Patriot Platinum Travel Medical Insurance

Schedule of Benefits

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

PLAN INFORMATION
Maximum Limits	$1,000,000, $5,000,000, $8,000,000
Individual Deductible	Your choice of $0, $100, $250, $500, $2,500, $5,000, $10,000 or $25,000
On the Application Form, you will be asked to circle your choice of a deductible. Your premium rate is dependent on the deductible you choose. Please see the Application Form for more information.
Family Deductible	Three times the individual deductible
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: No Coinsurance Outside the PPO Network: The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Maximum Limits
Benefit Period	12 months
If a covered injury or illness requires continuing treatment after the Period of Coverage expires, the twelve-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 twelve months before the Period of Coverage expired, benefits for the covered injury or illness will continue subject to the Maximum Limit and the other terms of the plan until there have been twelve months of continuous coverage for the covered injury or illness.
Global Concierge & Assistance Services^SM	Access to a dedicated service team for assistance services
MyIMG^SM	24 hour secure access from anywhere in the world to manage your account at anytime
eDocAmerica	Access to board-certified physicians, licensed psychologists, pharmacists, dentists, dieticians and fitness trainers to assist with any routine health related questions
World-class Medical Benefits	Premium coverage available for in-patient and out-patient medical expenses
International Emergency Care	A wide range of international emergency benefits available including emergency evacuation, emergency reunion, return of mortal remains, return of minor children and more

MEDICAL BENEFITS	Usual, reasonable and customary charges, subject to deductible and coinsurance when applicable
Hospital Room and Board	Up to the Maximum Limit
Intensive Care	Up to the Maximum Limit
Medical Expenses	Up to the Maximum Limit
Out-patient Medical Expenses	Up to the Maximum Limit
Local Ambulance	Up to the Maximum Limit
Emergency Room Accident	Up to the Maximum Limit
Charges incurred for the use of the Emergency Room due to an accident are covered up to the Maximum Limit.
Emergency Room Illness with In-patient Admission	Up to the Maximum Limit
Charges incurred for the use of the Emergency Room for treatment of an illness are covered up to the Maximum Limit if treatment requires admittance to the hospital.
Emergency Room 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 Platinum 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 $250 for the necessary treatment of sudden, unexpected pain to sound natural teeth.
Hospital Daily Indemnity	Up to $250
Patriot Platinum will pay directly to the insured person $250 for each night of a required overnight stay in a hospital up to a maximum of 10 days. However, the hospital stay must be covered under this plan in order to receive this benefit.
Supplemental Accident	Up to $300
Each Patriot Platinum plan provides up-front, additional protection for unexpected injuries. This benefit provides up to $300 of first-dollar benefits for treatment of an injury.

INTERNATIONAL EMERGENCY CARE	(when coordinated through the Plan Administrator)
Emergency Evacuation	Up to the Maximum Limit
Each Patriot Platinum plan includes coverage for Emergency Medical Evacuations 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 $100,000
Each Patriot Platinum plan also provides emergency reunion coverage, up to $100,000 for a maximum of 15 days, for the reasonable travel and lodging expenses of a relative or friend during an Emergency Medical Evacuation: 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 $100,000
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 $100,000.
Return of Minor Children	Up to $100,000
If an insured person is hospitalized due to a covered illness/injury and is traveling alone with child(ren) 19 or under that otherwise would be left unattended, the Patriot Platinum plans will pay up to $50,000 for one way economy fare to their home country, including a chaperone, if necessary, for the safety of the child(ren).
Political Evacuation	Up to $100,000
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. 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.
Natural Disaster	$250 per day for five days
This benefit is available in the event an insured person is required to depart his/her destination due to an evacuation order issued prevailing authorities in connection with a Natural Disaster. Natural Disaster is defined as widespread disruption of human lives disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe event resulting in migration of the population for its safety.
Remote Transportation	$5,000 per certificate period $20,000 lifetime maximum
In the event of a diagnosis of a critical medical condition which is not necessarily immediately life-threatening, but severe enough to result in death or a permanent disability if not treated right away, Remote Transportation will provide for eligible charges arising out of the transportation of an insured person to a qualified facility for further treatment (if the current facility is unable to provide such treatment). To be eligible for the Transportation, 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.
Identity Theft Assistance	Up to $500
If an imposter obtains key personal information such as a Social Security or Driver's License number, or other method of identifying an insured person in order to impersonate or obtain credit, merchandise or services in the insured person’s name, the Patriot Platinum plans will provide coverage for the reasonable, customary and necessary costs incurred by the insured for: re-filing a loan or other credit application that is rejected solely as a result of the stolen identity event; notarization of legal documents, long-distance telephone calls, and postage that has resulted solely as a result of reporting, amending and/or rectifying records as a result of the stolen identity event; up to three credit reports obtained within one year of the insured person’s knowledge of the stolen identity event; and stop payment orders placed on missing or unauthorized checks as a result of the stolen identity event. The identity theft event must occur during the Period of Coverage and must be reported within six months of the termination of coverage date.
Lost / Theft (luggage, valuables, personal papers)	Up to $500
This benefit will be paid in the event that damage to, loss of, or theft of your checked or stored baggage or personal items by a common carrier or while stored with your hotel and the replacement costs of travel documents.
Felonious Assault	Up to $10,000
If you are injured as a result of a Felonious Assault while traveling outside of your Home Country, each plan will pay up to $10,000. This benefit is in addition to any other benefit available under Patriot Platinum.

ADDITIONAL BENEFITS
Terrorism	Up to the Maximum Limit
Each Patriot Platinum plan plan provides coverage for injuries and illness incurred as a result of an act of Terrorism, limited in amount and by circumstances. If an insured person is injured as a result of an act of Terrorism, and the insured person has no direct or indirect participation in the act, the plan will reimburse eligible medical claims up to the Maximum Limit. However, claims incurred as a result of radiological, nuclear, chemical or biological weapons or events are not covered. Terrorism is defined as the systematic or planned use of violence, fear, or threat of violence in order to intimidate a population or government, especially as a means of coercion or to obtain a granting of any demand. However, this benefit does not cover an act of Terrorism in any country or location where the United States government has issued a travel advisory that has been in effect within the six months prior to the insured person's date of arrival. This benefit also does not cover an act of Terrorism in the event that an advisory to leave a certain country or location is issued by the United States government after the insured person's arrival date, and the insured person unreasonably fails or refuses to depart the country or location.
Sports & Leisure Activities	Up to the Maximum Limit for basic sports
Each Patriot Platinum plan covers injuries incurred during amateur athletic activities which are non-contact and engaged in by the insured person solely for leisure, recreation, entertainment or fitness purposes. Some of these sports and activities include, but are not limited to, motor cycle/motorscooter riding, scuba diving (to 10m), snorkeling, wakeboarding, and water skiing. However, activities not covered include amateur or professional sports or other athletic activity which is organized and/or sanctioned, or which involves regular or scheduled practices, games or competition. The following hazardous activities are excluded unless the Adventure Sports Rider is purchased: abseiling, BMX, bobsleigh, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, horseback riding, hot air ballooning, inline skating, jet skiing, kayaking, mountain biking, paragliding, parascending, piloting a non-commerical aircraft, rappelling, rock climbing or mountaineering (ropes and guides to 4500m from ground level), scuba diving (to 50m), skydiving, snow boarding, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), and wildlife safaris. To be covered under the Adventure Sports Rider, these adventure activities must be engaged in solely for leisure, recreation, or entertainment purposes. Injury sustained while participating in contact sports of any kind, racing of any kind, BASE jumping, kiteboarding, mountaineering or climbing or trekking above elevation 4500 meters above ground level or without proper ropes or guides; luge, motocross, Moto-X, rodeo activity, ski jumping, whitewater rafting exceeding Class V difficulty, scuba below 50 meters; and/or adventure sports not expressly covered hereunder are excluded regardless of which plan or rider is selected.
Sudden and Unexpected Recurrence of a Pre-existing Condition - Medical (for U.S. citizens only)	Click for more information
(U.S. citizens only) For those up to age 65 with a primary health plan, Patriot Platinum International will pay the Usual, Reasonable and Customary charges of a sudden and unexpected recurrence of a Pre-existing Condition (defined on the Exclusions page) up to the plan maximum. For those without a primary health plan, Patriot Platinum International will pay up to a $20,000 lifetime maximum. For those age 65 and older, with or without a primary health plan, Patriot Platinum International will pay up to a $2,500 lifetime maximum. The primary health plan must have existed prior to the effective date and during coverage of the Patriot Platinum plan, and the Pre-existing Condition must be covered under the primary health plan
Sudden and Unexpected Recurrence of a Pre-existing Condition - Emergency Medical Evacuation (for U.S. citizens only)	Click for more information
(U.S. Citizens Only) 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.
Sudden and Unexpected Recurrence of a Pre-existing Condition - Medical (for non-U.S. citizens only)	Click for more information
(Non-U.S. citizens only) For those under age 65, Patriot Platinum America will pay up to a $20,000 lifetime maximum for eligible medical expenses and up to a $20,000 lifetime maximum for emergency medical evacuation.
Incidental Home Country Coverage	Up to a cumulative two weeks
During the Period of Coverage an insured person may return to their home country for incidental visits up to a cumulative two weeks total, subject to: a. The insured person must have left their home country, b. The total Period of Coverage must be for a minimum of 30 days, and c. The return to the home country may not be taken to receive treatment for an illness or injury incurred while traveling.
End of Trip Home Country Coverage	One month for every four months of travel coverage, up to a maximum of three months
For every four months of continuous coverage you purchase, you can purchase one additional month of home country coverage as an accommodation and supplemental travel benefit, up to a maximum of three months. To purchase this special home country extension coverage, please check the appropriate box on the Application Form, and calculate your premium to include the additional month(s).
Trip Interruption	Up to $10,000
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, each Patriot Platinum 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.
Common Carrier Accidental Death	$100,000 per adult, $25,000 per child, maximum of $250,000 per family
If accidental death should occur while traveling on a commercial Common Carrier, $100,000 per adult and $25,000 per child will be paid to the designated beneficiary, to a maximum of $250,000 per family.
Accidental Death & Dismemberment	$50,000 principle sum
Each Patriot Platinum plan includes $50,000 principal sum benefit for Accidental Death and Dismemberment occurring during the Period of coverage: Accidental Loss of life - principal sum; Accidental Loss of two Members - principal sum; Accidental Loss of one Member - 50% of principal sum. "Member" means hand, foot or eye.
Small Pet Common Air Carrier Accidental Death	Up to $500
A benefit of up to $500 will be paid in the event of loss of life to a small pet while traveling with a covered insured on a common air carrier. This covers the pet while on the insured’s originating flight from his/her home country, and returning flight to the insured’s home country only. A small pet is a cat or dog up to 30 pounds in weight.

* This Web page contains only a consolidated and summary description of all current 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. These plans are amended, modified or replaced from time to time, and IMG reserves the right to issue the most current Certificate Wording 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. Current Certificate Wordings are available upon request.

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Patriot Platinum Travel Medical Insurance

Schedule of Benefits