Safe Travels USA

• Up to $1,000,000 Medical Maximum per Period of Insurance, Emergency Medical Evacuation, Medically Necessary Repatriation, Political and Natural Disasters Evacuation, Repatriation of Mortal Remains or Local Burial, Emergency Reunion, Wellness Benefit.
• This plan provides coverage to non-US citizens who reside outside the USA and are traveling outside of Their Home Country to visit solely the US, or to visit a combination of the US and other countries. It is not available to anyone age 90 or above
• This plan is not available to any individual who has been residing within the US for more than 365 days prior to their Effective Date
• Limited Coverage for an unexpected recurrence of a Pre-Existing Condition
• Coverage from 5 days to a maximum of 364 days
• Optional Sports Activity coverage and Return to Home Country coverage available

If coverage is purchased this benefit provides coverage to the Covered Person while performing, practicing, or participating in archery, tennis, swimming, cross country, track, volleyball, golf, ballet, baseball, basketball, cheerleading, equestrian, fencing, gymnastics, polo, rowing, soccer, and softball. Any Collision Sport, Extreme Sport or Sport Activity not expressly covered hereunder is excluded from this coverage. Professional and Semi-Professional sports are never covered.

If Coverage is purchased, the Covered Person may return to their Home Country for up to 60 days per 12 months of Coverage Purchased during the Period of Insurance for an Incidental Trip. If a Covered Injury or Sickness occurs while on their Incidental Trip, this benefit will pay to the maximum as outlined in the Schedule of Benefits for covered medical expenses incurred during the Incidental Trip. To be eligible for an Incidental Trip the Covered Person’s Period of Insurance must be greater than 30 days in length. If the Covered Person does not return from their Incidental Trip on their scheduled return date, the Coverage will be Terminated on the date of their scheduled return from their Home Country. If the Covered Person’s scheduled return date cannot be verified, the Coverage will terminate on the date the Covered Person departed for their Home Country. Any Injury or Sickness that occurred during the Incidental Trip will be considered a Pre-Existing Condition once the Incidental Trip has concluded and no further expenses for that Injury or Sickness will be covered.

24-hour travel assistance services are provided by On Call International.
*Not affiliated with Zurich Insurance Europe AG Belgian branch.

*Not subject to the Deductible
**This is a non-insurance service and is not a part of the insurance underwritten by Zurich Insurance Europe AG Belgian branch. See link for details on how to use Telemedicine.

Plan includes a $10 per person minimum premium

Max Limit: $50,000

Max Limit: $100,000

Max Limit: $250,000

Max Limit: $500,000

Max Limit: $1,000,000

Pre-certification is a general determination of Medical Necessity only.

• Inpatient Hospitalization, Surgery or Surgical procedure: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
• Deductible is taken after reduction.
• Coinsurance and Out of Pocket Maximum are applied to remainder of the reduced amount.
• Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met.
• Emergency Medical Evacuation or Medically Necessary Repatriation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION or MEDICALLY NECESSARY REPATRIATION provisions for complete requirements and coverage.
• Refer to the PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification.

All such determinations are made by the Company (acting through its authorized agents and representatives) in reliance and based upon the completeness and accuracy of the information provided by the Covered Person and/or their Relatives, guardians and/or healthcare providers at the time of Pre-certification. The Company reserves the right to challenge, dispute and/or revoke a prior determination of Medical Necessity based upon subsequent information obtained. Pre-certification is not an assurance, authorization, preauthorization, or verification of Treatment or coverage, a verification of benefits, or a guarantee of payment. The fact that Treatment or supplies are Pre-certified by the Company does not guarantee the payment of benefits, the availability of coverage, or the amount of or eligibility for benefits. The Company’s consideration and determination of a Pre-certification request, as well as any subsequent review or adjudication of all medical claims submitted in connection therewith, shall remain subject to all of the Terms of this insurance, including exclusions for Pre-existing Conditions and other designated exclusions, benefit limitations and sub-limitations, and the requirement that claims be Usual and Customary Charge. Any consideration or determination of a Pre-certification request shall not be deemed or considered as the Company’s approval, authorization, or ratification of, recommendation for, or consent to any diagnosis or proposed course of Treatment. Neither the Company nor the Plan Administrator (nor anyone acting on their respective behalf) has any authority or obligation to select Physicians, Hospitals, or other healthcare providers for the Covered Person, or to make any diagnosis or medical Treatment decisions on behalf of the Covered Person, and all such decisions must be made solely and exclusively by the Covered Person and/or their family members or guardians, Treating Physicians and other healthcare providers. If the Covered Person and their healthcare providers comply with the Precertification requirements of this coverage, and the Treatment or supplies are Pre-certified as Medically Necessary, the Company will reimburse the Covered Person for Eligible Medical Expenses up to the amount shown in the SCHEDULE OF BENEFITS incurred in relation thereto, subject to all Terms of this insurance. Eligibility for and payment of benefits are subject to all of the Terms of this insurance.

1. SPECIFIC REQUIREMENTS: The following must always be Pre-certified for Medical Necessity by the Company through the Plan Administrator before admission or receiving the Treatments and/or supplies: (a) Inpatient Hospitalization (b) Surgery or Surgical procedure.
2. GENERAL REQUIREMENTS: To comply with the Pre-certification requirements of this insurance for the Treatments and/or supplies or services listed in the SPECIFIC REQUIREMENTS provision, above, the Covered Person or their Physician or healthcare provider must perform all of the following: (a) contact the Company through the Plan Administrator at the contact information below and on the Covered Person's ID card as soon as possible and before the Treatment or supply is to be obtained (b) comply with the instructions of the Company and submit any information or documents required by the Company (c) notify all Physicians, Hospitals, and other healthcare providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with the Company.
3. LOSS OF COVERAGE/ BENEFITS FOR NON-COMPLIANCE OF PRE-CERTIFICATION REQUIREMENTS: If the Covered Person or their healthcare providers do not comply with the Pre-certification requirements for the Treatment or supplies identified in the SPECIFIC REQUIREMENTS subparagraphs above, or if such Treatment or supplies are not Pre-certified then (a) Eligible Medical Expenses incurred with respect to said Treatment and/or supplies will be reduced by the amount shown in the BENEFIT SUMMARY (b) any Deductible will be subtracted from the remaining amount (c) Coinsurance will be applied.
4. EMERGENCY PRE-CERTIFICATION: In the event of an Emergency Hospital admission, Pre-certification must be completed within forty-eight (48) hours after the admission, or as soon as is reasonably possible.
5. CONCURRENT REVIEW: For Inpatient Treatment of any kind, the Company will Pre-certify a limited number of days of confinement based upon the disclosed medical condition. Thereafter, Pre-certification must again be requested and approved if additional days of Inpatient Treatment are necessary.

This coverage contains a Pre-Existing Condition limitation. "Pre-Existing Condition" means any Injury, Illness, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existing at the time of Application or at any time during the three (3) years prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all subsequent, Chronic or recurring complications or consequences related thereto or resulting or arising therefrom.

Pre-Existing shall also include any Unexpected Recurrence of a Pre-existing Condition; meaning, a sudden and Unexpected outbreak or reoccurrence that is of short duration, is rapidly progressive, and requires urgent medical care. A Pre-existing Condition that is chronic or congenital, or that gradually becomes worse over time is not an Unexpected Recurrence of a Pre-existing Condition. An Unexpected Recurrence of Pre-existing Condition does not include any condition for which, as of the Effective Date, the Covered Person (i) knew or reasonably foresaw he/she would receive, (ii) knew he/she should receive, (iii) had scheduled, or (iv) were told that he/she must or should receive, any medical care, drugs, or Treatment.

Full cancellation and refund will only be considered if We receive written request prior to or on the Effective Date of the coverage. If We receive a written request for cancellation and refund after the Effective Date of coverage, a partial cancellation and refund may be allowed.

The following conditions apply:
a) If any claims have been filed with Us, the premium is fully earned and is non-refundable. If no claims have been filed with the Company, then (i) a cancellation fee of US $50 will be charged; and only unused days b) Premiums will be considered as refundable; and c) If after a refund is made, it is determined that a claim was presented to Us on a Covered Person’s behalf, the Covered Person will be fully responsible for that claim in its entirety. Upon effectuation of such cancellation and refund, neither the Company nor the Covered Person shall have any further rights, liabilities, or obligations under this insurance.

We know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public personal information about our Covered Persons or former Covered Persons to anyone, except as permitted or required by law. We maintain appropriate physical, electronic and procedural safeguards to ensure the security of your non-public personal information.

In the event that you remain dissatisfied and want to make a complaint you can do so to the Complaints team at SureGo Administrative Services.

If you are ordinarily resident in the European Economic Area (EEA), you should be aware that we may need to transfer your personal information to some of our recipients (e.g., our appointed agent (Trawick International, GmbH), claims handler (SureGo Administrative Services) and affiliates). Some of these recipients are located outside the EEA in countries which may not have laws that protect your personal information in the same way as the data protection laws in the EEA. Where these transfers occur, we ensure that: (a) they do not occur without our prior written authority (where applicable); and (b) an appropriate transfer mechanism or agreement is in place to protect your personal information (e.g. the European Commission's Standard Contractual Clauses, the EU-US Data Privacy Framework or the Swiss-EU Privacy Shield). For more information on these transfers, please contact the Data Protection Officer.

FOR ADDITIONAL INFORMATION

Phone: 415-994-4121
Website: polyakov.brokersnexus.com

Version: 10/15/2024