Patriot Adventure Travel Medical Insurance

Schedule of Benefits

All amounts shown are in U.S. dollars. Click the orange headers for further information.

PLAN INFORMATION
Deductible	$250 per Period of Coverage
Maximum Limit	$50,000
Coinsurance	As described below
For treatment received outside the U.S. & Canada: No coinsurance For treatment received within the U.S. & Canada: In the PPO Network: The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Maximum Limit Outside the PPO Network: The plan pays 80% of eligible expenses up to $5,000, then 100% up to the Maximum Limit

MEDICAL BENEFITS	Usual, reasonable and customary charges, subject to deductible and coinsurance
Hospital Room and Board	Up to the Maximum Limit for average semi-private room rate
Intensive Care	Up to the Maximum Limit
Medical Expenses	Up to the Maximum Limit
Out-patient Medical	Up to the Maximum Limit
Local Ambulance	Up to the Maximum Limit
Emergency Room Accident	Up to the Maximum Limit
Emergency Illness - with In-patient Admission	Up to the Maximum Limit
Emergency Illness - without In-patient Admission	Up to the Maximum Limit with additional $250 deductible
Charges incurred for the use of the Emergency Room for treatment of an illness are subject to an additional (extra) $250 deductible if treatment does not require admittance to the hospital.
Dental	As described below
Injury due to an accident: Each Patriot Adventure plan covers the cost of emergency dental treatment and dental procedures necessary to restore sound natural teeth lost or damaged in an accident up to the Maximum Limit. Sudden dental pain: Each plan will pay up to $100 for the necessary treatment of sudden, unexpected pain to sound natural teeth.

INTERNATIONAL EMERGENCY CARE	(when coordinated through the Plan Administrator)
Emergency Evacuation	Up to the Maximum Limit
Patriot Adventure includes coverage for Emergency Medical Evacuations from a medical facility to the nearest qualified medical facility; expenses for reasonable travel and accommodations resulting from the evacuation; and the cost of returning to either the home country or the country where the evacuation occurred up to the Maximum Limit.
Emergency Reunion	Up to $10,000
Patriot Adventure also provides emergency reunion coverage, up to $10,000 for a maximum of 15 days, for the reasonable travel and lodging expenses of a relative or friend during an emergency medical evacuation of the insured person: either the cost of accompanying the insured during the evacuation or traveling from the home country to be reunited with the insured.
Return of Mortal Remains	Up to $15,000
If a covered illness/injury results in death, expenses for Repatriation of bodily remains or ashes to the home country will be covered up to a maximum of $15,000. To be eligible for the Evacuation, Reunion and Return benefits, these must be recommended by the attending physician in critical medical situations, and approved in advance and coordinated by IMG.
Political Evacuation	Up to $10,000
If the United States Department of State, Bureau of Consular Affairs, or similar government organization of the Insured Person’s Home Country, orders the evacuation of all non-emergency government personnel from the Host Country, due to political unrest, that becomes effective on or after the Insured Person’s date of arrival in the Host Country, the Company will pay up to a $10,000 lifetime maximum for transportation to the nearest place of safety or for repatriation to the Insured Person’s home country or country of residence provided that: The Insured Person contacts the Company within 10 days of the United States Department of State, Bureau of Consular Affairs, or similar government organization of the Insured Person’s Home Country, issuance of the evacuation order; and The evacuation order pertains to persons from the same Home Country as the Insured Person; and Political Evacuation and Repatriation is approved and coordinated by the Company; In no event will the Company pay for a Political Evacuation if there is a Travel Warning in effect on or within six (6) months prior to the Insured Person’s date of arrival in the Host Country.

Additional Benefits
Benefit Period	Three months
If a covered injury or illness has continuing treatment after the certificate expires, the three-Month Benefit Period may provide continued coverage. When the certificate expires, the Company will review the date of initial treatment for the covered injury or illness. If treatment began less than three months before the certificate expired, benefits for the covered injury or illness will continue subject to the Maximum Limits until there has been three months of coverage for the covered injury or illness.
Common Carrier Accidental Death	$50,000 to Beneficiary; maximum of $250,000 per family
If accidental death should occur while traveling on a commercial Common Carrier, $50,000 will be paid to the beneficiary to a maximum of $250,000 per family
Sports & Activities	Up to the Maximum Limit for basic and Adventure sports as described below
Subject to the complete Certificate Terms and Conditions, Patriot Adventure covers injuries incurred during non-contact amateur athletic activities and the following activities: abseiling, BMX, bungee jumping, canyoning, caving, cave tubing, flying (private plane), hang gliding,heli-skiing, high diving, horseback riding, hot air ballooning, jet skiing, jungle zip lining, kayaking, inline skating, motorcycle/motorscooter riding, mountain biking, mountaineering (ropes and guides to 4500m from ground level), paragliding, parascending, rappelling, rock climbing (ropes and guides to 4500m from ground level), scuba diving (to 50m), skydiving, snorkeling, snow skiing, snowboarding, snowmobiling, spelunking, surfing, trekking, wakeboarding, water skiing, whitewater rafting (to Class V), wildlife safaris, and windsurfing. These advenutre activities must be engaged in solely for leisure, recreation or entertainment purposes. Activities may be organized and include scheduled practices, games, and/or competitions. Activities not covered include contact sports, professional sports and any athletic activities that are organized and/or sanctioned by the National Collegiate Athletic Association (or any other collegiate sanctioning body) or the International Olympic Committee.
Trip Interruption	Up to $5,000
If, during a covered trip, there is a death of an immediate family member (spouse, child, parent or sibling), a break-in at the insured’s principle residence, or the substantial destruction of the insured’s principal residence due to a fire or natural disaster, the plan will pay to return the insured to the area of principal residence. The plan will pay for a one way air or ground transportation ticket of the same class as the unused travel ticket, less the value of the unused return ticket.
Lost Luggage	Up to $50 per item; maximum of $250
This benefit will be paid in the event that the Common Carrier permanently loses an insured person's checked luggage. This coverage is secondary to any other available coverage, including the Carrier's.

Additional Benefits for U.S. Citizens
Indemnity	Click for more information
Patriot Adventure will pay directly to the insured person $100 for each night of a required overnight stay in a hospital. However, the hospital stay must be covered under this plan in order to receive this benefit.
Sudden Recurrence of a Pre-existing Condition	Click for more information
Up to $1,000 will be paid for the eligible expenses of a sudden and unexpected recurrence of a Pre-existing Condition while traveling outside of the U.S. In addition, up to $25,000 will be paid for the eligible costs and expenses of an Emergency Medical Evacuation arising or resulting from a sudden and unexpected recurrence of a Pre-existing Condition. For the definition of a Pre-existing Condition, please see Exclusion number 1 on the Exclusions page.

* This Web page contains only a brief summary of current benefits, conditions, limitations and exclusions, and is subject to all the terms and conditions of the full Certificate of Insurance. The complete Certificate of Insurance with all terms, conditions and exclusions will be included in the fulfillment kit sent to approved applicants. These plans are amended, modified or replaced from time to time, and IMG reserves the right to issue the most current Certificate of Insurance for this insurance plan in the event this Web page, application, and/or brochure has expired, is modified, or is replaced with a newer version. Samples of current Certificate wordings are available upon request.

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Schedule of Benefits

Patriot Adventure Travel Medical Insurance

Schedule of Benefits