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LIAISON GROUP TRAVEL PLAN |
| International Group Travel Medical Insurance. A simple and easy way
to insure groups of international travelers for medical, evacuation, and AD&D
Insurance. |
| Corporations and organizations often require a simple, easy way to ensure
their employees and/or members for international travel medical insurance. |
| Liaison Group Travel Plan is a group medical program that is easy to
understand and simple to begin. This brochure describes the program as well as contains
the application for enrollment. Liaison Group Travel Plan is a travel medical
program for international groups. It is not traditional U.S. medical insurance nor is it
permanent coverage. This brochure is a brief description
of Liaison Group Travel Plan. A complete description is contained in the Program Summary,
which will be mailed to your organization together with ID Cards after SRI receives your
completed application and correct premium. |
| THE USES OF LIAISON GROUP TRAVEL PLAN |
| Liaison Group Travel Plan is ideal for corporations and organizations
seeking a simple way to provide international group travel medical insurance to their
employees or members. A few examples of possible groups include: Missionary Trips,
Business Conferences Overseas, School Groups, International Consulting Contracts. |
| Simply complete the enclosed application and remit the appropriate
premium for the entire period of coverage. The participants listed will be covered for the
period of time requested. |
| ELIGIBILITY |
| Liaison Group Travel Plan provides coverage as outlined in this brochure
for persons traveling outside of their Home Country or Country of Residence. The program
will provide coverage for the employee/member, their spouse, and their unmarried dependent
children (over 14 days and under 19 years of age) while spending time outside of their
Home Country or Country of Residence. |
| 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. |
| PERIOD OF COVERAGE |
| The minimum period of coverage under this Liaison Group Travel Plan is 15
days. Coverage can be purchased in a combination of monthly and 15 day periods by paying
the appropriate premium. The maximum period of coverage is 12 months. If your
organization requires special coverage options or coverage in excess of 12 months, please
contact SRI for a specialized quotation. |
Effective Date - In general, individual coverage will begin
on the latest of the following:
. Moment of departure from Home Country; or
2. The date the Application and full premium are received by SRI; or
3. The date requested on the Application. |
Expiration Date - Coverage will end on the earlier of the
following:
1. The arrival of the Insured Person back in their Home Country; or
2. The date for which premium has been paid. |
| SCHEDULE OF BENEFITS |
| All coverage's, benefits and premiums listed in this brochure are in U.S.
Dollar amounts. |
| Deductible: Please see Application for Details |
| Maximum: Please see Application for Details |
| Deductible is per person per policy period, maximum of 3 Policy Period
deductibles per family. |
| Coinsurance - In the United States
and Canada, after the Insured pays the deductible, LiaisonSM
Group Travel Plan pays 80% of the next $5,000 of eligible
expenses, then 100% to the selected Maximum.
Outside the United and Canada, after the Insured pays the deductible, the program pays 100% to
the selected maximum. |
| Emergency Medical Evacuation - $50,000 |
| Repatriation of Mortal Remains - $20,000 |
| Emergency Reunion - $10,000 |
| Return of Minor Child(ren) - $5,000 |
| Local Ambulance Expense - $2,500 |
| Accidental Death & Dismemberment - $25,000 Principal Sum for
Insured or Insured Spouse, $5,000 for Dependent Child. |
| Hospital Room & Board - Usual, reasonable and customary to the
selected Policy Maximum. |
| Intensive Date - Usual, reasonable and customary to the selected
Policy Maximum. |
| Outpatient Medical Expenses - Usual, reasonable and customary to
the selected Policy Maximum. |
| Benefit Period - six months. |
|
| DESCRIPTION OF MEDICAL BENEFITS |
| When a covered Injury or Illness is incurred by the Insured Person the
Company will pay Reasonable and Customary medical charges for Covered Expenses, excess of
the Deductible and Coinsurance as stated in the Schedule of Benefits. In no event shall
the Company's maximum liability exceed the maximum stated in the Schedule of Benefits. The
Deductible and Coinsurance amount consists of Covered Expenses which would otherwise be
payable under this Policy. These expenses must be borne by the Insured Person. |
| Only such expenses, incurred as the result of a disablement, which are
specifically enumerated in the following list of charges, and which are not excluded in
the Exclusions, shall be considered as 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 semiprivate room and board accommodation. |
| 2. |
Charges made for Intensive Care or 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, Physicians' 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, iron lungs, 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. |
Hotel room charge, when the Insured Person, otherwise necessarily confined
in a Hospital, shall be under the care of a duly qualified Physician in a hotel room owing
to unavailability of a Hospital room by reason of capacity or distance or to any other
circumstances beyond control of the Insured Person. |
| 10. |
Dressings, drugs, and medicines that can only be obtained upon a written
prescription of a Physician or Surgeon. |
| 11 |
Charges made for artificial limbs, eyes, larynx, and orthotic appliances,
but not for replacement of such items. |
| 12. |
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 that time the service is used. If the Insured Person is in a rural area,
then licensed ground ambulance transportation to the nearest metropolitan are shall be
considered a Covered Expense. |
| Only those expenses specifically described above which are incurred
within six months from the onset of an Injury or Illness and which are not excluded (see
"Exclusions") are considered Covered Expenses. Initial treatment must occur
within 60 days of the incident. Illness must first manifest itself during the Period of
Coverage. |
| Emergency Medical Evacuation/Repatriatin |
| The Company shall pay benefits for Covered Expenses incurred up to
$50,000, if any covered Injury or Illness commencing during the Period of Coverage results
in the Medically Necessary Emergency Medical Evacuation or Repatriation of the Insured
Person. The Emergency Medical Evacuation or Repatriation must be ordered by the Company's
appointed Assistance Company in consultation with the Insured Person's local attending
Physician. |
| Emergency Medical Evacuation or Repatriation means: a) the Insured
Person's medical condition warrants immediate transportation from the place where the
Insured Person is located to the nearest adequate medical facility where medical treatment
can be obtained; or b) after being treated at a local medical facility as a result of a
Medical Evacuation, the Insured Person's medical condition warrants transportation with a
qualified medical attendant to his/her Home Country to obtain further medical treatment or
to recover; or c) both a) and b) above. All transportation arrangements must be by the
most direct and economical route. |
| Return Mortal Remains |
| The Company will pay the reasonable Covered Expenses incurred up to a
maximum of $20,000 to return the Insured Person's remains to his/her then current Home
Country, if he or she dies. |
| Emergency Medical Reunion |
| When Emergency Medical Evacuation or Repatriation occurs, the Company
will arrange and pay, up to $10,000, for round trip economy-class transportation for one
individual selected by the Insured Person, from the Insured Person's current Home Country
to the location where the Insured Person is hospitalized and return to the current Home
Country. Emergency Medical Reunion must be recommended by the attending Physician.
(Additional information contained in the Certificate of Insurance). |
| Return of Minor Child(ren) |
| Should the Insured Person be traveling alone with a Minor Child(ren) and
is hospitalized because of a covered Illness or Injury and the Minor Child(ren), under age
19, is left unattended, The Company will arrange and pay for one way economy fares to
their current Home Country. These arrangements will be made at no cost to the Insured
Person. Meals and lodging are the responsibility of the Insured Person. If an
attendant/escort is necessary to insure the safety and welfare of Minor Child(ren), The
Company will arrange and pay for these services as stated in the Schedule of Benefits. |
| NOTE: In the event of an Emergency Medical Evacuation, Repatriation of
Mortal Remains, Emergency Reunion or Return of Minor Child(ren) benefit is needed,
arrangements must be made by the Assistance Service Provider. Complete details about
required notification of the Assistance Service Provider are contained in the Certificate
of Insurance. |
| Refund Of Premium |
| Refund of premium will be considered only if written request is received
by SRI prior to the Effective Date of Coverage. After the Effective Date of Coverage, the
premium is considered fully earned and nonrefundable. |
| Billing |
| In order to keep enrollment as simple as possible, premium for the entire
period of coverage is due at the time of application. Naturally, SRI does have the ability
to bill significant groups once an initial payment is made. Please contact SRI directly
for additional information regarding billing. |
| What You Will Receive |
| Once received and processed, SRI will mail ID Cards and Certificates of
Insurance to the organization for distribution to the individual participants. |
| ENROLLING IN LIAISON GROUP TRAVEL PLAN |
1. Complete the entire LiaisonSM Group Travel Plan
Application.
a. Complete the Premium Calculation section.
b. Premium for the entire period of coverage is due at the time of
application. |
| 2. If paying by check or money order, make payable to: "SRI"
and enclose it together with completed Application. |
| 3. If paying by credit card, complete Application and mail or fax to SRI.
Be sure to sign Method of Payment section. |
| 4. Read the Declaration section, if agreeable, please be sure to
sign. |
Complete and return the Application with your payment for the total
premium to:
SRI
9200 Keystone Crossing, Ste 300
Indianapolis, IN 46240
Fax 1-212-504-8085
(If paying by credit card only. Originals are not required if application is faxed to SRI
with credit card payment.)
|
Premiums are listed on the Application
|
| INSURANCE CARRIER |
| The MEGA Life and Health Insurance Company (MEGA) is a wholly owned
subsidiary of UICI. MEGA is a leader in the Self-Funded Medical Insurance, Student
Accident and Health, and College Fund Individual Life Markets. MEGA is the largest writer
of student insurance in the United States. The MEGA Life and Health Insurance Company,
ranked "A" (Excellent) by A.M. Best and "AA-" by Duff & Phelps
Credit Rating Co. (claims paying ability). |
| Please be aware that this is not a general health insurance policy,
but an interim travel medical program intended for use while away from your Home Country
or Country of Residence. Liaison Group Travel Plan does not guarantee payment to a
facility or individual for medical expenses until the Company determines that it is an
eligible expense. |
Additional Liaison Group Travel Plan Information
Unexpected Recurrence
Up to
$500 potential in pre-existing condition coverage is possible for
Insured Persons traveling outside the United States or Canada. See
Exclusion number one for additional details.
Interruption of Trip
If the Insured is unable to continue the Trip due to the
death of an Immediate Family member (parent, spouse, sibling or
child) or due to serious damage to the Insured’s principal residence
from fire, flood or similar natural disaster (tornado, earthquake,
hurricane, etc.), the program will reimburse, (up to $5,000), the
Insured for the cost of travel (economy), less the value of applied
credit from an unused return travel ticket, to return home to their
area of principal residence.
Loss of Checked Luggage
If
the Insured's checked luggage is permanently lost by the airline,
the program will reimburse the Insured for the replacement of
clothing and personal hygiene items lost to a maximum per article
limit of $50 (up to $250). This benefit is secondary to any other
(including airline) coverage available. The Insured must furnish
proof to the Company that full reimbursement has been obtained from
the airline.
Dental - Emergency Only
Emergency Dental treatment
necessary to resolve acute, spontaneous and unexpected inception of
pain to natural teeth (up to $100 maximum) or Dental treatment
necessary to restore or replace sound natural teeth lost or damaged
in an Accident which is covered under the program (up to $500
maximum).
|
| ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) |
| Liaison Group Travel Plan includes $25,000 AD&D 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, Liaison Group Travel Plan will pay for loss as
follows: |
| For Loss of: |
Insured or Spouse |
Each Child |
| Loss of Life |
Principal Sum |
$5,000 |
| Loss of two Members |
Principal Sum |
$5,000 |
| Loss of one Member |
50% of Principal Sum |
$2,500 |
| Quadriplegia |
Principal Sum |
$5,000 (total paralysis of both upper and lower limbs) |
| Paraplegia |
75% of the Principal Sum |
$3,750 (total paralysis of both lower limbs) |
| Hemiplegia |
50% of the Principal Sum |
$2,500 (total paralysis of both upper and lower limbs of one side of the body) |
| Uniplegia |
25% of the Principal Sum |
$1,250 (total paralysis of one limb) |
|
| Additional information regarding AD&D coverage and definitions are
contained in the Certificate of Insurance. |
| ASSISTANCE SERVICES |
Upon enrollment into Liaison Group Travel Plan, you are eligible to use
any of the assistance services listed below provided by the Assistance Services Provider.
Additional information is contained in the Program Summary.
|
OPTIONAL COVERAGES
Home Country Coverage
- This option covers the Insured Person for incidental trips to
their Home Country (maximum of 60 days per 12 months of coverage or
pro-rata thereof). The Maximum Benefit is reduced to $50,000 while
the Insured Person is in their Home Country.
Hazardous
Sport Coverage - To cover motocycle/motor scooter riding,
mountaineering (max. elevation is 4500 meters), hang gliding,
parachuting, bungee jumping, water skiing, snowmobiling and snow
boarding.
|
| EXCLUSIONS |
| For Medical benefits, this Insurance does not cover: |
| 1. |
Any Injury or Illness which
meets the following criteria: 1) condition(s) that would have
caused a person to seek medical advise, diagnosis, care or treatment
during the 36 months prior to the Effective Date of coverage under
this Policy; 2) condition(s) for which manifestation,
medical advise, diagnosis, care or treatment was recommended or
received during the 36 months prior to the Effective Date of
coverage under this Policy; If the Injury or Illness is an
Unexpected Recurrence and the Insured Person is
traveling outside the United States, the program will reimburse up to $500 for treatment
of that particular condition. An Unexpected Recurrence is a sudden and unexpected outbreak or recurrence of
a condition defined in a & b above. The condition must occur
spontaneously and without advanced warning, for example: prior symptoms, Physician visit, failing to take medication. |
| 2. |
Charges for treatment which
exceed Reasonable and Customary charges; or Charges incurred for
Surgeries or treatments which are Investigational, Experimental, or
for research purposes; expenses which are nonmedical in nature; expenses for Vocational, Speech, Recreational or Music Therapy; |
| 3. |
Expenses which were not recommended, approved and
certified as Medically Necessary and reasonable by a
Physician; |
| 4. |
Suicide or any attempt there
at, while sane or self destruction or any attempt there at, while insane;
intentionally self-inflicted Injury or Illness; or expenses as a result or in connection with the
commission of a felony offense; |
| 5. |
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; |
| 6. |
Injury sustained while participating in professional, sponsored Amateur or
Interscholastic Athletics; |
| 7. |
Routine physicals, inoculations, or other examinations where there are no objective indications or
impairment in normal health; |
| 8. |
Treatment of the Temporomandibular joint. |
| 9. |
Services or supplies performed or provided by a Relative of the Insured
Person, or anyone who lives with the Insured Person. |
| 10. |
Treatment and the provision of false teeth or
dentures, normal ear tests and the provision of hearing aids,
cosmetic or plastic Surgery (including deviated nasal septum),
routine dental expenses, eye care or eye related expenses, unless
caused by Accidental bodily Injury incurred while insured
hereunder; |
| 11. |
Treatment in connection with
alcoholism and drug addiction, or use of any drug or narcotic agent;
any Mental and Nervous disorders or rest cures; Injury sustained
while under the influence of or Disablement due to wholly or partly to the effects of
intoxicating liquor or drugs; |
| 12. |
Congenitial abnormalities and conditions arising out of or resulting
therefrom; |
| 13. |
Expenses incurred during a hospital emergency room
visit which is not of an emergency nature; |
| 14. |
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, water skiing,
snow skiing and snow boarding; |
| 15. |
Treatment paid for or furnished under any other individual or group policy
or charges provided at no cost to the Insured Person. |
| 16. |
Treatment of venereal or
sexually transmitted disease. |
| 17. |
Pregnancy expenses or Illness resulting from pregnancy, childbirth, or
miscarriage; or for miscarriage resulting from Accident. |
| 18. |
Drug, treatment or
procedure that either promotes or prevents conception, or prevents childbirth; |
| 19. |
Expenses incurred while the
Insured Person is in their Home Country (except after approved
Emergency Evacuation / Repatriation or if treatment is a follow-up to a covered disablement during coverage); * |
| 20. |
Expenses incurred for which
travel was undertaken to seek medical treatment for a condition; or
incurred after the Insured Person’s physician has limited or
restricted travel.
* Options are available to include all or part
of these risks. |
| With regards to Accidental Death and Dismemberment, Emergency
Evacuation/Repatriation, Return of Mortal Remains, this Insurance does not cover: |
| 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 or sickness of any kind; |
| 3. |
Bacterial infections except
pyogenic infection which shall occur through an accidental cut
or wound; (only applicable to AD&D) |
| 4. |
Hernia of any kind; (only applicable to AD&D) |
| 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. |
Any consequence, whether directly or indirectly, proximately or remotely
occasioned by, contributed to by, or traceable to, or arising in connection with: |
|
| a. |
war, invasion, act of foreign enemy hostilities, warlike operations
(whether war be declared or not), or civil war. |
| b. |
mutiny, riot, strike, military or popular uprising insurrection,
rebellion, revolution, military or usurped power. |
| c. |
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. |
| d. |
martial law or state of siege or any events or causes which determine the
proclamation or maintenance of martial law or state of siege (hereinafter for the purposes
of this Exclusion called the "Occurrences"). |
|
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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 for which the Company shall
no be liable under this Policy except to the extent that the Insured Person shall prove
that such consequence happened independently of the existence of such abnormal conditions. |
| 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, endurance tests, rocket-propelled aircraft, 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. |
| 10. |
Being under the influence of alcohol or having taken drugs or narcotics
unless prescribed by a legally qualified physician or surgeon. |
| 11. |
Injury occasioned or occurring while the Insured Person is committing or
attempting to commit a felony or to which a contributing cause was the Insured Person
being engaged in an illegal occupation. |
| 12. |
Riding or driving in any kind of competition. |
| 13. |
Pregnancy, childbirth, miscarriage or abortion. |
| 14. |
Covered Expenses incurred after the Insured Person’s physician has limited or
restricted travel; or Covered Expenses incurred as a result of a change in prescribed
treatment during, or within the three months prior to the effective date
of coverage. |
For Cancellation of Trip, this insurance does not
cover: 1) war or any act of war, whether declared or not; participation in
a felony, riot or insurrection; participation in contests of speed; a
Pre-existing Condition existing prior to the Insured’s departure from
their Home Country that has the likelihood of causing death.
For
Lost of Checked Luggage, this insurance does not cover: animals;
automobiles or automobile equipment; boats; motors; motorcycles; other
conveyances or their appurtenances (except bicycles while checked as
baggage with a Common Carrier); household furniture; eye glasses or
contact lenses; artificial teeth or dental bridges; hearing aids;
prosthetic limbs; musical instruments; money or securities; tickets or
documents; or sporting equipment if loss or damage results from the use
thereof.
Contact your agent with any questions:
Global Cover
107 81st Avenue Kew Gardens
NY 11415, USA
Toll-Free: 1-866-452-6837 (1-866-GL-Cover)
Tel: 1-561-868-2441
Fax: 1-212-504-8085
email: marketing@globalcover.com
Copyright 1998-2000 by
Specialty Risk International, Inc.
Click here to view and print application.
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