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Accident & Sickness Insurance for Travel Inside the U.S.
15 Days to 365 Days
Plan A - $50,000, Plan B - $100,000, Plan C - $250,000, Plan D - $500,000, Plan E - $1,000,000;
Persons age 60-69 are eligible for plan A, B, and C. Persons age 70 - 79 are eligible for plans A and B; Persons age 80+ are eligible for a maximum benefit of $20,000.
$0, $50, $100, $250, $500, $1,000, $2,500, $5,000 per person/plan period
After you pay the selected deductible, the plan pays 80% up to $5,000 of eligible costs, then 100% to the Medical Maximum. There will be an additional $250 deductible for each emergency room visit as a result of an Illness. The emergency room deductible will be waived if hospital admittance is within 12 hours of the incident.
24 Months prior to the start date of coverage
$500,000
$50,000
$50,000
$50,000
$5,000
$50 per article; up to a maximum of $250
Accident: Usual & Customary Expense
Palliative: $100
$25,000 (Enhanced Benefit Amounts available) with paralysis and coma, seat belt and airbag, felonious assault and home alteration and vehicle modification benefits.
$50,000
Travel insurance designed to cover and Non-U.S. Residents traveling to the United States. This valuable travel protection is ideal for students, business and leisure travelers, study abroad, international exchange students, tourists, holiday travelers, and church or missionary travelers.
Nationalized or government sponsored health plans rarely provide adequate medical coverage for injuries or illnesses which occur in the United States. Most travelers are unaware of how expensive medical care is in the United States. Not to mention, that U.S. medical facilities may not recognize insurance provided by a "foreign" insurance company and could deny services or demand up-front payment for treatment.
This brochure is meant to be a brief summary of the plan features only for the Diplomat America Plan and does not cover all the terms, conditions and limitations of the Plan Document. If there is any conflict between this brochure and the Plan Document, the Plan Document will govern in all cases. Benefits and plan costs are subject to change.
The Diplomat America provides Accident and Sickness Medical Coverage and AD&D benefits those traveling outside their Home Country to the United States. Applicant must reside outside of the United States. Coverage is available for you, a second adult, unmarried dependent Children, or Children traveling alone. Travel assistance services are also available.
The minimum period of coverage that can be purchased is 15 days, the maximum is 365 days.
A Person will become a Plan Participant under the Plan Document, provided proper premium payment is made, on the latest of:
Insurance for a Plan Participant will end on the earliest of:
The Diplomat America plan was designed mainly to provide accident & sickness and evacuation coverage for foreign nationals traveling inside the USA. It is also available to US citizens returning to the US for vacation or business trips while living abroad. A valid international address is required in order to apply.
All plan cost and benefits will be paid in U.S. dollars. We will pay Usual and Customary charges for Covered Expenses incurred during your travel. Benefits in excess of your chosen deductible and co-insurance, up to the selected Medical Maximum will be considered for payment. The initial Treatment of an Injury or Illness must occur within 30 days of the date of Injury or onset of Illness.
Only such Expenses that are specifically enumerated in the following list of charges that are incurred for medical care and supplies which are: (a) necessary and customary; (b) prescribed by a Physician for the therapeutic treatment of a disablement; (c) are not excluded under the policy; (d) are not more than the Usual and Customary charges (as determined by the Company); and (e) are incurred within 180 days from the date of the Disablement will be considered.
The charges enumerated above shall in no event include any amount in excess of the Usual and Customary charges (as determined by the Company).
To determine if Expenses are Usual and Customary, the Company will consider the following: the medical care or supplies usually given and the fees usually accepted for like cases in the area. "Area" means a region large enough to get a cross section of providers or medical care or supplies. All Expenses are deemed to be incurred on the date such service is received.
Benefits are paid for Usual and Customary Expense for emergency Dental Treatment to natural teeth.
Benefits are paid for Usual and Customary Expense up to $100 for the emergency Treatment for the relief of pain to natural teeth.
Benefits are paid for Covered Expense incurred up to $500,000. The decision for an Emergency Medical Evacuation or Repatriation must be pre-approved and arranged by the Assistance Company in consultation with Your local attending Physician. Emergency Medical Evacuation or Repatriation means: a) Your medical condition warrants immediate transportation from the place where You are located (due to inadequate medical facilities) to the nearest adequate medical facility where medical Treatment can be obtained; b) After being treated at a local medical facility, Your medical condition warrants transportation with a qualified medical attendant to Your Home Country to obtain further medical Treatment or to recover; c) Both a. and b. above. Non-Emergency use of special transportation is excluded from this plan.
If You should die, Benefits will be paid for Expenses incurred up to $50,000 to return Your remains to Your Home Country. All Covered Expense in connection with a Return of Mortal Remains or Cremation must be pre-approved and arranged by the Assistance Company.
If the Plan Participant is a non-U.S. citizen, under age 70, traveling in the United States, he or she is covered for an Acute Onset of a Pre-existing Condition(s). This benefit does not apply to Plan Participants age 70 or older. Acute Onset of a Pre-Existing Condition(s) shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.
When it is determined that it is necessary and prudent for You to have an Emergency Medical Evacuation or Repatriation, this Plan will arrange to bring an individual of Your choice, from Your current Home Country, to be at Your side while You are hospitalized and then accompany You during Your return to Your current Home Country. Benefits will be paid up to $50,000 for reasonable travel and accommodation Expense up to a maximum of 10 days, as pre-approved and arranged by the Assistance Company.
The Plan will pay for these services up to a maximum of $50,000 provided all transportation and services are pre-approved and arranged by the Assistance Company.
If Your trip is interrupted due to one of the following reasons: 1) Death of an Immediate Family Member; 2) Serious damage to Your principal residence from fire, flood or similar Natural Disaster (tornado, earthquake, hurricane, etc.). Benefits will be paid up to $5,000 for the expense of economy return travel ticket to return you to your area of principal residence.
Coverage is provided up to $50,000 if the Insured requires emergency evacuation, which places him/her in Imminent Bodily Harm or due to a Natural Disaster, which makes his/her location Uninhabitable. The Assistance Company shall arrange, and the plan will pay for Insured's transportation to the nearest safe location. If evacuation becomes impractical due to hostile or dangerous conditions, the Assistance Company will maintain contact with and advise the Insured until evacuation becomes viable or the Natural Disaster situation has been resolved. Should commercial flights be available, but transportation to the airport will place the Participant in Imminent Bodily Harm, the Assistance Company shall arrange and pay for his/her secure transport to the airport. No benefit shall be payable if there is a travel warning in effect within 30 days prior to the insured person's date of arrival in the host country. The Assistance Company must make all arrangements for the Insured. Services rendered without the Assistance Company's coordination and approval is not covered. No claims for reimbursement will be accepted. Expenses for non-emergency transportation are the responsibility of the Participant.
This plan will reimburse You for loss, theft, or damage to Your baggage or personal effects, checked with a Common Carrier. This plan is secondary to any coverage provided by a Common Carrier and all other valid and collective insurance. $50 per article, to a maximum of $250.
Coverage under all provisions of the plan is provided up to a maximum of 15 days for Incidental Trips to Canada, Mexico, and the Caribbean Islands only. Incidental Trip means temporary travel (not more than 15 days) outside of the United States to Canada, Mexico, and the Caribbean Islands only. NOTE: Incidental Trips does not: 1) Provide coverage in your Home Country; and 2) Extend coverage beyond the coverage dates of the plan. Participant is responsible for having their Passport stamped when entering and exiting the visited country.
If within 365 days after the date of a Covered Accident, the Insured Person's Injury results in death or dismemberment, this Plan provides the following benefits for loss of:
Description of Loss | Indemnity |
---|---|
Life | 100% of Principal Sum |
Both Hands or Both Feet or Sight of Both Eyes or One Hand and One Foot or Either Hand or Foot and Sight of One Eye: | 100% of Principal Sum |
Speech and Hearing in both Ears | 100% of Principal Sum |
Speech or Hearing in both Ears | 50% of Principal Sum |
Either Hand or Foot or Sight of One Eye | 50% of Principal Sum |
Thumb and index finger of same hand | 25% of Principal Sum |
The amount of the Principal Sum is $25,000. If the Enhanced AD&D Benefit purchased, the $25,000 is included in the total benefit amount.
The maximum AD&D benefit for Diplomat America is $1 million of coverage, $25,000 if under 18 years of age.
If the body of an Insured Person has not been found within one year of the disappearance, forced landing, stranding, sinking, or wrecking of a conveyance in which such person was an occupant, then such Person shall have suffered loss of life within the meaning of the plan.
If a Covered Accident renders an Insured Person Paralyzed within 365 days of the date of the Covered Accident that caused the Injury, in any one of the types of paralysis specified below:
Type of Paralysis (Loss) | Indemnity |
---|---|
Quadriplegia | $25,000 |
Paraplegia | $18,750 |
Hemiplegia | $12,500 |
Uniplegia | $6,250 |
If a covered Injury renders an Insured Person Comatose within 90 days of the date of the accident that caused the Injury, and if the Coma continues for a period of 30 consecutive days, The Company will pay a monthly benefit of $250. No benefit is provided for the first 30 days of the Coma. The benefit is payable monthly as long as the Insured remains Comatose due to that Injury, but ceases on the earliest of: 1) the date the insured ceases to be Comatose due to the Injury; 2) the date the Insured dies; 3) the date the total amount of monthly Coma Benefit paid for all Injuries caused by the same accident equals $25,000.
The Company will pay a $25,000 benefit when the Insured Person suffers accidental death such that an Accidental Death benefit is payable under the plan and the accident causing death occurs while the Insured Person is operating, or riding as a passenger in an Automobile if: 1) You are wearing a properly fastened seat belt, properly installed by a factory authorized dealer; and 2) You were positioned in a seat protected by a properly functioning Supplemental Restraint System, properly installed by a factory authorized dealer that inflates on impact. This benefit is in addition to any other Expenses of the program.
The Company will pay a $25,000 benefit when an Insured Person suffers one or more losses for which benefits are payable under the Accidental Death & Dismemberment Benefit or Coma Benefit provided by the plan as a result of a Felonious Assault. Only one benefit is payable for all losses as a result of the same Felonious Assault. This benefit is in addition to any other Expenses of the program.
The Company will pay Covered Home Alteration and Vehicle Modification Expenses that are incurred within one year after the date of the accident causing such loss(es), up to a maximum of $2,500 for all such losses caused by the same accident.
After you enroll in the Diplomat America you are eligible to use any of the assistance services provided by On Call International.
The Plan Document does not cover any loss resulting from any of the following unless otherwise covered under the Plan Document by Additional Benefits:
In addition to any of the exclusions listed above, for Eligible Expenses under Trip Interruption, this Insurance also does not cover the following:
In addition to any of the exclusions listed above, for Eligible Expenses under Baggage Loss, this Insurance also does not cover the following:
Coverage is not available for residents of the United States or citizens of Australia or Iran or any travel outside the United States.
A refund of the plan cost, less a $25 processing fee, will be considered only when written request is received by Global Underwriters prior to the Effective Date of Individual coverage. After the Effective Date of Individual coverage, the plan cost is considered fully earned and non-refundable. Partial refunds are not available.
Coverage under this Plan is not renewable. If additional coverage time is needed, a new application and subscription agreement must be completed and correct plan cost submitted to Global Underwriters Agency. A new Deductible, Coinsurance, other limits, and Pre-existing Condition Exclusion will apply at each succeeding or subsequent Period of Coverage.
All Coverage, except Accidental Death & Dismemberment, shall be in excess of all other valid and collectible insurance.
Subscription Agreement - I hereby apply to be a Plan Participant of the Fairmont Specialty Trust (the "Trust") and to participate in the insurance coverage extended by certain underwriters at C&F Cayman SPC ('the Insurers') to Plan Participants under the Trust (the "Coverage"). I understand that the Coverage is not a general health insurance product, but is intended for use in the event of a sudden and unexpected event while traveling outside my Home Country. I understand that the Coverage extended to me will terminate upon my return to my Home Country unless I qualify for a Benefit Period or Home Country Coverage. I understand that I may obtain full details of the Coverage by requesting a copy of the Master Policy from the Plan Manager. I understand that the liability of the Insurers as underwriters of the Coverage is as provided in the Master Policy. By acceptance of coverage and/or submission of any claim for benefits, the Plan Participant ratifies the authority of the signer to so act and bind the Plan Participant. The Plan Participant undertakes to make all premium payments as they fall due in respect of the Coverage extended to them. The Trustee shall not be responsible for the administration of such payments. If the Plan Participant fails to make any premium payment due in respect of the Coverage extended to them, subject to the discretion of the Insurance Company, such Coverage will lapse. The Plan Participant hereby confirms the accuracy of all information validity of all representations and warranties provided to the Trustee in connection with its participation in the Plan and/or the subscription for the insurance coverage, howsoever provided, including the terms of this Subscription Agreement, (together "Representations & Warranties"). The Plan Participant acknowledges that certain of such information will be relied upon by the Insurers as providers of the Coverage and that any inaccuracy therein may result in the invalidity of such Coverage as it relates to the Plan Participant, the loss of Coverage and all monies paid in relation thereto. The Plan Participant hereby undertakes to inform the Trustee of any change to any of matter that forms the subject of any of the Representation & Warranties. The Plan Participant hereby undertakes to indemnify and hold harmless the Trustee against any loss or damage (including attorney's fees) occasioned by any inaccuracy in any Representation & Warranty or failure to advise the Trustee of any change in any matter that forms the subject of any of the Representation & Warranties. The Plan Participant agrees that the Trustee shall be entitled to rely on and to act in accordance with any written instruction purported to be provided by the Plan Participant and the Plan Participant hereby undertakes to indemnify and hold harmless the Trustee against any loss or damage (including attorney's fees) occasioned by the Trustee acting in accordance with any such instruction. Payments under the terms of the Coverage shall be paid by the Insurers to the Plan Participant or directly to a provider if assignment of benefits has been authorized. The Trustee shall not be responsible for the administration of such payments. I confirm that I have satisfied myself that the coverage is appropriate for me and that I meet the eligibility criteria.
Complaints - In the event that You are dissatisfied and wish to make a complaint You can do so to the Complaints team at Global Claims Administration at 1-800-513-2981 or 513-533-1330.
Please keep this Evidence of Coverage as a general summary of the insurance as specified in the Plan Document issued to and on file with Diplomat America. The Plan Document contains a complete description of all of the terms and conditions including: the benefits, provisions, exclusions of the insurance plan as underwritten by C&F Cayman SPC for and on behalf of ITI SP. The Plan Document will prevail in the event of any discrepancy between this Evidence of Coverage and the Plan Document.
This insurance is not subject to, and does not provide certain insurance benefits required by the United States' Patient Protection and Affordable Care Act ("PPACA"). PPACA requires certain US citizens or US residents to obtain PPACA compliant health insurance, or "minimum essential coverage." PPACA also requires certain employers to offer PPACA compliant insurance coverage to their employees. Tax penalties may be imposed on U.S. residents or citizens who do not maintain minimum essential coverage, and on certain employers who do not offer PPACA compliant insurance coverage to their employees. In some cases, certain individuals may be deemed to have minimum essential coverage under PPACA even if their insurance coverage does not provide all of the benefits required by PPACA. You should consult your attorney or tax professional to determine whether this policy meets any obligations you may have under PPACA. This plan is not designed to cover US residents. This policy is not subject to guaranteed issuance or renewal.
With $250 deductible | |||||
---|---|---|---|---|---|
Plan A - $50,000 | Plan B - $100,000 | Plan C - $250,000 | Plan D - $500,000 | Plan E - $1,000,000 | |
Ages 18-29 | $1.60 | $1.89 | $2.09 | $2.43 | $2.92 |
Ages 30-39 | $2.13 | $2.55 | $2.81 | $3.21 | $3.76 |
Ages 40-49 | $3.21 | $3.70 | $4.16 | $4.91 | $5.50 |
Ages 50-59 | $4.66 | $5.70 | $6.19 | $6.98 | $8.02 |
Ages 60-64 | $5.87 | $7.20 | $7.72 | N/A | N/A |
Ages 65-69 | $6.70 | $8.60 | $8.88 | N/A | N/A |
Ages 70-79 | $9.05 | $12.23 | N/A | N/A | N/A |
80+ ($20K max) | $19.10 | N/A | N/A | N/A | N/A |
Dependent Child | $1.04 | $1.14 | $1.28 | $1.43 | $1.53 |
Child Alone | $1.53 | $1.83 | $2.04 | $2.30 | $2.58 |
This plan is for individuals while traveling outside their home country and inside the USA. Diplomat America must be purchased for a minimum of 15 days.
Enhanced AD&D Benefit Rates (Per Person / Month) *Enhanced AD&D amount and additional rate only apply to age 18+ | |
---|---|
$100,000 Total Coverage | $6.00 |
$250,000 Total Coverage | $18.00 |
$500,000 Total Coverage | $38.00 |
$750,000 Total Coverage | $58.00 |
$1,000,000 Total Coverage | $78.00 |
Total AD&D coverage includes the $25,000 base amount.
Provides coverage if Your Injury or Illness results from the below enumerated Athletic Sports & Hazardous activities. NOTE: Any Athletic Sport & Hazardous Activity not expressly covered hereunder is excluded from this policy unless the activity is approved by the company prior to purchase or the activity is non-contact and engaged in by You solely for leisure, recreation, entertainment, or fitness purposes only.
BMX; Bobsledding; Bungee Jumping; Canoeing/Kayaking; Canopying; Cave tubing; Hang Gliding; Horseback Riding; Hot Air Ballooning; Jet Skiing; Martial Arts/Karate (Non-competitive); Motor Scooter; Motorcycling; Mountain Biking; Piloting any Non-commercial Aircraft; Safari; Scuba Diving (Not to exceed 30 feet, Resort Course or equivalent required); Snow Skiing (Recreational); Snowboarding(Recreational); Snowmobiling; Spelunking/Caving; Surfing (Recreational); Trekking (Not exceeding Class IV Difficulty on Yosemite Decimal System); Wakeboarding; Water skiing; Whitewater Rafting (Class I through V rapids); Wind Surfing; Zip Lining.
Aerial Photograph (Use of proper restraints required); BMX (Racing or Competitive); Flying in any chartered/leased aircraft or helicopter; Heli-skiing; High Diving; Hot Air Ballooning (As a pilot); Mountain Climbing (14,000 ft. & below - Ropes & proper safety equipment required); Parachuting; Paragliding; Parasailing; Parascending; Rock Climbing (Ropes & proper safety equipment required); Scuba Diving (Below 30 feet, PADI/NAUI Certification required, or insured must be accompanied by a certified diving instructor); Skydiving; Snow Skiing Off-Piste.
Big Game Hunting (Use of Firearms); Diving with Sharks; Mountain Climbing (14,000 ft. & above - Ropes, proper safety equipment & certified guide required); Running with the Bulls; Security Detail (use of firearms).
Under this enhancement, the Benefit is reduced to $20,000 for any Covered Injury or Illness resulting from:
Ballet; Baseball; Cheerleading; Cross Country; Diving; Equestrian; Fencing; Field Hockey; Golf; Polo (Horse); Polo (Water); Rowing; Softball; Surfing; Swimming; Tennis; Track & Field; Volleyball.
Basketball; Competitive Cycling (Road, Track, CX); Ice Hockey; Inline Skating (Helmet & Proper Equipment Required); Lacrosse; Martial Arts/Karate; Modern Pentathlon; Skiing (Slalom, Giant Slalom, Downhill); Ski Jumping; Wrestling.
Football (No Division One); Gymnastics; Rugby (No Division One); Soccer.
Diplomat America is designed and administered by the company. With over 50 years of experience in the insurance industry, the administrator has established itself as a leader in the development, administration and marketing of international health and life insurance products. We offer exceptional International Travel Accident and Sickness coverage for groups and individuals. So whether you're traveling on business, vacationing, or are residing in a foreign country, we have a plan designed just for you.
Diplomat America is Underwritten by C&F Cayman SPC for and on behalf of ITI SP; rated "A" (excellent) by A.M. Best.
Toll Free:
+1 (866) INSUBUY
Phone:
+1 (972) 985-4400
Fax:
+1 (972) 767-4470
Website:
www.insubuy.com
Version:
12/2020
Release: 12/2020
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