Patriot Exchange - J1 Student Insurance

Schedule of Benefits and Limits
Schedule of Benefits Benefit Description
Plan Maximum Choice of $50,000, $250,000 or $500,000 per illness or injury with a Lifetime Maximum of $5,000,000
Coinsurance 100%
Deductible $100 per illness or injury
Treatment Period 60 days per chronic illness
Inpatient/Outpatient Benefits
Hospital Room & Board Up to semi-private room rate
Hospital Intensive Care URC*
Physical Therapy URC*, 1 visit per day
Physician Visit URC*
Student Health Center $5 co-pay per visit
Eligible Medical Expenses URC*
Emergency Room URC*
Emergency Illness-with in-patient admission URC*
Emergency Illness-without in-patient admission Additional $250 deductible
Dental - Treatment Due to Accident $500 maximum
Evacuation Benefits
Emergency Medical Evacuation $50,000 lifetime maximum
Emergency Reunion $15,000 lifetime maximum
Return of Mortal Remains or Cremation/Burial $25,000 maximum for Return of Mortal Remains or $5,000 for Cremation/Burial
Political Evacuation $10,000 lifetime maximum
Additional Benefits
Accidental Death $25,000
Dismemberment $25,000 two limbs; $12,500 one limb
Terrorism Coverage Up to $50,000 lifetime maximum
Pre-Existing Conditions For conditions existing within 36 months before effective date, charges excluded after 12 months of coverage and then $500 maximum per period of coverage and $50,000 lifetime maximum
Incidental Trip Coverage Up to a cumulative two weeks
Sudden Recurrence of a Pre-existing Condition (U.S. citizens)
Medical Up to $5,000 of eligible expenses
Emergency Medical Evacuation Up to $25,000 of eligible costs and expenses
Optional Add-on Riders
Schedule of Benefits Benefit Description
Lost Personal Property $250 maximum
Legal Assistance
Binder Fee $500 maximum
Personal liability
Injury to third party $2,000 maximum after $100 deductible
Damage to third person property $500 maximum after $100 deductible.
High School, Interscholastic, Intramural, or Club Sports URC*

*Usual, Reasonable and Customary (URC) charges for eligible expenses in the area where you receive treatment.

This web page contains only a consolidated and summary description of all current Patriot Exchange Program Insurance benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included in the fulfillment kit. IMG 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.

Patient Protection and Affordable Care Act (“PPACA”): This insurance is not subject to, and does not provide certain of the insurance benefits required by, the United States PPACA. PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney or tax professional to determine if PPACA’s requirements are applicable to you. The policy contains the plan benefits, including a lifetime maximum that you have selected. Please review your choices to ensure that you have sufficient coverage to meet your medical needs.