Schedule of Benefits: Patriot Travel Insurance Plan
The table below shows a summary schedule of the Patriot Travel benefits. Please note that all benefits are listed in $USD:
| MEDICAL BENEFITS Usual, reasonable and customary charges, subject to deductible and coinsurance | |
| Hospital Room and Board | Up to Policy Maximum for an average semi-private room rate |
| Intensive Care | Up to Policy Maximum |
| Medical Expenses | Up to Policy Maximum |
| Outpatient Medical | Up to Policy Maximum |
| Local Ambulance | Up to Policy Maximum |
| Prescription Drugs | Up 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) $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 $100 for the necessary treatment of sudden, unexpected pain to sound natural teeth. | |
| INTERNATIONAL EMERGENCY CARE (when coordinated through the Plan Administrator) | |
| Emergency Evacuation | Up to $ 500,000-lifetime maximum (independent of policy maximum) |
| Each Patriot 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 $500,000. | |
| Emergency Reunion | Up to $50,000 |
| Each Patriot plan also provides emergency reunion coverage, up to $50,000 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. | |
| Return of Mortal Remains | Up to $50,000 |
| 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 $50,000; or up to $5,000 for the preparation, local burial or cremation of your mortal remains at the place of death. | |
| Return of Minor Children | Up to $50,000 |
| If a covered illness/injury results in a hospitalization and/or death and the insured person is traveling alone with child(ren) 19 or under that otherwise would be left unattended, the Patriot plans will pay up to $50,000 for one way economy fare to their home country, including a chaperone, if necessary, for the safety of the child(ren). | |
| Political Evacuation | Up to $10,000 |
| 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 $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: | |
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| To be eligible for the Evacuation, Reunion and Return benefits, these must be recommended by the attending physician in critical medical situations, and approved in advance and coordinated by IMG. | |
| PLAN INFORMATION | |
| Deductible | Your choice of $0, $100, $250, $500, $1,000 or $2,500 |
| 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 |
| Treatment received outside the U.S. & Canada: None For treatment received within the U.S. & Canada: In the PPO Network: The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Policy MaximumOutside the PPO Network: The plan pays 80% of eligible expenses up to $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 would 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. | |
| ADDITIONAL BENEFITS | |
| Home Country Coverage | As described below |
Incidental Trip – As an accommodation and supplemental benefit and subject to the Terms of this insurance, the Insured Person will be covered under this insurance during incidental return trips to his/her Country of Residence up to the number of days shown in the BENEFIT SUMMARY during the Period of Coverage beginning with the date the Insured Person first arrives back in his/her Country of Residence provided that:
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| Natural Disaster | $100 per day for five days |
| This benefit is available in the event an insured person is required to depart his/her destination due to an evacuation order issued by prevailing authorities in connection with a Natural Disaster. Natural Disaster is defined as a widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storms, landslide, or other natural catastrophe or event resulting in migration of the population for its safety. | |
| Trip Interruption | Up to $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 | Up to $50 per item of personal property; maximum of $250 per Period of Coverage |
| This benefit will be paid if 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 | $50,000 to Beneficiary; maximum of $250,000 per family |
| If accidental death should occur while traveling on a commercial Common Carrier, $50,000 will be paid to the designated beneficiary, to a maximum of $250,000 per family. | |
| Sports & Activities Coverage | Up 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 sanctioned, or which involves regular or scheduled practices, games or competition. The following hazardous activities are excluded unless the Extreme Sports Rider is purchased: abseiling, aviation (except when traveling as a passenger in a commercial aircraft), BMX, bobsleigh, bungee jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning, inline skating, jet skiing, kayaking, mountain biking, paragliding, parascending, rappelling, rock climbing, sky diving, snow skiing, snowboarding, snowmobiling, spelunking, surfing, trekking, wind-surfing and whitewater rafting. Racing of any kind, BASE jumping, mountaineering, climbing or trekking above elevation 4500 meters above ground level or without proper ropes or guides; luge, motocross, Moto-X, rodeo activity, ski jumping, whitewater rafting exceeding Class V difficulty; and/or extreme sports not expressly covered hereunder are excluded regardless of which plan or rider is selected.Optional Extreme Sports Rider: Please see the brochure for more information. | |
| Accidental Death & Dismemberment | $25,000 principal sum |
| Each Patriot plan includes $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 the principal sum. “Member” means hand, foot or eye. | |
| Terrorism Coverage | Up to $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 $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 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 six months before the insured person’s date of arrival. This benefit also does not cover an act of Terrorism if 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 $500 per Period of Coverage |
| If an impostor obtains key personal information such as a Social Security or Driver’s License number, or another 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 six months of the termination of coverage date. | |
| Sudden and Unexpected Recurrence of a Pre-existing Condition – Medical (for U.S. citizens only) | |
| For those up to age 65 with a primary health plan, Patriot International will pay the Usual, Reasonable and Customary charges of a sudden and unexpected recurrence of a Pre-existing Condition (defined on the Exclusions page) up to the plan maximum. For those without a primary health plan, Patriot International will pay up to a $ 20,000-lifetime maximum. For those age 65 and older, with or without a primary health plan, Patriot International will pay up to a $ 2,500-lifetime maximum. The primary health plan must have existed before the effective date and during coverage of the Patriot plan, and the Pre-existing Condition must be covered under the primary health plan. | |
| Sudden and Unexpected Recurrence of a Pre-existing Condition – Medical (for non-U.S. citizens only) | |
| For those under age 65, Patriot America will pay up to a $50,000 lifetime maximum for eligible medical expenses. For those age 65 and older, Patriot America will pay up to a $2,500-lifetime maximum. | |
| Sudden and Unexpected Recurrence of a Pre-existing Condition – Emergency Medical Evacuation | |
| Also, up to $25,000 will be paid to U.S. and non-U.S. citizens for the for the eligible costs and expenses of an Emergency Medical Evacuation arising or resulting from a sudden and unexpected recurrence of a Pre-existing Condition. | |
| Hospital Daily Indemnity | |
| Each plan pays $100 directly to the insured person for each night of a required overnight stay in a hospital up to a maximum of 10 days. The hospital stay must be covered under this plan to receive this benefit. This benefit is not available for Patriot America (non-U.S. citizens) if the hospitalization is due to the Sudden Recurrence of a Pre-existing Condition. | |
| Optional Riders | ||||||||||||
EXTREME SPORTS RIDER: The Extreme Sports Rider is available on both Patriot plans for those up to the age of 65. The following activities are covered to the maximum lifetime amounts listed on page 7: abseiling, aviation, BMX, bobsleigh, bungee jumping, canyoning, caving,flying (private plane), hang gliding, heli-skiing, high diving, hot air ballooning, inline skating, jet skiing, kayaking, mountain biking, paragliding, parascending, rappelling, rock climbing (ropes and guides to 4500m from ground level), skydiving, snowboarding, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), wind-surfing. These extreme activities must be engaged in solely for leisure, recreation, or entertainment purposes.
PATRIOT RETURN RIDER The Patriot Return Rider is only available to non-U.S. citizens who have purchased Patriot America. When purchased at the time of application, Patriot Return provides temporary medical coverage for non-U.S. citizens returning to their home country. Base Premium x 5% ENHANCED AD&D RIDER This optional coverage is available for the primary insured person only. This coverage is in addition to the Accidental Death and Dismemberment already included in the Patriot plans. Coverage must be purchased for a minimum of three months. Monthly Rates – coverage must be purchased for a minimum of three months
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| 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 Certificate Wording with all terms, conditions, and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate Wording for this insurance plan in the event this application and brochure has expired is modified or is replaced with a newer version. Current Certificate Wordings are available upon request. |
Patriot Travel Medical Insurance Plan:
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