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Diplomat America Medical Coverage for
Foreign Nationals Visiting the USA
Eligibility
Period of Coverage
Description of Benefits
Covered Expenses
Policy Maximums
Deductible Choices
Co-insurance
Additional Benefits
Definitions
Exclusions
Accidental Death & Dismemberment Benefits
Accidental Death & Dismemberment Exclusions
Optional Benefits
ELIGIBILITY
Diplomat America provides Accident and Sickness medical coverage, travel
assistance, and Accidental Death and Dismemberment benefits to foreign nationals
while visiting the United States. Coverage is available for you, your spouse and
unmarried dependent children, ages 14 days up to 18 years, while traveling to
the United States. Coverage for traveling outside the United States is available
through the Diplomat International and Diplomat LT programs.
Brochure and
rates
are available online.
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PERIOD OF COVERAGE
The minimum period of coverage that can be purchased under this plan is 15 days
and the maximum is 12 months. You can also combine these two increments to suit
your travel needs. Rates are listed on the back of this brochure. This plan is
not renewable.
EFFECTIVE DATE
Coverage will begin on the latest of the following:
a) Your departure from your Home Country ; or
b) The date your completed enrollment form and correct premium are received by
Global Underwriters; or
c) The effective date requested on the enrollment form.
EXPIRATION DATE
Coverage will end on the earlier of the following:
a) Your permanent return to your Home Country; or
b) Twelve months after your coverage’s effective date; or
c) The termination date shown on the enrollment form, for which premium has been
paid.
REFUND OF PREMIUM
Refund of premium, less a $25 processing fee, will be considered only if written
request is received by Global Underwriters prior to the effective date of
coverage. After that date, the premium is considered fully earned and
non-refundable. Partial refunds are not available.
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Description of Benefits
All coverage, benefits and premiums are in U.S. Dollar amounts. If an Injury or
Illness occurs in the USA during the Period of Coverage and the Insured Person
requires medical or surgical treatment; this plan will pay, subject to the
selected deductible and co-insurance, the following Covered Expenses, up to the
selected policy maximum.
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Covered Expenses
Only such expenses incurred as the result of and within 52 weeks from a
Disablement, which shall mean an illness or an accidental bodily Injury
necessitating medical treatment, and which are specifically enumerated in the
following list of charges:
1. Charges made by a Hospital for room and board, floor nursing and other
services, including charges for professional services, except 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 accommodation, or two
(2) times the average semi-private room charge if confinement to an intensive
care unit is required, or the actual charge for an intensive care unit made by
the servicing Hospital, whichever is less;
2. Charges made for diagnosis, treatment and surgery by a Physician;
3. Charges made for the cost and administration of anesthetics;
4. Charges for medication, x-ray services, laboratory tests and services, the
use of radium and radio-active isotopes, oxygen, blood transfusions, iron lungs,
and medical treatment;
5. Charges for physiotherapy, if recommended by a Physician for the treatment of
a specific Disablement and administered by a licensed physiotherapist;
6. Hotel room charge, when the Insured, otherwise necessarily confined in a
Hospital, shall be under the care of a duly qualified Physician in a hotel room
owing to the unavailability of a Hospital room by reason of capacity or distance
or to any other circumstances beyond the control of the Insured;
7. Dressings, drugs, and medicines that can only be obtained upon written
prescription of a Physician.
With regard to chiropractic care, if recommended by a Physician for the
treatment of a specific Disablement and administered by a licensed chiropractor,
80% of eligible charges up to $35.00 per visit, with a maximum of 10 visits per
Injury or Illness is allowable. The charges enumerated above shall in no event
include any amount of such charges which are in excess of Regular & Customary
charges. A charge incurred by an Insured shall be deemed a regular and customary
charge for the services and supplies for which the charge is made if it is not
in excess of the average charge for such services and supplies in the locality
where received, considering the nature and severity of the Illness or bodily
Injury in connection with which such services and supplies are received. If the
charge incurred is in excess of such average charge such excess amount shall not
be recognized as Covered Expenses. All charges shall be deemed to be incurred on
the date such services or supplies which give rise to the expense or charge are
rendered or obtained. The maximum total payment under the policy for an Illness
that is first manifested, treated or diagnosed during an Insured Person’s first
thirty (30) days of coverage, commencing as of the Insured Person’s effective
date, is $1,000.
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Policy Maximum Choices
Plan A - $50,000
Plan B - $100,000
Plan C - $250,000
Plan D - $500,000
Persons up to age 59 are eligible for all plans;
Persons age 60-69 are eligible for plans A, B, and C;
Presons age 70+ are eligible for plan A only.
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Deductible Choices
$100, $250, $500, $1,000, $2,500 per person per policy period.
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Co-insurance
After you pay your selected deductible this plan will pay: 80% of Covered
Expenses up to $5,000 and 100% thereafter up to the selected policy maximum.
Eligible expenses are based on Regular & Customary charges.
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Emergency Medical Evacuation
The Company will pay benefits for Covered Expenses incurred for the necessary
Emergency Medical Evacuation of an Insured Person up to a $100,000 maximum.
Emergency Medical Evacuation means: a) the Insured Person’s medical condition
warrants immediate transportation from the place where the Insured Person is
Injured or Ill, to the nearest Hospital where appropriate medical treatment can
be obtained; or b) after being treated at a local Hospital, the Insured Person’s
medical condition warrants transportation to his/her Home Country to obtain
further medical treatment or to recover. Covered Expenses are expenses for the
transportation, medical services and supplies recommended by the attending
Physician and necessarily incurred, in connection with an Insured Person’s
Emergency Medical Evacuation. All transportation for an Insured Person’s
Emergency Medical Evacuation must be arranged by AIG Assist utilizing the most
direct and economical conveyance.
Emergency Reunion
In the event of an Emergency Medical Evacuation due to a covered Injury or
Illness, where the Physician feels that it would be beneficial for the Insured
to have a Family Member at their side during transport, the Company will
reimburse the Insured for travel and lodging expenses, up to a maximum of
$10,000.00. AIG Assist must make all arrangements and must authorize all
expenses in advance. The Company reserves the right to determine the benefit
payable, including reductions, if it is not reasonably possible to contact AIG
Assist in advance.
Repatriation of Remains Expenses
If Injury or Illness commencing during the period of coverage results in death,
all reasonable expenses incurred for preparation and return of the remains to
your Home Country are covered up to a maximum of $20,000. The Repatriation must
be arranged by AIG Assist utilizing the most direct and economical conveyance.
Definitions
The term “Home Country” shall mean, the country where an eligible person(s) has
his/her fixed and permanent home establishment and to which he/she has the
intention of returning.
The term “Hospital” shall mean, a facility that: (1) is operated according to
law for the care and treatment of Injured people; (2) has organized facilities
for diagnosis and surgery on its premises or in facilities available to it on a
prearranged basis; (3) has 24hour nursing service by registered nurses (R.N.’s);
and (4) is supervised by one or more Physicians. A Hospital does not include:
(1) a nursing, convalescent or geriatric unit of a Hospital when a patient is
confined mainly to receive nursing care; (2) a facility that is, other than
incidentally, a rest home, nursing home, convalescent home or home for the aged;
nor does it include any ward, room, wing, or other section of the Hospital that
is used for such purposes; or (3) any military or veterans Hospital or soldiers
home or any Hospital contracted for or operated by any national government or
government agency for the treatment of members or ex-members of the armed forces.
The term “Illness” shall mean, sickness or disease of any kind first manifested,
treated or diagnosed after the effective date of coverage for an Insured Person;
and causing loss covered by this Plan.
The term “Injury” shall mean, bodily Injury caused solely and directly by
violent, accidental, external, and visible means occurring while the Policy is
in force; and resulting directly and independently of all other causes of loss
covered by this Plan.
The term “Physician” shall mean, a licensed practitioner of the healing arts
acting within the scope of his or her license who is not: (1) the Insured; (2)
an Immediate Family Member; or (3) retained by the Policyholder. Such definition
will exclude chiropractors and physiotherapists. In the event services are
provided by chiropractors or physiotherapists these healthcare professionals
must be licensed and acting within the scope of their license and may not be (1)
the Insured; (2) an Immediate Family Member; or (3) retained by the
Policyholder.
The term “Immediate Family Member” means a person who is related to the Insured
in any of the following ways: spouse, brother-in-law, sister-in-law,
daughter-in-law, son-in-law, mother-in-law, father-in-law, parent (includes
stepparent), brother or sister (includes stepbrother or stepsister), or child
(includes legally adopted or stepchild).
The term “Pre Existing Condition” means any Injury or Illness which was
contracted or which manifested itself, or for which treatment or medication was
prescribed three (3) years prior to the effective date of this insurance.
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Exclusions
No benefit shall be payable for any expenses or losses incurred for:
1. Illnesses first manifested, treated or diagnosed while you are visiting your
Home Country;
2. Injuries incurred while you are visiting your Home Country;
3. Treatments or services rendered in your Home Country.
With respect to Medical Expense, no benefit shall be payable with respect to
expenses incurred:
1. For Pre-Existing Conditions, defined as any Injury or Illness which was
contracted or which manifested itself, or for which treatment or medication was
prescribed 3 years prior to the effective date of this insurance;
2. For services, supplies, or treatment; including any period of Hospital
confinement, which were not recommended, approved and certified as necessary and
reasonable by a Physician;
3. For suicide or any attempt thereat while sane or self-destruction or any
attempt thereat while insane;
4. Due to declared or undeclared war; or any act thereof;
5. For Injury sustained while participating in professional athletics;
6. For sickness resulting from pregnancy, childbirth, or miscarriage;
7. For miscarriage resulting from an accident;
8. For routine physicals or other examinations where there are no objective
indications or impairment in normal health, and laboratory diagnostic or x-ray
examinations except in the course of a disability established by the prior call
or attendance of a Physician;
9. For cosmetic or plastic surgery; except as the result of an accident;
10. For elective surgery which can be postponed until the Insured returns to
his/her Home Country;
11. For any mental or nervous disorders or rest cures;
12. For dental care; except as the result of Injury to natural teeth caused by
an accident;
13. For eye refractions or eye examinations for the purpose of prescribing
corrective lenses or for the fitting thereof; unless caused by accidental bodily
Injury incurred while insured hereunder;
14. In connection with alcoholism or drug addiction; or the use of any drug or
narcotic agent;
15. For congenital anomalies and conditions arising out of or resulting
therefrom;
16. For expenses which are non-medical in nature;
17. For the ordinary cost of a one-way airplane ticket used in the
transportation back to the Insured’s country where an air ambulance benefit is
provided;
18. As a result of or in connection with any intentionally self-inflicted
Injury;
19. As a result of or in connection with the commission of a felony offense;
20. For specific named hazards: motorcycle driving, scuba diving, skiing,
mountain climbing, sky diving, professional or amateur racing, and piloting any
aircraft;
21. Treatment paid for or furnished under any other individual or group policy,
or other service or medical pre-payment plan arranged through the employer to
the extent so furnished or paid, or under any mandatory government program or
facility set up for treatment without cost to any individual.
22. For pregnancy or childbirth, organ transplants, marrow procedures, and
chemotherapy.
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Accidental Death and Dismemberment
The amount of the Principal Sum is $25,000
If Injury to the Insured results, within 365 days of the date of the accident
that caused the Injury, in any one of the types of losses specified below, the
Company will pay the percentage of the Principal Sum shown below for that type
of loss:
Description of Loss/Indemnity - Percentage of the Principal Sum
Life - 100%
Both Hands or Both Feet or Sight of Both Eyes - 100%
One Hand and One Foot - 100%
Either Hand or Foot and Sight of One Eye - 100%
Either Hand or Foot - 50%
Sight of One Eye - 50%
The term “loss” as used herein shall mean, with regard to hands and feet, actual
severance through or above wrist or ankle joint, and with regard to eyes, entire
irrecoverable loss of sight.
Paralysis Benefit
If Injury to the Insured results, within 365 days of the date of the accident
that caused the Injury, in any one of the types of paralysis specified below,
the Company will pay the percentage of the Principal Sum shown below for that
type of paralysis:
| Type of Paralysis |
Percentage of the Principal Sum |
| Quadriplegia |
100% |
| Paraplegia |
75% |
| Hemiplegia |
50% |
| Uniplegia |
25% |
“Quadriplegia” means the complete and irreversible paralysis of both upper and
both lower limbs.
“Paraplegia” means the complete and irreversible paralysis of both lower limbs.
“Hemiplegia” means the complete and irreversible paralysis of the upper and
lower limbs of the same side of the body.
“Uniplegia” means the complete and irreversible paralysis of one limb.
“Limb” means entire arm or entire leg.
If the Insured suffers more than one type of paralysis as a result of the same
accident, only one amount, the largest, will be paid.
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Excess Benefits
All Coverage, except Accidental Death & Dismemberment, shall be in excess of all
other valid and collectible insurance.
Accidental Death and
Dismemberment Exclusions
For Accidental Death and Dismemberment Indemnity this plan does not cover any
loss caused by or resulting from:
1. For suicide or any attempt thereat by the Insured Person while sane or
self-destruction or any attempt thereat by the Insured Person while insane;
2. Disease of any kind;
3. Bacterial infections except pyogenic infection which shall occur through an
accidental cut or wound;
4. Hernia of any kind;
5. Flying in any aircraft being used for or in connection with acrobatic or
stunt flying, racing or endurance tests; flying in any rocket propelled
aircraft; flying in any aircraft being used for or in connection with crop
dusting, or seeding or spraying, firefighting, exploration, pipe or power line
inspection, any form of hunting bird or fowl herding, aerial photography, banner
towing or any test or experimental purpose; flying any aircraft which is engaged
in flight which requires a special permit or waiver from the authority having
jurisdiction over civil aviation, even if granted;
6. Declared or undeclared war or any act thereof;
7. Service in the military, naval, or air service of any country.
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OPTIONAL RIDERS
Hazardous Activity Coverage - Motorcycling, scuba diving, jet, snow, and water
skiing, mountain climbing, sky diving, amateur racing, piloting any aircraft,
bungee jumping, spelunking, whitewater rafting, surfing, and parasailing
coverage.
Athletic Coverage - For participation in amateur, club, intramural,
interscholastic or intercollegiate tennis, swimming, cross country, track,
baseball, softball, volleyball and golf sports only. All other sports must be
approved in advance by the Company.
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