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15 DAYS TO 3 YEARS OF COVERAGE FOR:
SCHEDULE OF BENEFITS
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WHY INTERNATIONAL
MEDICAL INSURANCE?
Form M\COMB328
Each year, millions of people travel outside of
their Home Countries, beyond the boundaries of their medical insurance. They're
concerned with the potential out-of-pocket expenses that could result from an
injury or sickness abroad. Liaison International offers medical coverage and
emergency services to individuals and families traveling outside their Home
Countries. This brochure is a brief description of Liaison International. For a
full description, see the Program Summary, which will be mailed to you once you
are approved for insurance.
ELIGIBILITY
Liaison International provides coverage as outlined in this brochure for
individuals and families (including unmarried dependent children over 14 days
and under 19 years of age) while traveling outside of their home country.
Home Country is defined as - The
country where an insured person(s) has his/her true, fixed and permanent home
and principal establishment.
PERIOD OF
COVERAGE
The minimum period of
coverage under Liaison International is 15 days, maximum is 12 months (up to 3
years available, see Renewal Option section on page 11). Coverage can be
purchased in a combination of monthly and 15 day periods by paying the
appropriate premium. If you are interested in our renewable coverage, please
refer to "Renewal Option" section.
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 shown on the ID Card, for which premium
has been paid; *See Home Country Coverage Section.
DESCRIPTION OF BENEFITS
Medical
When the Insured incurs
a covered Injury or Illness, the program will pay Usual, Reasonable and
Customary medical charges for Covered Expenses, excess of the chosen Deductible
and Coinsurance, up to the selected Policy Maximum. Only such expenses,
incurred as the result of a disablement, which are specifically enumerated in
the following list of charges, are incurred within six months from the onset of
an Injury or Illness, and which are not excluded in the Exclusions, shall be
considered as Covered Expenses:
Dental - Emergency Only
The
Emergency Dental Benefit is only available to programs purchased for 1 month or
more. Treatment necessary to resolve acute, spontaneous and unexpected inception
of pain to natural teeth ($100) or Dental treatment necessary to restore or
replace sound natural teeth lost or damaged in an Accident which is covered
under the program ($500).
Emergency Medical Evacuation /
Repatriation
The Program will pay Covered Expenses incurred 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 Insured Person's medical condition warrants immediate
transportation from the medical facility where the Insured Person is located to
the nearest adequate medical facility where medical treatment can be obtained).
The benefit must be ordered by the Assistance Company in consultation with the
Insured Person s local attending Physician. *
Return of Mortal Remains
The
Program will pay the reasonable Covered Expenses incurred up to a maximum of
$20,000 to return the Insured Person's remains to his/her Home Country, if he or
she dies. *
Emergency Medical Reunion
When
Emergency Medical Evacuation or Repatriation is ordered and the attending
Physician recommends that a family member travel with the Insured, the program
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
Home Country to the location where the Insured Person is hospitalized and return
to the Home Country.*
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 program will arrange and
pay up to $5,000 for one way economy fare to their Home Country (including the
cost of an attendant/escort, if necessary to insure the safety and welfare of
the Minor Child(ren)). *
Hospital Indemnity
If you are
hospitalized while traveling outside of the United States or Canada, and the
hospitalization is considered a Covered Expense, the program will indemnify the
Insured $100 for each night spent in the hospital (this benefit is in addition
to any other covered expenses of the program).
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 economy travel, 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 bag 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.*
Home Country Coverage
This
benefit covers you for incidental trips to your Home Country (60 days per 12
months of purchased coverage or pro rata thereof - example: approximately 5 days
per month). Maximum benefit is reduced to $50,000 while in your Home
Country.
Assistance Services
Upon
enrollment into Liaison International, you are eligible to use any of the
assistance services provided by the Assistance Service Provider. Additional
information is contained in the Program Summary.
* NOTE: In the event of an Emergency Medical Evacuation, Repatriation, Return of Mortal Remains, Emergency Reunion, Return of Minor Child(ren), Interruption of Trip, Loss of Checked Luggage benefit is needed or utilized, arrangements must be made by the Assistance Service Provider. Complete details about the benefits and about the required notification of the Assistance Service Provider are contained in the Program Summary.
OPTIONS
Renewal
Option
Intended for longer international trips, this option allows for
continuous coverage for up to three years while paying premiums on a minimum
quarterly basis (however, you may purchase longer increments if you wish).
If this option is chosen, SRI will send you renewal notices to your Address of
Correspondence, giving you the option of continuing coverage under the same
program. To be valid, you must purchase at least 3 months initially
(you can purchase up to 12 months if desired). The renewal notices will
be sent one month before your expiration date. Coverage may then be
renewed for between 1 and 12 months (at the premium rate in force at the time of
renewal), depending upon your specific need. If you choose to renew for
less than 3 months, SRI will assume that your international trip will be over
and not send any further notices. If you renew coverage for 3 months or
more, SRI will continue to send renewal notices. Maximum period of
coverage is 3 years. For persons age 70 and over, maximum period of
coverage is 1 year. A $5.00 Administrative Fee will be charged each time
coverage is renewed. Please note that the maximum policy period for the
deductible and coinsurance is 12 months.
Hazardous Sport
Coverage
To cover motorcycle / motor scooter riding, mountaineering (4500
meter limit), hang gliding, parachuting, bungee jumping, water skiing, snow
skiing, snowmobiling, and snow boarding.
PRENOTIFICATION / REFERRAL
In order to ensure your claims are
addressed as efficiently as possible, the Insured or the provider of service,
must contact the Assistance Company for prenotification prior to: hospital
admissions and inpatient / outpatient surgeries. The Assistance Company has
trained personnel available 24 hours a day, 7 days a week throughout the year to
answer your questions, provide assistance, and guide you to an appropriate
facility if necessary. In the case of an Emergency Admission, the Assistance
Company must be contacted within 48 hours, or as soon as reasonably possible.
Prenotification does not guarantee that benefits will be paid. Failure to
prenotify will result in a 20% reduction in Eligible Benefits.
Please be aware that this is not a general health insurance policy, but an interim, limited benefit period, travel medical program intended for use while away from your Home Country. Liaison International does not guarantee payment to a facility or individual for medical expenses until SRI determines that it is an eligible expense.
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.
CLAIM
SUBMISSION
Filing a claim with SRI is easy. You will receive a Liaison International
identification card and claim form once you are approved for insurance. When you
receive treatment, you send the original, itemized bills to SRI within 90 days.
Eligible bills are automatically converted from local currencies to US dollars.
For payment of eligible medical expenses, notify SRI of pending treatments and
we can refer you to approved health care providers worldwide. You're simply
responsible for your deductible, coinsurance amounts and non-eligible expenses.
For more details, consult the Program Summary that is provided with your
insurance kit, or contact the SRI Claim Department.
EXCLUSIONS
For Medical benefits, this Insurance does not cover:
* Options are available to include all or part of these risks.
Detailed Exclusions pertaining to the benefits of this product are listed in the Program Summary, which will be mailed to you along with the ID Card once coverage is purchased.
About SRI
Since 1993, Specialty Risk International has provided medical insurance to corporations, international travelers, expatriates, students, overseas visitors, immigrants and global citizens. With expertise and efficiency, we've served clients in more than a hundred countries.
ENROLLING IN LIAISON INTERNATIONAL
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Return the Application
with your payment for the total premium to: |
MONTHLY PREMIUMS
Effective until December 31, 2001
Premiums Based on a $250
Deductible.
Premiums for 15 day coverage are 1/2 the monthly premium.
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For those Traveling to the United
States |
For those Traveling Outside the
U.S. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| *Ages 80+ limited to $15,000. Dep. Child rate is applicable when at least one parent will also be covered under Liaison International. Child Alone rate is used when a child will be insured by themselves. [Blanket Accident and Sickness Policy MEGA-SRI98] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
INSURANCE CARRIER
The MEGA Life and Health
Insurance Company, rated "A-" (Excellent) by A.M. Best
Liaison
International 2001 Application
Effective Until December 31,
2001
| OFFICIAL USE ONLY: Cert#: Processed: Eff Date: Agent: 5236 |
APPLICANT INFORMATION
| Last Name: | |
| First Name: | M.I.: |
| Country of Permanent, fixed Residence (Home Country): | |
| Passport Number / Country: | |
| AD&D Beneficiary: | Relationship: |
ADDRESS OF CORRESPONDENCE - where ID card is to be sent:
| Name: | |
| Address: | |
| City: | State: |
| Postal Code: | Country: |
| Work Phone: ( _____ ) | Home Phone: ( _____ ) |
| Previously insured by SRI? | ID Number: |
| Departure date from your Home Country? (MM/DD/YY) ____ / ____ / ____ | |
| When would you like coverage to begin? (MM/DD/YY) ____ / ____ / ____ | |
| Destination? | Length of Trip? |
| Please note: The minimum period of coverage is 15 days, the maximum is 12 months (please see Renewal Option). Coverage must be purchased in increments of no less than 15 days. Coverage cannot begin until your departure from your Home Country, nor will coverage begin until SRI receives your application and correct premium. | |
COVERAGE SPECIFICS - please check your chosen item
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CALCULATING YOUR PREMIUM - (Please complete entire sections.)
| Name of Persons to be Insured: |
Date of Birth MM/DD/YY |
Monthly Premium |
| Applicant: | ||
| Spouse: | ||
| Child: | ||
| Child: | ||
| Child: | ||
|
Total: [A] |
||
| Multiply [box A] by number of months |
X |
|
|
Total: |
$ | |
| If desired, add 15 day premium (1/2 of box A) |
+ |
$ |
|
Total: |
$ | |
| Multiply by deductible factor: |
X |
|
|
Total: |
$ | |
| Multiply Coverage Option Factor: (if applicable) |
X |
|
|
Total Payment Enclosed: |
$ | |
METHOD OF PAYMENT - please check your payment method
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| Card Number: | ||||||
| Expiration Date: | Day Phone Number: | |||||
| Name on Card: | ||||||
| Billing Address | ||||||
| Signature (Required): | ||||||
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I hereby subscribe to the Global International Trust and enroll in the group coverage for which I am eligible under the group contract issued by The MEGA Life and Health Insurance Company. ____________________________________________________ | ||||||