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International Military Student PLUS Benefits

Medical Expenses: International Military Student Plus plan shall pay Reasonable and Customary charges for Covered Expenses, excess of the chosen Deductible and Coinsurance up to the selected Medical Maximum, incurred by You due to an Accidental Injury or Illness which occurred during the Period of Coverage outside Your Home Country (except as provided under the Home Country Coverage). All bodily disorders existing simultaneously which are due to the same or related causes shall be considered one Disablement. If a Disablement is due to causes which are the same or related to the cause of a prior Disablement, the Disablement shall be considered a continuation of the prior Disablement and not a separate Disablement. The initial treatment of an Injury or Illness must occur within thirty (30) days of the date of Injury or onset of Illness.

Only such expenses which are specifically enumerated in the following list of charges are incurred within one hundred eighty (180) days from the date of accident or onset of Illness and which are not excluded, shall be considered Covered Expenses:

1. Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the Hospital’s average charge for semi-private room and board accommodations.
2. Charges made for Intensive Care or Coronary Care charges and nursing services.
3. Charges made for diagnosis, Treatment and Surgery by a Physician.
4. Charges made for an operating room.
5. Charges made for Outpatient Treatment, same as any other Treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations, clinic care, and Surgical opinion consultations.
6. Charges made for the cost and administration of anesthetics.
7. Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood, transfusions, iron lungs, and medical Treatment.
8. Charges for physiotherapy, if recommended by a Physician for the Treatment of a specific Disablement and administered by a licensed physiotherapist.
9. Dressings, drugs, and Medicines that can only be obtained upon a written prescription of a Physician or Surgeon.
10. Local transportation to or from the nearest Hospital or to and from the nearest Hospital with facilities for required Treatment. Such transportation shall be by licensed ground ambulance only to a limit of $5,000, within the metropolitan area in which You are located at that time the service is used. If You are in a rural area, then licensed air ambulance transportation to the nearest metropolitan area shall be considered a Covered Expense.

Pre-Notification / Referral: In order to ensure Your claims are addressed as efficiently as possible, You or the provider of service must contact the Assistance Company for pre-notification prior to: any medical Treatment in the U.S. as well as hospital admissions and inpatient / outpatient surgeries incurred worldwide. The Assistance Company has trained personnel available twenty-four (24) hours a day, seven (7) days a week throughout the year to answer Your questions, provide assistance, and guide You to an appropriate facility if necessary. In the case of an Emergency Admission, the Assistance Company must be contacted within forty-eight (48) hours, or as soon as reasonably possible. Pre-notification does not guarantee that benefits will be paid.

Additionally, the Company’s appointed network provider must be utilized for medical expenses incurred inside the United States (when available – contact Seven Corners Assist with questions). A listing of network facilities can be found at www.sevencorners.com/findproviders on the worldwide web. Pre-notification does not guarantee that benefits will be paid. Failure to follow Pre-Notification / Referral will result in a 20% reduction of Eligible Benefits. (For Emergency admissions and situations, Seven Corners Assist must be contacted within 48 hours, or as soon as reasonably possible.)

Please be aware that this is not a general health insurance policy, but an interim, limited benefit period, travel medical plan intended for use while away from Your Home Country. The International Military Student Plus plan cannot guarantee payment to an individual or a facility for medical expenses until it has been determined that it is an eligible expense and a signed agreement has been received from the appropriate medical facility.

Maternity - This plan shall pay up to a maximum of $4,000 (subject to the chosen Deductible and Coinsurance) after 9 months of continuous coverage, for Covered Expenses incurred before, during, and after delivery of a Child(ren), including Physician(s), Hospital, laboratory, and ultrasound services. Coverage for the Inpatient postpartum stay for the Insured Person(s) and her Newborn Child(ren) in a Hospital will, at a minimum, be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their guidelines for Prenatal Care, but not to exceed a maximum of 31 days. The Insured Person(s) may Pre-Notify a Pregnancy with the Administrator by utilizing the following:

1. Call 1-800-690-6295 within the United States or from outside the United States call (Collect) 0-317-818-2808, or;
2. Fax 317-575-2256, or;
3. E-mail: assist@sevencorners.com

Newborn Care-When a parent remains eligible for Coverage, Newborn Child(ren) are automatically covered for the first thirty one (31) days after birth to a maximum of $25,000. In order to continue Coverage beyond the first thirty one (31) days and be accepted as any other new Insured Person(s) subject to the Insurance Provisions, Scope of Coverage and Exclusions sections of this Certificate or other sections relating to a Newborn Child(ren) up to the maximum amount of this Certificate, the following conditions must be met:

1. any applicable Premium is submitted and Approved by the Company within thirty one (31) days of the birth of a Newborn Child(ren);
2. The Pregnancy which led to the birth of a Newborn Child(ren) was an eligible Pregnancy covered under this Certificate;
3. The mother of the Newborn Child(ren) remains covered under this Certificate;
4. The mother and Newborn Child(ren) meets and will continue to meet the Eligibility Requirements of this Certificate.

Annual Adult Physicals-This plan shall pay up to $175 per Period of Coverage for routine annual physical examinations. Adults must be over the age of 19 and have been continuously covered under the Certificate for 12 consecutive months prior to the date of the physical examination. 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.

Annual Mammogram- This plan shall pay up to $250 per Period of Coverage for an Annual Mammogram. Females must be over the age of 19 and have been continuously covered under the Certificate for 12 consecutive months prior to the date of the preventive examination.

Mammogram:

1. A baseline mammogram for women.
2. An annual screening for mammogram for women.

Well-Child Care Benefit-This benefit applies to Eligible Dependent Child(ren). This plan shall pay up to $55 per visit, with a maximum of three (3) visits per year for Dependent Child(ren) under nineteen (19) years of age. Covered Expenses include preventive and primary care services, including physical examinations, measurements, sensory screening, neuropsychiatry evaluation, and development screening. Preventive and primary care services shall also include, as recommended by the Physician(s), hereditary and metabolic screening at birth, immunizations, urinalysis, tuberculin tests, and hematocrit, hemoglobin, and other appropriate blood tests, including tests to screen for sickle hemoglobinopathy.

Mental and Nervous Benefits- When the Insured Person(s) incurs covered Mental and Nervous expenses, the Company will pay up to $5,000 per Period of Coverage, after a 6 month waiting period, subject to the chosen Deductible and Coinsurance. In no event shall the Company’s maximum liability exceed the maximum stated in the Schedule of Benefits as to Eligible Benefits during the stated period of time.

Mental or Nervous
For the purpose of this section, only such expenses incurred as the result of Mental or Nervous Treatment(s) or Medication, which are specifically enumerated in the following list of charges, and which are not excluded in the Exclusions, shall be considered as Eligible Benefits:

1. Inpatient Care:
   1. Charges made by a Hospital or mental institution for room and board, floor nursing and other services inclusive of charges for professional service and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the Hospital's or mental institution's average charge for semiprivate room and board accommodation.
   2. Charges made for diagnosis and Treatment(s) by a Physician(s).
   3. Charges made for the cost and administration of anesthetics.
   4. Charges for Medication, x-ray services, laboratory tests and services, oxygen, and medical Treatment(s).
   5. Medicines that can only be obtained upon a written prescription of a Physician(s) and dispensed by a licensed pharmacist.
2. Outpatient Care:
   1. Charges made for diagnosis and Treatment(s) by a Physician(s).
   2. Charges made for the cost and administration of anesthetics.
   3. Charges for Medication, x-ray services, laboratory tests and services, oxygen, and medical Treatment(s).
   4. Medicines that can only be obtained upon a written prescription of a Physician(s) and dispensed by a licensed pharmacist.

Only those expenses specifically described above which are incurred within the Limits stated in the Schedule of Benefits from the onset of the Mental Illness and which are not excluded in the Exclusions are considered Eligible Benefits. In no event shall the Company’s maximum liability exceed the maximum stated in the Schedule of Benefits, as to Eligible Benefits during any one Period of Coverage. Mental and Nervous disorder must first Manifest(ed) itself during the Insured Person(s)’s Period of Coverage.

Dental Accident Coverage: This plan shall pay in excess of the chosen Deductible and Coinsurance of up to a maximum of $500, for emergency treatment to repair or replace sound natural teeth damaged as the result of a covered accident. (*Only available to programs purchased for 1 month or more.)

Emergency Medical Evacuation/Repatriation: The plan will pay Covered Expenses incurred if any covered Injury or Illness commences during the Period of Coverage that results in the Medically Necessary Emergency Medical Evacuation or Repatriation (Your medical condition warrants immediate transportation from the medical facility where You are located to the nearest adequate medical facility where medical Treatment can be obtained). This benefit must be approved and arranged by the Assistance Company in consultation with the local attending Physician.

Return of Mortal Remains: The plan will pay the reasonable Covered Expenses incurred up to a maximum of $50,000 to return Your remains to Your Home Country, if You should die. This benefit must be approved and arranged by the Assistance Company.

Return of Minor Child(ren): Should You be traveling alone with a Minor Child(ren) and are hospitalized because of a covered Illness or Injury and the Minor Child(ren), under age nineteen (19), is left unattended, the plan will arrange and pay up to $50,000 for a one way economy fare to their Home Country (including the cost of an attendant/escort, if necessary to insure the safety and welfare of a Minor Child(ren). This benefit must be approved and arranged by the Assistance Company.

Emergency Medical Reunion: When Emergency Medical Evacuation or Repatriation is ordered and the attending Physician recommends that a family member travel with You, the plan will arrange and pay, up to $50,000, for a round trip economy-class transportation for one individual of Your choice, from Your Home Country, to be at Your side while You are hospitalized. This benefit must be approved and arranged by the Assistance Company.

Interruption of Trip: If You are unable to continue the trip due to the death of an Immediate Family member (parent, spouse, sibling or child) or due to serious damage to Your principal residence from fire, flood or similar natural disaster (tornado, earthquake, hurricane, etc.), the plan will reimburse (up to $5,000) for the cost of economy travel, less the value of applied credit from an unused return travel ticket, to return You home to Your area of principal residence. This benefit must be approved and arranged by the Assistance Company.

Home Country Coverage: Incidental Trips to the Home Country – This benefit covers You for incidental trips to Your Home Country (thirty (30) days per six (6) months of purchased coverage or pro rata thereof - example: approximately five (5) days per month of purchased coverage). Maximum benefit is reduced to $50,000 for any illness or injury occurring while on an incidental trip to Your Home Country. Please note: If You do not use Your Home Country Coverage days within Your Period of Coverage, they do not extend after Your Expiration Date. Home Country Extension of Benefits – The plan shall pay up to a maximum of $5,000 for Covered Expenses incurred in Your Home Country related to an Injury or Illness which occurred, was diagnosed and treated outside Your Home Country during Your Period of Coverage (does not apply for Emergency Evacuation or Repatriation). Only those Covered Expenses that are incurred within 180 days from the date of accident or onset of Illness and which are not excluded shall be considered eligible.

Assistance Services: Upon enrollment, You are eligible to use any of the assistance services provided by the Assistance Services Provider. Additional information is contained in the plan summary. Open 24 hours/day, 365 days a year • Multi-lingual personnel • Physicians / Nurses on staff • Locate local facilities • Help with emergency situations.

Plan Definitions

Benefit Period shall mean the allowable time period You have from the date of Injury or onset of Illness to receive Treatment for a Covered Injury or Illness. If Your plan terminates during Your Benefit Period, You will still be eligible to receive Treatment so long as the treatment is within Your Benefit Period and outside Your Home Country (except as provided under the Home Country Coverage).

Coinsurance shall mean the percentage amount of Covered Expenses, after the Deductible, which is Your responsibility to pay.

Common Carrier shall mean any land, sea, and/or air conveyance operating under a valid license for the transportation of passengers for hire.

Company shall mean Certain Underwriters at Lloyds, London.

Deductible shall mean the amount of Covered Expenses which is Your responsibility to pay before benefits under the plan are payable.

Disablement (as used with respect to medical expenses) shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician. Eligible

Eligible Dependent Child shall mean Your unmarried children over fourteen (14) days and under nineteen (19) years of age.

Eligible Spouse shall mean Your legal spouse.

Home Country shall mean the country where You have Your true, fixed and permanent home and principal establishment.

Hospital shall mean a place that

1. Is legally operated for the purpose of providing medical care and Treatment(s) to Sick or Injured persons for which a charge is made that the Insured Person(s) is legally obligated to pay in the absence of insurance
2. Provides such care and Treatment(s) in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use;
3. Provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and
4. Operates under the supervision of a staff of one or more Physician(s). Hospital also means a place that is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Heath Care Organizations (JCAHO).

Hospital does not mean:

• A Convalescent, nursing, or rest home or facility, or a home for the aged;
• A place mainly providing Custodial, Educational, or Rehabilitative Care; or
• A facility mainly used for the Treatment(s) of drug addicts or alcoholics

Illness shall mean sickness or disease of any kind contracted and commencing while this plan is in force as to the Insured Person whose Illness is the basis of claim. Any complication or any condition arising out of an Illness for which the Insured Person is being treated or has received Treatment will be considered as part of the original Illness.

Injury shall mean accidental bodily injury or injuries caused by an accident which occurs after the Effective Date of this policy. The Injury must be the direct cause of the loss, independent of disease or bodily infirmity.

Inpatient shall mean if You are confined in an institution and are charged for room and board.

Mountaineering shall mean the sport, hobby or profession of walking, hiking, and climbing up mountains either:

1. utilizing harnesses, ropes, crampons or ice axes; or
2. ascending 4,500 meters or above.

Outpatient shall mean if You receive care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician’s office, for an Illness or Injury, but who is confined and is not charged for room and board.

Parachuting shall mean an activity involving the breaking of a free fall from an airplane using a parachute.

Period of Coverage shall mean the Period of Coverage issued by the Company to the Insured Person, typically beginning with the Effective Date and ending with the Expiration Date or the date coverage is renewed by the Underwriter.

Physician(s) or Surgeon shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery(ies) in accordance with the laws of the jurisdiction where such professional services are performed.

Reasonable and Customary shall mean the maximum amount that the plan determines is Reasonable and Customary for Covered Expenses You receive, up to but not to exceed charges actually billed. The determination considers:

1. Amounts charged by other Service Providers for the same or similar service in the locality where received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received;
2. Any usual medical circumstances requiring additional time, skill or experience; and
3. Other factors included but not limited to, a resource based relative value scale.

Treatment means a specific in-office or Hospital physical examination of or care rendered to You, consultation, diagnostic procedures and services, Surgery, medical services and supplies including medication prescribed or provided by a Service Provider.

You or Your shall mean the Primary Insured Person and the Primary Insured’s Spouse or Dependent.