Diplomat Long Term Insurance Plan

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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 LT provides Accident and Sickness medical coverage, Accidental Death and Dismemberment benefits and Travel Assistance to individuals while traveling outside their Home Country for a minimum of 3 months. Coverage is available for you, your spouse and unmarried dependent children, ages 14 days up to 18 years. This coverage is only available to persons traveling outside their Home Country.

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PERIOD OF COVERAGE

The minimum initial period of coverage that can be purchased is 3 months, the maximum is 12 months. Additional coverage may be available for up to 12 months at a time, to a maximum of 36 consecutive months.

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.

Premium Refund

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 outside your Home Country during the Period of Coverage and the Insured Person requires medical or surgical treatment; this plan will pay, subject to the selected deductible and applicable 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 and customary charges. A charge incurred by an Insured shall be deemed a Regular & 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 - $500,000
Plan B - $1,000,000
Persons up to age 69 are eligible for all plans;
Persons age 70-79 are limited to a $100,000 maximum;
Persons age 80+ are limited to a $50,000 maximum;

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Deductible Choices

$100, $250, $500, $1,000, $2,500 per person per policy period.
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Co-insurance

AAfter you pay your selected deductible this plan will pay 100% of Covered Expenses outside the USA and Canada up to the selected policy maximum. Any Covered Expenses incurred in the USA and Canada are paid at 80% of the first $5000 then 100% to the policy maximum. Eligible expenses are based on Regular & Customary charges.
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Lost Baggage

Coverage is provided if a checked baggage is lost due to theft or misdirection if the Insured is a ticketed passenger on any land, water or air conveyance licensed for the transportation of passengers. Benefits will be paid only in excess of amounts paid or payable by the Common Carrier or any other valid and collectible insurance. $50 per Bag/$250 Maximum.

Trip Interruption

Coverage is provided if an Insured is unable to continue his/her trip due to; a) death, occurring prior to the Insured’s return to his/her Home Country, of an Insured Person’s Immediate Family Member; b) serious damage to the Insured Person’s principal residence from fire, flood or similar natural disaster (tornado, earthquake, hurricane, etc.) $5,000 Maximum.

In Hospital Benefit

If you are in the Hospital while traveling outside of the United States or Canada, and the Hospital is considered a Covered Expense, the program will pay the covered Insured $100 for each night spent in the Hospital for a maximum of 10 consecutive days (this benefit is in addition to any other expenses of the program).

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.

Emergency Dental Benefit

With regard to dental care up to $100 per tooth for the necessary treatment of sudden, unexpected pain to sound natural teeth is allowable.

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 24 hour 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 exmembers 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

For the Medical Expense no benefit shall be payable with respect to expenses incurred:

Unless Home Country Coverage has been purchased, 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:
 

“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.

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.

Home Country Coverage - If a covered person has been enrolled on this plan for a minimum of 30 days, coverage for an incidental trip to your Home Country, as listed on your application, is available up to a maximum of two (2) months per twelve (12) months of coverage. Coverage shall be prorated five (5) days for each month purchased, in the event that an insured person’s coverage is less than twelve (12) months. Any claims paid are subject to the deductible and co-insurance and the medical benefit amount is reduced by 50% to a maximum of $75,000.
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