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Patriot Executive
Medical insurance for traveling executives
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As an executive who travels
frequently throughout the
year, you have plenty of
responsibilities. You don’t
want to think about your medical
coverage while you’re
abroad. But what would happen
if you became ill or injured
during your trip?
Most executives assume they
will be covered by their standard
medical plan. The truth is,
while traditional plans offer
adequate domestic coverage, they are not designed for international
travel.
You have enough to worry about when you’re traveling. Don’t
let your medical coverage be an uncertainty. International
Medical Group® (IMG®) has developed two Patriot Executive®
plans to provide you Coverage Without Boundaries® so you
can spend more time enjoying your international experience,
and spend less time worrying about your medical security.
The two Patriot Executive plans offer a complete package of international
benefits available 24 hours a day. Patriot Executive
International is a plan for U.S. citizens that provides coverage for
executives traveling outside the U.S., while Patriot Executive
America is a plan for non-U.S. citizens that provides coverage for
executives traveling outside their home country. Both plans provide
coverage for you, your spouse and/or children for each trip
taken outside your home country during a period of up to one
year, in accordance with the terms of the plan.
Additionally, the plans offer excellent benefits and services to
meet your global needs. You have access to international, multilingual
customer service centers, claims administrators who
process claims from all over the world, handling virtually every
language and currency, and 24 hour access to highly qualified
coordinators of emergency medical services and international
treatment. You also have access to more than 17,000 providers
when seeking treatment outside the U.S. using our International
Provider Accesssm(IPA). You can also reduce your out-of-pocket
costs when seeking treatment in the U.S. by locating providers
through the independent Preferred Provider Organization.
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®.
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Maximum Limit
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$1,000,000
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Individual Deductible
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$250 per each covered illness
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Coinsurance - for treatment
received outside the U.S. & Canada
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No Coinsurance
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Coinsurance - for treatment
received within the U.S. & Canada
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In the PPO Network - The plan pays
90% of eligible expenses up to
$5,000, then 100% up to the
Maximum Limit
Out of the PPO Network - The plan
pays 80% of eligible expenses up to
$5,000, then 100% up to the
Maximum Limit
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MyIMGsm
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24 hour secure access from
anywhere in the world to manage
your account at anytime
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World-class Medical Benefits
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Coverage available for in-patient and
out-patient medical expenses
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International Emergency Care
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A wide range of international emergency
benefits available including
emergency evacuation, emergency
reunion, return of mortal remains,
return of minor children and more
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All coverages, benefits and premium amounts shown in this brochure are in U.S. dollars.
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MEDICAL BENEFITS
Usual, reasonable and customary charges. Subject to deductible and coinsurance.
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Hospital Room and Board
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Up to the Maximum Limit for
average semi-private room rate
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Intensive Care
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Up to the Maximum Limit
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Medical Expenses
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Up to the Maximum Limit
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Out-patient Medical Expenses
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Up to the Maximum Limit
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Local Ambulance
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Up to the Maximum Limit
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Emergency Room Accident
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Up to the Maximum Limit
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Emergency Room Illness with
In-patient Admission
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Up to the Maximum Limit
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Emergency Room Illness without
In-patient Admission
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Up to the Maximum Limit with
additional $250 deductible
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Dental - Injury Due to Accident
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Up to the Maximum Limit
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Dental - Sudden Dental Pain
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Up to $100
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INTERNATIONAL EMERGENCY CARE
When coordinated through the Plan Administrator.
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Emergency Medical Evacuation
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Up to the Maximum Limit
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Emergency Reunion
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Up to $15,000
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Return of Mortal Remains
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Up to $25,000
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Return of Minor Children
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Up to $5,000
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Political Evacuation
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Up to $10,000
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Identity Theft Assistance
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Up to $500 per Period of
Coverage
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Pre-existing Conditions
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Up to $5,000 per period of
coverage
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ADDITIONAL BENEFITS
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Terrorism
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Up to $50,000 lifetime maximum
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Sports & Activities Coverage
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Up to the Maximum Limit for
basic sports
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Trip Interruption
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Up to $5,000
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Common Carrier
Accidental Death
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$50,000 to beneficiary; maximum
of $250,000 per family
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Accidental Death
& Dismemberment
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$25,000 principle sum
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Lost Luggage
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Up to $50 per item of luggage;
maximum of $250
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The benefits are a summary only.
Please see below for a list of descriptions.
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PATRIOT EXECUTIVE INTERNATIONAL RATES
Rates are through age 75*
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Maximum Trip Duration
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30 Days
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45 Days
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Annual Premium
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$200
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$245
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Spouse and two children
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$100
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$122
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Each additional child
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$40
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$49
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PATRIOT EXECUTIVE AMERICA RATES
Rates are through age 75*
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Maximum Trip Duration
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30 Days
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45 Days
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Annual Premium
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$236
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$289
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Spouse and two children
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$118
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$145
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Each additional child
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$47
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$58
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*The plan pays a Maximum Limit of $50,000 for travelers who are 70-75 years old.
Rates include surplus lines tax where applicable. Rates are effective through 3/31/2011.
- The Period of Coverage is for one year from the effective date of the Certificate of Coverage.
- Coverage and benefits are subject to the applicable deductible, and the other terms of the plan as contained in the complete Certificate Wording and Master Policy.
- Coverage under the Patriot Executive plan is secondary to any other coverage or contractual benefits.
- Coverage and benefits are for medically necessary, usual, reasonable and customary charges only. Benefits under the plan are available only for injuries and illnesses for which treatment is first obtained during the first 30 days of the trip.
- Charges must be administered or ordered by a physician.
- Charges must be incurred during the Period of Coverage.
- Claims must be presented to IMG for payment within the
Period of Coverage, or during the three months immediately
following the Period of Coverage.
- (U.S. citizens) You, your spouse and children are eligible for Patriot Executive International while traveling outside the United States if you: 1) are under the age of 76, 2) are covered by an individual or group medical plan, and 3) travel outside the United States frequently throughout the year.
- (Non-U.S. citizens) You, your spouse and children are eligible for Patriot Executive America while traveling outside your home country if you: 1) are under the age of 76, 2) are covered by an individual or group medical plan, and 3) travel outside your home country frequently throughout the year.
Although the Patriot Executive plan is not renewable, it can be rewritten for succeeding or subsequent coverage periods. New Deductible, Eligibility, Conditions of Coverage and Pre-Existing Condition Exclusions apply to any succeeding or subsequent Period of Coverage. A new application also must be completed.
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 the effective date, for cancellation
and refund of your premium.
You may either apply online for
Instant
Quotes & Purchase
or complete a Paper
Application
If you are applying online, no papers are required to be mailed
or faxed. If you are completing a paper application, you can
either fax the credit card applications to (972) 767-4470 or
mail all applications to
Insubuy ®, Inc.
4700 Dexter Dr, Suite 100
Plano, TX 75093 USA
You can apply over the phone as well by calling toll-free (866) INSU-BUY.
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:
- the date IMG receives your completed Application Form and the appropriate premium;
- the date you depart from your home country; or
- the date requested on your Application Form.
Patriot Travel Medical Insurance coverage ends on the earliest of the following dates:
- The end of the period for which premium has been paid;
- the date requested on your Application Form; or
- the date you return to your home country (however, see Home Country Coverage for incidental coverage).
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 you require express mail delivery, there is an additional charge listed on the Application Form.
For your convenience, you may choose to download your fulfillment kit from
our web site
rather than having it mailed to you.
To do this, you must check the appropriate box listed in Section 2 of the Application Form.
We must have your correct email address to complete this process.
Once IMG has received and processed your Application Form, you will receive an email from IMG that
contains all of the hyperlinks to easily obtain the fulfillment information through the Internet.
PRECERTIFICATION
Each proposed hospital admission and in-patient or out-patient surgery
must be Precertified for medical necessity, and requires the
Insured Person or their attending Physician to call the number listed
on the 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. Please review the
Precertification pamphlet and the certificate wording enclosed
with each fulfillment kit. All medical expenses must meet usual,
reasonable, customary, and eligible payment guidelines.
Note: You may begin the Precertification process through MyIMG or the Client Resources
section of our website, www.imglobal.com. Simply look for the Precertification option.
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.
CLAIM PAYMENT
All benefits payable under Patriot Executive are subject to the
complete terms and provisions contained in the Certificate
Wording. To make claim processing efficient, claims may be paid in
two ways.
- Eligible claims that have been paid by or on behalf of the
Insured Person will be reimbursed by check directly to the
Insured Person.
- Eligible claims that have not yet been paid by the Insured
Person will, at the sole option of the Company, be paid either
to the Insured Person or, as an accommodation to the Insured
Person, directly to the provider.
Please mail completed claim forms to: International Medical Group, P.O.
Box 88500, Indianapolis, IN 46208-0500 USA. All contact numbers, claim
forms and the complete Certificate Wording will be included in the fulfillment
kit. The Company may be contacted through IMG as Plan
Administrator by fax 1.317.655.4505
The following is a partial list of benefits and terms that are offered
on the Patriot Executive plans.
DEDUCTIBLE:
The deductible option is $250 per each covered illness. This deductible
is waived for claims incurred as a result of a covered accident.
EMERGENCY ROOM:
Charges incurred for the use of the
Emergency Room due to an accident are
covered up to the Maximum Limit.
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 - Each 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 Maximum Limit.
Sudden dental pain - Each plan will pay up to $100 for the necessary
treatment of sudden, unexpected pain to sound natural teeth.
PRE-EXISTING CONDITIONS:
The plan will cover up to $5,000 maximum, per insured person,
per period of coverage (not per trip), for the sudden and unexpected
recurrence of a Pre-existing Condition, as defined in the
Certificate Wording.
INTERNATIONAL EMERGENCY CARE
POLITICAL EVACUATION:
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:
- The Insured Person contacts the Company within 10 days of the
United States Department of State, Bureau of Consular affairs
issues the travel advisory;
- Political Evacuation and Repatriation is approved and coordinated
by the Company.
EMERGENCY EVACUATION:
The Patriot Executive plan includes coverage for emergency medical
evacuation 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. The plan will pay up to the
Maximum Limit for covered incidents for insured persons under age
66; up to $50,000 for covered incidents for insured persons from
ages 66 to 75; and up to $25,000 for evacuations resulting from a
pre-existing condition.
EMERGENCY REUNION:
The Patriot Executive plan also provides emergency reunion coverage,
up to $15,000 for a maximum of 15 days, for the reasonable
travel and lodging expenses of a relative or friend during an emergency
medical evacuation of the insured person: 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:
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 $25,000.
RETURN OF MINOR CHILDREN:
If an insured person is hospitalized due to a covered illness/injury
and is traveling alone with child(ren) 19 or under that otherwise
would be left unattended, the Patriot Executive plan will reimburse
up to $5,000 for one way economy fare to the home country,
including a chaperone, if necessary, for the safety of the child(ren).
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.
SPORTS & ACTIVITIES COVERAGE:
The Patriot Executive 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/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, windsurfing
and whitewater rafting.
ACCIDENTAL DEATH & DISMEMBERMENT:
The Patriot Executive 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 life which occurred during a hijacking, kidnapping
or attempted kidnapping - two times the principal sum* •
Accidental Loss of two Members - principal sum • Accidental Loss
of one Member - 50% of principal sum. "Member" means hand, foot
or eye. *Notwithstanding separate benefits, limits and sublimits for
Common Carrier Accidental Death benefit (page 4) and Accidental
Death & Dismemberment benefits (page 4), no more than $50,000 per
individual will be paid to a beneficiary in the event of any death that
occurs while covered by the Patriot Executive plan.
COMMON CARRIER ACCIDENTAL DEATH:
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. Notwithstanding separate
benefits, limits and sublimits for Common Carrier Accidental
Death benefit (page 4) and Accidental Death & Dismemberment
benefits (page 4), no more than $50,000 per individual will be paid
to a beneficiary in the event of any death that occurs while covered
by the Patriot Executive plan.
TRIP INTERRUPTION:
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, the Patriot
Executive plan will reimburse the insured up to $5,000 for the cost
of returning the insured to the area of principal residence. The plan
will cover reimbursement 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.
TERRORISM:
The Patriot Executive plan provides coverage for injuries and illness
incurred as a result of an act of Terrorism, subject to a $50,000 lifetime
maximum.
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. Claims incurred as a result of radiological,
nuclear, chemical or biological weapons or events are not covered.
Terrorism is 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.
This benefit does not cover an act of Terrorism in a country or location
where the United States government has issued a travel advisory
that has been in effect within the six months prior to the
insured person's date of arrival.
This benefit 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.
IDENTITY THEFT ASSISTANCE:
If an imposter obtains key personal information such as a Social
Security or Driver's License number, or other method of identifying
an insured person in order to impersonate or obtain credit, merchandise
or services in the insured person’s name, the Patriot
Executive 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.
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.
Charges for the following services, treatments and/or conditions,
among others, are excluded from coverage under the Patriot
Executive plan.
- Treatment for Pre-existing Conditions in excess of $5000, per Insured Person, per Period of Coverage (not per trip). 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 prior thereto, including any subsequent, chronic or recurring complications or consequences relating thereto or arising therefrom, whether or not previously manifested or known, diagnosed, treated, or disclosed.
- Treatment or surgeries which are elective, investigational, experimental or for research purposes.
- 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.
- Immunizations and routine physical exams.
- Treatment of Temporomandibular Joint or dental treatment, except as provided for in the Certificate of Coverage.
- Venereal disease, AIDS virus, AIDS related illness, ARC Syndrome, or AIDS, 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.
- Pregnancy, childbirth, birth control, artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
- 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.
- Vision or ear tests and the provision of visual or hearing aids.
- Vocational, recreational, speech or music therapy.
- Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services.
- 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.
- Treatment for, and injuries and/or illnesses resulting or arising from, substance abuse or drug addiction.
- 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.
- Willful self-inflicted injury or illness.
- Treatment required as a result of or arising from complications from a treatment or condition not covered hereunder.
- Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured.
- Treatment for mental and nervous disorders.
- Organ or tissue transplants or related services.
- Treatment for illness or injury where the trip is undertaken for the purpose of obtaining such treatment or advice for a Pre-existing Condition.
- Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).
This brochure contains only a consolidated and summary description of
all current Patriot Executive benefits, conditions, limitations and exclusions,
and is subject to all of the terms and conditions of the full Certificate
Wording. A certificate containing the complete Certificate Wording with
all terms, conditions and exclusions will be included in the fulfillment kit.
The Company 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.
MyIMGsm
Service at your fingertips anytime, anywhere - that’s what MyIMG provides.
MyIMG is our proprietary online service that allows you to
access information and manage accounts, 24 hours a day, seven days a
week, from anywhere in the world. Our service centers in the U.S. and
Europe are always available to help or handle emergencies 24 hours a
day, but through MyIMG you have immediate access to a wealth of
information about your account and can manage routine areas to help
you save time when you may need it most. Some features include:
- Get explanation of benefits
- Locate a provider
- Request ID cards
- Initiate precertification
- Obtain certificate documents
- Recommend provider/facility
Locating a Provider
With the Patriot Executive plans, you may seek treatment with the
hospital or doctor of your choice. When seeking treatment in the U.S.,
you can reduce your out-of-pocket costs by using the independent
Preferred Provider Organization (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. You can quickly search the network through MyIMG.
Additionally, to help you locate health care providers outside the U.S.,
IMG provides its online International Provider Access (IPA), a database
of over 17,000 providers.
Universal Rx Pharmacy Discount Savings
This is a discount savings program available to every certificate holder
of the Patriot Executive 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 Executive plans. Use of the discount
card does not guarantee that prescribed medication is covered
under the insurance benefit plan.
Akeso Care Management®(ACM®)
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 checkups
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.
Plan Administrator:
As the Plan Administrator for Patriot Executive ®, 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 Executive plans are a surplus lines
products underwritten by Sirius International Insurance Corporation
(publ). Sirius International is rated A (excellent) by A.M. Best and A?
by Standard & 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, Patriot Executive, Coverage Without Boundaries and Global Peace of Mind 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).
04/15/2010
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