 |
$36 |
$45 |
$57 |
Cost Saver Program |
Program pays 70% of all expenses up to
the selected maximum. |
| |
Option A |
Option B |
Option C |
Option D |
| Age |
$50,000 |
$100,000 |
$250,000 |
$500,000 |
| 15 days to 20 |
$29 |
$36 |
$45 |
$59 |
| 21 - 29 |
$34 |
$43 |
$53 |
$66 |
| 30 - 39 |
$55 |
$64 |
$76 |
$95 |
| 40 - 49 |
$86 |
$98 |
$109 |
$135 |
| 50 - 59 |
$119 |
$133 |
$157 |
$183 |
| 60 - 69 |
$154 |
$172 |
$199 |
$224 |
| 70 - 79 |
$306 |
$384 |
N/A |
N/A |
| Dep. Child* |
$21 |
$27 |
$33 |
$42 |
*Dependent Child rate is applicable when at least one
parent will also be covered under Short Term Immigrant Insurance.Please be aware that this is not a general health insurance
policy, but an interim travel medical program intended for use while waiting to be
eligible for domestic U.S. medical coverage. Short Term Immigrant Insurance does
not guarantee payment to a facility or individual for medical expenses until the Company
determines that it is an eligible expense.
Bon Voyage!
Haben Sie eine sichere
Reise! Abbia un viaggio sicuro!
”Tenga un viaje seguro! Ayez un
voyage sūr! Have a safe trip!
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