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International Major Medical Plan from Petersen International Underwriters

Limitations

Expenses which have limitations are as follows:

1. Services and supplies for Cardiac Related Conditions and Cancer Related Conditions a 1. re limited to either (i) the medical costs of stabilizing your condition and the transportation costs of returning you to your Home Country or (ii) a maximum reimbursement for Eligible Expenses of $25,000, at the option of Underwriters.
2. The maximum Eligible Expense for Repatriation of Remains or Global Medical Transportation is $100,000 in the aggregate.
3. The maximum Eligible Expense for room and board charges for an intensive care unit is three times the Provider’s semi-private room.
4. The maximum Eligible Expense for outpatient prescription medication(s) is $500.00 in the aggregate and for a maximum prescribed period of ninety (90) days for any one prescription.
5. Insured age 70-74 is limited to $250,000 maximum benefit or as shown on the Schedule of Benefits page, whichever is the least. All other terms and conditions apply.
6. Insured age 75-79 is limited to $100,000 maximum benefit or as shown on the Schedule of Benefits page, whichever is the least. All other terms and conditions apply.
7. Insured age 80-84 is limited to $50,000 maximum benefit or as shown on the Schedule of Benefits page, whichever is the least. All other terms and conditions apply.

Pre-existing Conditions Limitations

A preexisting condition means a condition, disease or Injury for which medical advice, diagnosis, care or treatment, including the use of prescription medication including but not limited to ongoing condition(s), was recommended by or received from a licensed health care practitioner, and/or any symptom(s) and/or any condition(s) which would have caused a reasonable prudent person to seek medical attention during the 12 months immediately preceding the Effective Date of the insurance described in this Certificate, whether disclosed or not on Your application

Exclusions

Expenses which are not eligible for reimbursement are as follows:

1. Any expense which You are not legally obligated to pay.
2. Services which are not Medically Necessary or are not furnished by and under supervision of a Physician.
3. Expenses for services and supplies for which You are entitled to benefits, services or reimbursement through the Veterans’ Administration, Workers’ Compensation insurance, any private health plan or from any other source except Medicaid.
4. Expenses in excess of UCR.
5. Self-inflicted injuries while sane or insane.
6. Treatment for alcoholism, drug addiction, allergies, and/or Mental or Nervous Disorders.
7. Rest cures, quarantine or isolation.
8. Cosmetic surgery unless necessitated by an accidental Injury.
9. Dental exams, dental x-rays and general dental care except as a result of an accidental Injury.
10. Eye glasses or eye examinations.
11. Hearing aids or hearing examinations.
12. General or routine examinations.
13. Injuries sustained from participation in Hazardous Sports or Activities.*
14. Pregnancy and pregnancy-related conditions including but not limited to fertility, pre-natal care, childbirth, miscarriage, abortion or postpartum conditions.
15. Injuries or Illnesses due to War or any act of War whether declared or undeclared.*
16. Injuries or Illnesses due to Terrorism or any act of Terrorism whether declared or undeclared.*
17. Injuries or Illnesses due to an act of Terrorism involving the use or release of any nuclear weapon or device or chemical or biological agent, regardless of any contributory cause(s).
18. Injuries or Illnesses sustained while committing a criminal or felonious act.
19. Expenses incurred for or resulting from pain which is not supported by medical diagnosis.
20. Cataract surgery.
21. Any elective surgery, including but not limited to complications of previous elective or cosmetic surgeries.
22. Custodial Care.
23. Expenses for supplies and services that were not incurred with in the specified Geographic Area.
24. Pre-existing conditions.
25. Racing of any kind, all professional or semi-professional sports, and collegiate, sponsored, or interscholastic athletics.**

* This exclusion can be removed if the appropriate additional premium has been paid and the optional benefit is indicated on the Schedule or attached by an endorsement.

** This exclusion can be removed if the appropriate additional premium has been paid and the optional benefit is indicated on the Schedule or attached by an endorsement. Please note this exclusion cannot be removed with the online enrollment.

This is not intended to be a complete outline of coverage. Actual wording may change without notice.
Underwriters reserve the right to modify terms and benefi ts at time of underwriting.
Plan administered by Petersen International Underwriters.