WHY YOU NEED THIS PROGRAM. While the
As a solution, Inbound Immigrant was
developed to provide a simple program to visitors and immigrants that will
provide up to 5 years of protection.
This is a brief description of the
Inbound Immigrant program. Detailed wording is outlined in the Program Summary,
which will be mailed to you once you have enrolled into Inbound Immigrant.
ELIGIBILITY. This program is available to non-United
States citizens who are traveling to the
PERIOD OF COVERAGE
You may initially enroll into Inbound Immigrant
for between 1 and 12 months. If you initially purchase at least 3
months, you may continue to renew coverage for a minimum 3 months at a time, at
the premium rate in force at the time of renewal. Total period of coverage for
Inbound Immigrant cannot exceed 60 months and the product cannot be
rewritten.
Effective
Date - Your coverage will begin on the latest of the following:
1. Your
departure from your Home Country; or
1. The
date your Application and premium are received by
2. The
date your Application and premium are accepted by
3. The
date you request on the Application.
Expiration
Date - Your coverage will end on the earlier of the following:
1. The
date shown on the Insurance Confirmation Card, for which premium has been paid;
or
2. The
date you return to your Home Country; or
3. 60
months after your original Effective Date; or
4. The
day an insured becomes a
5. The
date of entry into active military service.
Upon each renewal, rates, benefits, and
program in general are subject to change.
RENEWAL.
If Inbound Immigrant is initially purchased for at least
three months, one month before the expiration date,
SCHEDULE OF BENEFITS
When
your covered Injury or Sickness requires treatment by a physician, this program
will provide benefits for the Usual and Customary (U&C) charges scheduled
below which exceed the chosen Per Person Deductible (either $75 or $150, or a
$250 deductible for age 70 and over) for each Injury and each Sickness and
which are incurred within the 52 weeks following the Injury or Sickness (within
32 weeks for those insureds age 70 and over). Payment for any covered service will be no
more than the Benefit Limit shown for it. The total payable by all Benefits
will be no more than $50,000 or $100,000 for each Injury and each Sickness.
For
persons age 70 and over, the maximum benefit limit is $50,000, the period in
which covered expenses must be incurred is 32 weeks following the Injury or
Sickness, and a separate schedule applies.
COVERED SERVICES INJURY
|
|
Age 14 days to
Age
69 |
Age 14 days
to
Age
69 |
|
Age 70 and
over
|
INPATIENT
|
$50,000 Max per injury/sickness |
$100,000 Max per injury/sickness |
|
$50,000 Max per injury/sickness |
|
Hospital Room &
Board including miscellaneous |
$1450/day, 30 day
max |
$2000 per day, 30
day max |
|
$1050/day, 30 day
max |
|
Hospital Intensive
Care Unit |
Additional
$600/day, 8 day max |
Additional
$850/day, 8 day max |
|
Additional
$450/day, 8 day max |
|
Surgical Treatment |
$3,500 |
$5,750 |
|
$2,850 |
|
Anesthetist |
25% of surgical
benefit |
25% of surgical
benefit |
|
25% of surgical
benefit |
|
Assistant Surgeon |
25% of surgical
benefit |
25% of surgical
benefit |
|
25% of surgical
benefit |
|
Physician’s
Non-Surgical Visits |
$60/visit, 1/day,
30 visits |
$85/visit, 1/day,
30 visits |
|
$55/visit, 1/day,
30 visits |
|
Consultant
Physician, when requested by attending Physician |
$450 |
$500 |
|
$400 |
|
Pre-Admission Tests
w/in 7 days before Hospital admission |
$1150 |
$1150 |
|
$800 |
|
Private Duty Nurse |
$575 |
$575 |
|
$575 |
OUTPATIENT
|
|
|
|
|
|
Surgical Treatment |
$3,500 |
$5,750 |
|
$2,800 |
|
Anesthetist |
25% of surgical
benefit |
25% of surgical
benefit |
|
25% of surgical
benefit |
|
Assistant Surgeon |
25% of surgical
benefit |
25% of surgical
benefit |
|
25% of surgical
benefit |
|
Physician’s
Non-Surgical Visits |
$60/visit, 1/day,
10 visits |
$85/visit, 1/day,
10 visits |
|
$55/visit, 1/day,
10 visits |
|
Diagnostic X-rays
& Lab Services |
$450 |
$500 |
|
$400 |
|
|
Additional $280 -
One Cat scan, PET scan or |
Additional $850 -
One Cat scan, PET scan or |
|
Additional $285 -
One Cat scan, PET scan or |
|
Hospital Emergency
Room |
75% of U&C to
$345 max |
75% of U&C to
$575 max |
|
75% of U&C to
$280 max |
|
Prescription Drugs |
$115 |
$175 |
|
$90 |
|
Day surgery
miscellaneous, related to outpatient scheduled surgery performed at a
Hospital or licensed outpatient surgery center; including the cost of
operating room, anesthesia, drugs and medicines and medical supplies. |
$1000 |
$1150 |
|
$900 |
OTHERS
|
|
|
|
|
|
Ambulance Services |
$450 |
$450 |
|
$450 |
|
Initial Orthopedic
Prosthesis/brace |
$1150 |
$1400 |
|
$900 |
|
Chemotherapy and/or radiation therapy |
$1150 |
$1425 |
|
$900 |
|
Dental Treatment
for Injury to Sound, Natural Teeth |
$575 |
$575 |
|
$575 |
|
Mental &
Nervous Disorder & Substance Abuse |
Same as any
Sickness |
Same as any
Sickness |
|
Same as any
Sickness |
|
Maternity (conception
occurs at least 90 days after your effective date) |
$2,500 max |
$2,500 max |
|
N/A |
|
Physiotherapy |
$40/visit, 1/day,
12 visits |
$40/visit, 1/day,
12 visits |
|
$40/visit, 1/day,
12 visits |
|
Emergency
Evacuation |
$10,000 |
$10,000 |
|
$10,000 |
|
Repatriation of
Remains |
$7,500 |
$7,500 |
|
$7,500 |
|
AD&D Principal
Sum |
$25,000 Common
Carrier |
$25,000 Common
Carrier |
|
$25,000 Common
Carrier |
Should an insured
person turn 70 during the purchased coverage period, the 70 and over benefit
schedule becomes effective upon
the day the insured turns 70.
Emergency Medical Evacuation Expenses
If you or any covered dependents become
sick or injured during the period of coverage and it has been determined that
an Emergency Medical Evacuation is required to either the nearest medical
facility, where appropriate medical treatment can be obtained, or to your
Country of Residence, all eligible expenses incurred are covered up to
$10,000. An Emergency Medical Evacuation must be recommended by a legally
licensed physician who certifies that the severity of the Injury or Sickness
necessitates such Emergency Medical Evacuation, and agreed to by you or your
representative. All arrangements must be coordinated by the Assistance
Provider.
Repatriation of Mortal Remains Expenses
If Injury or Sickness commencing during
the Period of Coverage results in death, all reasonable expenses incurred for
preparation and return of the remains to the Country of Residence are covered
up to a maximum of $7,500 provided that all arrangements are coordinated by the
Assistance Provider.
Common Carrier Accidental Death and
Dismemberment (AD&D)
Accidental
Death and Dismemberment shall apply to covered accidents sustained by an
insured person while riding as a passenger in or on any land, water or air
conveyance operated under a license for the transportation of passengers for
hire. A loss must occur within 365 days
after the date of accident causing the loss:
Life................................................................................................ Principal
Sum
Both Hands or
Both Feet or Sight of Both Eyes................................. Principal
Sum
One Hand and
One Foot.................................................................. Principal
Sum
Either Hand or
Foot and Sight of One Eye........................................ Principal
Sum
Either Hand or
Foot........................................................................ One-Half
the Principal Sum
Sight of One
Eye............................................................................ One-Half
the Principal Sum
DEFINITIONS
“Injury” means: bodily injury: (1)
directly and independently caused by specific accident which is unrelated to
any pathological, functional, or structural disorder of injury, (2) treated by
a Physician within 30 days after the date of accident; and (3) which causes
loss during the term of the policy.
“Sickness” means: sickness or disease
of the insured Person which causes loss and originates while the Insured Person
is covered under the policy. All related conditions and recurrent symptoms of
the same or a similar condition will be considered one sickness.
“Pre-Existing Condition” means: (1) the
existence of symptoms within the 6 months (or 12 months for persons 70 and
older) immediately prior to the Insured’s Effective Date under the policy, or,
(2) any condition which originates, is diagnosed, treated or recommended for
treatment within the 6 months (or 12 months for persons 70 and older) immediately
prior to the Insured’s Effective Date under the policy; or (3) congenital
conditions.
“Usual and Customary Charges” means: a
reasonable charge which is: (1) usual and customary when compared with the
charges made for similar services and supplies; and (2) made to persons having
similar medical conditions in the locality of the Policyholder. No payment will
be made under the policy for any expenses incurred which in the judgment of the
Company are in excess of Usual and Customary Charges.
EXCLUSIONS
No
benefits will be paid for loss or expense caused by, contributed to, or
resulting from:
1.
Pre-existing Conditions;
2.
Any loss that occurs while traveling solely for the purpose
of obtaining medical treatment while on a waiting list for a specific treatment,
or while traveling against the advice of a physician;
3.
Expense incurred within the Insured Person’s Home Country or
country of regular domicile;
4.
Routine physical or other examinations where there are no
objective indications of impairment of normal health, or well baby care;
5.
Eye examinations; prescriptions or fitting of eyeglasses and
contact lenses; or other treatment for visual defects and problems.
"Visual defects: means any physical defect of the eye which does or can
impair normal vision;
6.
Hearing examinations or hearing aids; or other treatment for
hearing defects and problems. "Hearing defects: means any physical defect
of the ear which does or can impair normal hearing:
7.
Dental treatment, except as the result of injury to sound,
natural teeth as stated in the Schedule of Benefits:
8.
Professional services rendered by a Member of the Insured
Person’s immediate family, or anyone who lives with the Insured Person;
9.
Services or supplies not necessary for the medical care of
the patient’s injury or sickness;
10.
Weak, strained or flat feet, corns, calluses, or toenails;
11.
Cosmetic surgery, or treatment for congenital anomalies
(except as specifically provided), except reconstructive surgery as the result
of a covered Injury or Sickness. Correction of a deviated nasal septum is
considered cosmetic surgery unless it results from a covered Injury or covered
Sickness;
12.
Elective Surgery and Elective Treatment;
13.
Diagnostic or surgical procedures in connection with
infertility unless infertility is a result of a covered Injury or covered
Sickness;
14.
Birth control, including surgical procedures and devices;
15.
Routine new-born baby care, well-baby nursery and related
Physician charges;
16.
Participation in professional or intercollegiate athletics;
17.
Injury or Sickness for which benefits are paid or payable
under any Worker’s Compensation or Occupational Disease Law or Act, or similar
legislation;
18.
Organ transplants;
19.
War or any act of war, declared or undeclared; or while in
the armed forces of any country (a pro-rata premium will be refunded upon
request for such period not covered);
20.
Participation in a riot or civil disorder, commission of or
attempt to commit a felony in the country in which it was attempted or
committed;
21.
Suicide or attempted suicide (including drug overdose),
while sane or insane (while sane in
22.
Charges of an institution, health service, or infirmary for
whose service payment is not required in the absence of insurance;
23.
Treatment of nervous or mental disorders, except as stated
in the Schedule of Benefits, or treatment of alcoholism or drug abuse, except
as provided for treatment of mental or nervous disorders, according to the
Schedule of Benefits;
24.
Loss incurred from riding in any aircraft, other than as a
passenger in an aircraft licensed for the transportation of passengers;
25.
Treatment services, supplies or facilities in a hospital
owned or operated by: a) The Veteran’s Administration; or b) A national
government or any of its agencies. (This exclusion does not apply to treatment
when a charge is made which the Insured is required by law to pay);
26.
Duplicate services actually provided by both a certified
nurse-midwife and Physician;
27.
Expenses payable under any prior policy which was in force
for the person making the claim;
28.
Expenses incurred during a hospital emergency room visit
which is not of an emergency nature;
29.
Expenses incurred for outpatient treatment in connection
with the detection or correction by manual or mechanical means of structural
imbalance, distortion or sublimation in the human body for purposes of removing
nerve interference and the effects thereof, where such interference is the
result of or related to distortion, misalignment or subluxation
of or in the vertebral column;
30.
Injury sustained as the result of the Insured operating a
motor vehicle while not properly licensed to do so in the jurisdiction the
motor vehicle accident occurs;
31.
Voluntary or elective abortion;
32.
Expense covered by any other valid and collectible medical,
health or accident insurance;
33.
Expense incurred after the date insurance terminates for an
Insured Person except as may be specifically provided;
34.
Expenses incurred for injuries resulting from the use of
alcohol or intoxicants, or any drugs unless prescribed by a Physician;
35.
Sexually transmitted diseases, including AIDS.
ENROLLING IN INBOUND IMMIGRANT INSURANCE
1.
Complete entire application
2.
Select method of payment.
3.
If paying by check or money order, make payable to: "
4.
If paying by credit card, complete Application and mail or fax to
|
Complete
and return the Application with your payment for the total premium to: 303 Congressional Boulevard Fax:
(You may fax if paying by credit card
only. Originals are not required if applications is faxed to |
Monthly
Rates (Effective
$75 Per Injury / Sickness Deductible Per Person
|
|
$50,000
Maximum |
$100,000
Maximum |
|
Age
2 weeks – 49 |
$65 |
$95 |
|
Age
50 - 69 |
$103 |
$145 |
|
Dependent
Child (Age 2 weeks through age 18) |
$54 |
$81 |
$150 Per Injury / Sickness Deductible Per Person
|
|
$50,000
Maximum |
$100,000
Maximum |
|
Age
2 weeks – 49 |
$62 |
$91 |
|
Age
50 – 69 |
$100 |
$142 |
|
Dependent
Child (Age 2 weeks through age 18) |
$51 |
$76 |
$250 Per Injury / Sickness Deductible Per Person
|
|
$50,000
Maximum |
$100,000
Maximum |
|
Age
70 – 79 |
$111 |
N/A |
|
Age
80 + |
$144 |
N/A |
Dependent Child rate is applicable when
at least one parent will also be covered under Inbound Immigrant.
Please be aware that this is not a
general health insurance policy, but an interim program intended
for
temporary use. Inbound Immigrant does
not guarantee payment to a facility or individual for medical
expenses
until the Company determines that it is an eligible expense.
Refund
of Premium
Refund of premium shall be considered
only if written request is received by
What
You Will Receive
Upon successful enrollment in Inbound
Immigrant, you will receive an information packet from
The
Insurance Company
Inbound Immigrant is underwritten by
The Insurance Company of the State of
|
InboundSM Immigrant Application - 2006 |
|
OFFICIAL USE ONLY: Cert#: Processed: Eff.
Date: Agent: Tonya L. Choryan 5015 |
All sections must be
completed. Incomplete applications will be returned to the applicant without
coverage.
Applicant Information
Mr. Mrs. Miss Ms.
Last Name:
__________________________________First Name: _______________________
U.S.
Correspondence Address: Name :
________________________________________________________________
Address: ____________________________________________ City:
_________________ State: ___ Zip: _________
(Address
must be in the United States)
Phone Number:
_______________________________________ Email:
______________________________________
AD&D
Beneficiary: ____________________________________ Relationship:
_________________________________
Passport & Travel Information
Passport
Number: ________________ Country
Issuing Passport: ___________________________________________
When did
or will you arrive in the United States? ___ / ___ / ____ Date you would like
coverage to begin: ___ / ___ / ____
Note: This
program is not available to United States citizens. Your coverage must begin within twenty-four
(24) months of your arrival in the United States. The minimum period of coverage is 1 month,
maximum is 12. If 3 or more months of
premium is sent, an automatic renewal notice will be
sent to the address above. Total program
length available is 60 months. Coverage
cannot begin until you depart from your Home Country and
Coverage Requested
Have you purchased insurance through
Selected
Medical Policy Maximum: ¨ Plan A:
$50,000 ¨ Plan B: $100,000
Selected
Per Injury/Sickness Deductible: ¨ $75
¨
$150 (or 70 and over at $250)
If there are one or more
applicants below age 70 and one ore more applicants age 70 and above, separate
applications must be submitted.
Name
of Persons to be Insured Date of
Birth Monthly Premium
Applicant: ______________________ __ / __ / ____ _____________
Spouse: _______________________ __ / __ / ____ _____________
Child: _________________________ __ / __ / ____ _____________
Child: _________________________ __ / __ / ____ _____________
Child: _________________________ __ / __ / ____ _____________
Totals: _____________
|
A |
x |
|
= |
B |
+ |
$10 |
= |
C |
|
Total from Above |
|
Number of months |
|
|
|
Administrative Fee
(required) |
|
Total Payment
Enclosed |
Method of Payment
¨ Check ¨
Money Order ¨ MasterCard ¨ Visa ¨
Discover
Card
Number: ________________________________ Name
on Card: _______________________________
Expiration
Date: _______________________________ Daytime
Phone: ______________________________
Billing
Address:
____________________________________________________________________________
Signature (Required)
______________________________________________________________________
Make Check or Money Order Payable
to: "
I hereby subscribe to the
__________________________________________________________________________________________
Signature
of Insured or Proxy (Required)
Date