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Patriot Exchange Program
Exchange visitors medical insurance
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Traveling abroad can be an exciting experience, especially when you’re involved in an educational or cultural exchange program. But what would happen if a member of your group became ill or injured while away from home? Your experience can quickly turn frightening if you’re not prepared for a medical emergency.
Whether your trip takes you abroad for a few weeks or a year, your cultural exchange experience should be an enjoyable one. Your group has enough to worry about when they travel. Don’t let their medical coverage be an uncertainty. International Medical Group®(IMG®) has developed three Patriot Group Exchange ProgramSM plans to provide you and your group Coverage Without Boundaries®. Each plan offers a complete package of international benefits available 24 hours a day. Simply select the one that best fits your needs.
The Basic Short-Term Travel Plan is an economical plan designed for a student studying abroad or a participant of a cultural exchange program. The plan may be purchased in monthly increments and can include coverage for the student or participant, his or her spouse and unmarried dependent children traveling with them. If the plan is purchased for a minimum of three months, coverage may be renewed (without break in coverage) for a total of up to 48 months. See the "Renewal of Coverage" section below for more information.
The Standard Short-Term Travel Plan is designed to meet the U.S. visa travel insurance requirements for a student studying abroad or a participant of a cultural exchange program. The plan
may be purchased in monthly increments and can include coverage for the student or participant, his or her spouse and unmarried dependent children traveling with them. If the plan is purchased for a minimum of three months, coverage may be renewed (without break in coverage) for a total of up to 48 months. See the "Renewal of Coverage" section below for more information.
At IMG, we know that the reasons to travel abroad are many and varied - that’s why our services are designed to provide you with the security you need no matter where you are. Our goal is to make the medical process smooth and efficient. By providing global products and services to vacationers, those working or living abroad for short or extended periods, people traveling frequently between countries, and those who maintain multiple countries of residence, IMG is the single resource for all your international travel needs.
How we service and support your needs is what sets us apart. Since 1990, we’ve served more than a million people around the globe - always focused on the specific needs of each individual. We’ve set the benchmark for industry service levels by integrating independent credentialing services with in-house, fully owned and operated service divisions. At IMG, we’re with you, wherever you go - bringing support for all your insurance needs around the globe - providing you Global Peace of Mind®.
MyIMG is our proprietary online service that lets you access a wealth of information and manage routine areas of your account 24 hours a day, seven days a week, from anywhere in the world. You can check the status of your claims submissions, retrieve explanation of benefits, obtain certificate documents, initiate precertification and access a list of physicians within the Preferred Provider Organization (PPO) as well as through the International Provider AccessSM (IPA), a database of over 16,000 providers outside the United States!
You may seek treatment with the hospital or doctor of your choice. You are not required to use a preferred provider network. However, if you need assistance in finding a provider in the U.S., you may use the independent PPO, a separately organized network of hundreds of thousands of established, highly qualified health care physicians and many well-recognized hospitals in the U.S. contracted by IMG.
IMG also provides its online International Provider Access (IPA) database that can be used to locate health care providers outside the
U.S. as needed.
(Note: Use of this service is subject to the terms and conditions specified online. These terms must be agreed to prior to using the service.) You may access these services at
provider directory.
The ability to access quality health care is of paramount importance when a medical emergency arises abroad. To
coordinate care and provide U.S. and internationally based medical management services, IMG formed ACM, a URAC accredited, on-site specialized division devoted entirely to medical management. ACM’s clinical members are experts at assessing the need for services and ensuring those services are delivered in a timely, cost-effective manner.
From routine medical care to complex case management, from check-ups to emergency medical evacuations, ACM is there for you. They are committed to consumer protection and empowerment, quality operations and regulatory compliance. This translates into better
care for you - around the world, around the clock.
All coverages, benefits and premium amounts shown in this brochure are in U.S. dollars.
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PLAN INFORMATION
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Plan Maximum
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$10,000 per illness or
injury
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Coinsurance
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100%
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Deductible
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$100 per illness or injury
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Treatment Period
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60 days per chronic illness
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MEDICAL BENEFITS
* Usual, Reasonable and Customary charges for eligible expenses in the area where you receive treatment.
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Hospital Room and Board
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Up to semi-private room rate
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Hospital Intensive Care
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URC*
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Physical Therapy
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URC*, 1 visit per day
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Physician Visit
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URC*
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Student Health Center
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$5 co-pay per visit
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Eligible Medical Expenses
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URC*
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Emergency Room
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URC*
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Emergency Illness- with in-patient admission
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URC*
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Emergency Illness- without in-patient admission
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Additional $250 deductible
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INTERNATIONAL EMERGENCY CARE
When coordinated through the Plan Administrator
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Emergency Medical Evacuation
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$25,000 lifetime maximum
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Emergency Reunion
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$5,000 lifetime maximum
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Return of Mortal Remains
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$7,500
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Political Evacuation
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Up to $10,000
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This is a summary of benefits only. Please see below for a list of benefit descriptions.
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ADDITIONAL BENEFITS
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Accidental Death
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$5,000
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Dismemberment
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$5,000 two limbs;
$2,500 one limb
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Terrorism Coverage
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Up to $50,000 lifetime maximum
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Sudden Recurrence of a Pre-existing Condition (U.S. citizens)
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Medical
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Up to $5,000 of eligible expenses
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Emergency Medical Evacuation
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Up to $25,000 of eligible costs and expenses
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OPTIONAL ADD-ON PLAN
Basic Short-Term Travel Plan
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Baggage
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Loss/theft of Baggage
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$250
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Loss/theft of Valuables
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$250
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Loss/theft of Personal Papers
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$250
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Legal Assistance
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Binder Fee
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$500 when served with summons
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Personal Liability
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Injury to third party
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$2,000 limit after $100 deductible
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Damage to third person property
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$500 limit after $100 deductible. Secondary to any other insurance in force
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Limited High School Sports Coverage
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This is a summary of benefits only. Please see below
for a list of benefit and optional add-on descriptions.
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$10,000 per illness/injury
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$25.55
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$28.10
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$10,000 per illness/injury
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$18.95
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$20.95
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$10,000 per illness/injury
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$15.85
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$17.45
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All premium rates are effective through 12/31/09. Rates include surplus lines tax where applicable. A dependent child is your child shown on the Application Form over 14 days
and under 18 years of age, traveling with you, and for whom premium has been paid.
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PLAN INFORMATION
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Plan Maximum
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Choice of $50,000, $250,000 or $500,000 per illness or
injury
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Coinsurance
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100%
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Deductible
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$100 per illness or injury
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Treatment Period
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60 days per chronic illness
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MEDICAL BENEFITS
* Usual, Reasonable and Customary (URC) charges for eligible expenses in the area where you receive treatment.
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Hospital Room and Board
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Up to semi-private room rate
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Hospital Intensive Care
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URC*
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Physical Therapy
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URC*, 1 visit per day
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Physician Visit
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URC*
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Student Health Center
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$5 co-pay per visit
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Eligible Medical Expenses
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URC*
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Emergency Room
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URC*
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Emergency Illness- with in-patient admission
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URC *
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Emergency Illness- without in-patient admission
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Additional $250 deductible
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Dental
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Injury due to accident
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$500
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Sudden & unexpected pain
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$350
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INTERNATIONAL EMERGENCY CARE
When coordinated through the Plan Administrator
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Emergency Medical Evacuation
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$50,000
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Emergency Reunion
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$15,000
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Return of Mortal Remains
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$25,000
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Political Evacuation
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Up to $10,000
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This is a summary of benefits only. Please see below for a list of benefit descriptions.
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ADDITIONAL BENEFITS
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Accidental Death
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$25,000
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Dismemberment
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$25,000 two limbs;
$12,500 one limb
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Terrorism Coverage
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Up to $50,000 lifetime maximum
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Sudden Recurrence of a Pre-existing Condition (U.S. citizens)
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Medical
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Up to $5,000 of eligible expenses
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Emergency Medical Evacuation
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Up to $25,000 of eligible costs and expenses
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OPTIONAL ADD-ON PLAN
Standard Short-Term Travel Plan
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Baggage
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Loss/theft of Baggage
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$250
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Loss/theft of Valuables
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$250
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Loss/theft of Personal Papers
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$250
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Legal Assistance
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Binder Fee
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$500 when served with summons
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Personal Liability
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Injury to third party
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$2,000 limit after $100 deductible
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Damage to third person property
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$500 limit after $100 deductible. Secondary to any other insurance in force
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Limited High School Sports Coverage
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This is a summary of benefits only. Please see below
for a list of benefit and optional add-on descriptions.
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A. $50,000 per illness/injury
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$41.10
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$43.15
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B. $250,000 per illness/injury
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$51.10
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$53.65
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C. $500,000 per illness/injury
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$53.90
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$56.55
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A. $50,000 per illness/injury
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$30.55
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$32.05
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B. $250,000 per illness/injury
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$37.80
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$39.65
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C. $500,000 per illness/injury
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$40.00
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$42.00
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A. $50,000 per illness/injury
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$25.55
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$26.85
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B. $250,000 per illness/injury
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$31.10
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$32.65
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C. $500,000 per illness/injury
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$33.35
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$35.00
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All premium rates are effective through 12/31/09. Rates include surplus lines tax where applicable. A dependent child is your child shown on the Application Form over 14 days and under 18 years of age, traveling with you, and for
whom premium has been paid.
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The optional rider is available on all plans and applies to all individual listed on the Application Form.
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Sports Rider
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Up to Policy Maximum
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This is a summary of the optional rider benefit only. Please see below for the optional rider description.
This is a discount savings program available to every certificate holder of the Patriot Exchange Program plans. This program allows card members to purchase prescriptions at one of over 35,000 participating pharmacies in the U.S. and receive the lower of 1) Universal Rx contract price or 2) the pharmacy regular retail price.
This discount program is not insurance coverage. It is purely a discount program to purchasers of the Patriot Exchange Program plans. Use of the discount card does not guarantee that prescribed medication is covered under the insurance benefit plan.
Your satisfaction is very important to IMG and the plan underwriter. If you are not pleased with this product for any reason, you may submit a written request, prior to your effective date, for cancellation and refund of your premium.
1. Coverage and benefits are subject to the deductible and coinsurance, and all terms of the certificate of coverage and Master Policy.
2. Coverage under a Patriot Exchange Program plan is secondary to any other coverage.
3. Coverage and benefits are for medically necessary and usual, reasonable and customary charges only.
4. Charges must be administered or ordered by a physician.
5. Charges must be incurred during the Period of Coverage.
6. Claims must be presented to IMG for payment within the Period of Coverage or during the three months immediately following the Period of Coverage.
The following conditions apply to all persons applying for and/or enrolling in a Patriot Exchange Program plan.
· · The member must be actively engaged or participating in an educational or cultural exchange program in the country of assignment through a sponsoring organization or school.
· · The member and his/her traveling dependents must have legally departed the Home Country and entered the Host Country and must not be a citizen of the Host Country.
If the Short-Term plans are purchased for a minimum of three months, coverage may be renewed (without break in coverage) for a total of up to 48 months. Renewals may be completed by using a paper application.
Short-Term Travel Plans - Before you
begin traveling, simply fill out the
Application Form and calculate the premium for the time period you and your family will be traveling. Once the Application Form is completed, return it to us. You, your spouse and unmarried dependent children (over 14 days and under 18 years of age) listed on the Application Form and for whom premiums have been paid will be covered from the latest of the following dates: 1) the date IMG receives your completed Application Form and the appropriate premium; 2) the date you depart from your country of citizenship; or 3) the date requested on the Application Form.
Patriot Exchange Program coverage ends on the earliest of the following dates: 1) the end of the period for which premium has been paid; 2) the date requested on the Application Form; or 3) the date you return to your country of residence.
Short-Term Travel Plans - IMG normally processes Application Forms within 24 hours of receipt. Once processing is complete, IMG will mail a fulfillment kit to the mailing address listed on the Application Form. The fulfillment kit will include an IMG Identification Card, IMG contact numbers, Claim Forms and your insurance certificate providing a complete description of your rights and benefits under the contract. Please note: If express mail delivery is required, there is an additional charge listed on the Application Form.
Each proposed hospital admission, inpatient or outpatient surgery, and other procedures as noted in the Certificate Wording must be Precertified for medical necessity, which means the insured person or their attending physician must call the number listed on the IMG Identification Card prior to admittance to a hospital or performance of a surgery. In case of an Emergency Admission, the Precertification call must be made within 48 hours of the admission, or as soon as reasonably possible. If a hospital admission or a surgery is not Precertified, eligible claims and expenses will be reduced by 50%. It is important to note that Precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits or a guarantee of payment. All medical expenses must meet usual, reasonable, customary, and eligible payment guidelines. Please refer to the Certificate Wording for full details of the precertification requirements.
For precertification, emergency evacuation and repatriation, please call: IMG in the U.S.: 1.800.628.4664 (toll free) or 1.317.655.4500. Call IMG outside the U.S.: 001.317.655.4500 (collect if necessary). This information will also be provided on your ID card.
Note: An insured person may begin the precertification process at IMG's website. Simply click the "Current Clients" title, then click the
"Initiate Precertification" option. You will be asked to provide the required information, which can then be submitted electronically to IMG. The Medical Department at IMG will notify you upon receipt of the email, and once IMG has received the request, our utilization management and review team will review the information provided and respond to the insured person or the provider within 48 business hours. Please note that this online service will only initiate the precertification process, and it should not be used to precertify emergency admissions, procedures or evacuations.
All benefits payable under Patriot Exchange Program are subject to the provisions described in this brochure and as contained in the Certificate Wording and certificate of coverage. To make claim processing efficient, claims may be paid in two ways:
1. Eligible claims that have been paid by or on behalf of the Insured Person will be reimbursed by check directly to the Insured Person.
2. Eligible claims that have not yet been paid by the Insured Person will, at the option of IMG, be paid either to the Insured Person or directly to the provider.
Please mail completed claim forms to International Medical Group, P.O. Box 88500, Indianapolis, IN 46208-0500 USA. All IMG contact numbers, claim forms and Certificate Wordings will be included in the fulfillment kit. IMG may also be contacted by fax: 1.317.655.4505.
The following is a partial list of benefits and terms that are offered on the Patriot Exchange Program plans.
EMERGENCY ROOM:
Charges incurred for the use of the Emergency Room due to an accident.
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:
Injury due to an accident - The Standard Short-Term Travel Plan covers the cost of emergency dental treatment and dental procedures necessary to restore sound natural teeth lost or damaged in an accident.
Sudden dental pain - The Standard Short-Term Travel Plan will pay for the necessary treatment of sudden, unexpected pain to sound natural teeth.
SUDDEN RECURRENCE OF A PRE-EXISTING CONDITION (U.S. CITIZENS ONLY):
Up to $5,000 will be paid for the eligible expenses of a sudden and unexpected recurrence of a Pre-existing Condition (defined below) while traveling outside of the U.S. In addition, up to $25,000 will be paid 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.
INTERNATIONAL EMERGENCY CARE
POLITICAL EVACUATION:
If the United States Department of State, Bureau of Consular Affairs issues a mandatory evacuation order of the host country 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 lifetime maximum for transportation to the nearest place of safety or for repatriation to the insured person’s home country or country of residence provided that:
1. The Insured Person contacts the Company within 10 days of the United States Department of State, Bureau of Consular Affairs issues the evacuation order;
2. Political Evacuation and Repatriation is approved and coordinated by the Company.
EMERGENCY EVACUATION:
Each 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.
EMERGENCY REUNION:
Each plan provides emergency reunion coverage 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. The coverage also includes a round trip air ticket for a relative if the member is hospitalized for seven days or longer.
RETURN OF MORTAL REMAINS:
If a covered illness/injury results in death, expenses for Repatriation of bodily remains or ashes to the home country will be covered.
ACCIDENTAL DEATH AND DISMEMBERMENT:
Each plan includes a 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 - principal sum. "Member" means hand, foot or eye.
TERRORISM:
Each 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 for eligible medical claims. 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 in order 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 6 months prior to the insured person's date of arrival.
This benefit also does not cover an act of Terrorism in the event that 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.
LOST LUGGAGE:
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.
SPORTS RIDER:
The Sports Rider adds coverage for jet skiing, scuba diving, snow skiing, snowboarding, snowmobiling, snorkeling, surfing, wake-boarding, water skiing and windsurfing.
Charges for the following services, treatments and/or conditions, among others, are excluded from coverage under the Patriot Exchange Program plans.
1. 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 during the three years prior to the effective date of the insurance, whether or not previously manifested or symptomatic, diagnosed, treated, or disclosed prior to the effective date, including any subsequent, chronic or recurring complications or consequences related thereto or arising therefrom.
2. Treatment or surgeries which are elective, investigational, experimental or for research purposes.
3. War, military action, terrorism, political insurrection, protest, or any act thereof. The Company will not pay for a Political Evacuation if there is a travel advisory in effect on or within six (6) months prior to the Insured Person’s date of arrival in the Host Country.
4. Immunizations and routine physical exams.
5. Treatment of Temporomandibular Joint or dental treatment, except as expressly provided for in the certificate of insurance.
6. Venereal disease, AIDS virus, AIDS related illness, ARC Syndrome, or AIDS, and 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.
7. Pregnancy, childbirth, birth control, artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
8. 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.
9. Vision or ear tests and the provision of visual or hearing aids.
10. Vocational, recreational, speech or music therapy.
11. Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services.
12. 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.
13. Treatment for, and injuries and/or illnesses resulting or arising from, substance abuse or drug addiction.
14. 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.
15. Willful self-inflicted injury or illness.
16. Treatment required as a result of or arising from complications from a treatment or condition not covered under the certificate.
17. Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured.
18. Treatment for mental and nervous disorders.
19. Organ or tissue transplants or related services.
20. Illness or injury where the trip to the host country is undertaken for treatment or advice for such illness or injury, except as expressly provided for in the certificate of insurance.
21. Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).
22. Charges for Treatment of a Chronic Illness incurred beyond sixty (60) days from the date of initial Treatment thereof.
This brochure contains only a consolidated and summary description of all current Patriot Exchange Program 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/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.
U.S.-based administration & European Service Center:
Fast, efficient services and availability when and where you need it
On-site executive Medical Director/physician and registered nurses:
Provides 24 hour access to highly qualified
coordinators of emergency medical services
and international treatment
Multilingual claims adjudication
and customer service:
Ability to submit claims from any country and
communicate without language barriers
Verification of benefits and claim status inquiries available by phone, fax, internet and email:
Convenient contact with IMG at anytime from
anywhere to reduce your worries during
treatment and recovery
International currency conversions and claim reimbursements via check, direct
deposit and electronic transfer:
Helps eliminate costly conversion fees
and provide expedient receipt of funds
MyIMGSM:
Provides you with 24 hour secure access from anywhere in the world and the ability to manage your account at anytime for true Global Peace of Mind®
Plan Administrator:
As the Plan Administrator for Patriot Exchange Program SM,
IMG acts as the authorized agent for and on behalf of Sirius International.
International Medical Group ®, Inc.
P.O. Box 88509
Indianapolis, IN 46208-0809, USA
Plan Underwriter:

These Patriot Exchange Program plans are surplus lines products underwritten by Sirius
International Insurance Corporation (publ), rated A (excellent) by A.M. Best and A-
by Standard and Poor's (at the time of printing). Sirius International is a
White Mountains Re Company.
IMG, International Medical Group, the IMG block design logo, imglobal, Patriot Exchange Program, ACM, Akeso, Akeso Care Management, the ACM block design logo, and Coverage without Boundaries are the trademarks, service marks and/or registered marks of International Medical Group, Inc.
Sirius, Sirius International, and the Sirius design logo are the trademarks, service marks and/or registered marks of Sirius International Insurance Corporation (publ).
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