CCUSA - Premium Sirius International
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March 19, 2020 To Whom it May Concern, Your IMG group coverage includes a standard exclusion provision specific to epidemics, pandemics, puBlic emergencies, Natural Disasters and other disease outbreak conditions that may affect a person’s health when traveling. IMG has agreed to waive this exclusion provision specific to the COVID-19 pandemic. Any Illness or Injury incurred in the Destination Country as a result of epidemics, pandemics, public health emergencies, Natural Disasters, or other disease outbreak conditions that may affect a person’s health when, prior to the Insured Person’s entry into the Destination Country, any of the following were issued regarding the Destination Country(a) the World Health Organization had issued an Emergency Travel Advisory(b) the United States Centers for Disease Control & Prevention had issued a Warning Level 3 (avoid nonessential travel)(c) a similar governmental agency of the Insured Person’s Country of Residence had puBlished, communicated or issued a Travel Warning or Emergency Travel Advisory restriction or official declaration informing the puBlic aBout such health issues before the Insured Person traveled to the Destination Country Please contact me if you have any questions or concerns Sincerely, Amanda Winkle Chief Commercial Officer International Medical Group, Inc. Patriot Exchange ProgramSM Certificate of Insurance IMPORTANT NOTICE REGARDING PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA): This insurance is not subject to, and does not provide benefits required by, PPACA. On January 1, 2014, PPACA requires U.S. citizens, U.S. nationals and resident-aliens to obtain PPACA compliant insurance coverage unless they are exempt from PPACA. Penalties may be imposed on persons who are required to maintain PPACA compliant coverage but do not do so. Eligibility to purchase or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including PPACA. Please note that it is solely your responsibility to determine if PPACA is applicable to you and the Company and IMG shall have no liability whatsoever, including for any penalties that you may incur, for your failure to obtain required PPACA compliant coverage. Plan Administered by: CCUSA - Premium Sirius International Group/Certificate Number: EECPP00270115 Certificate Holder Name: CCUSA - Premium Certificate Holder Address: 901 E. Street Suite 300 San Rafael, CA 94901 USA Plan Type: Custom International Plan: Worldwide excluding Country of Residence The Period of Insurance From: January 1, 2020 To: January 1, 2021 Both days at 12:01 am Eastern Standard Time Law: Bermuda Jurisdiction: The Courts of Bermuda alone shall have jurisdiction in any dispute arising hereunder. Table of Contents Benefit Summary ........................................................................................................................ 1 A. Benefit Summary .................................................................................................................. 5 B. Agreement ............................................................................................................................ 5 C. Conditions and General Provisions ...................................................................................... 5 D. Eligibility ............................................................................................................................. 11 E. Pre-certification Requirements ........................................................................................... 12 F. United States Preferred Provider Organization (PPO) ....................................................... 13 G. Eligible Medical Expenses .................................................................................................. 13 H. Accidental Death and Dismemberment .............................................................................. 15 I. Adventure Sports ................................................................................................................ 15 J. Emergency Medical Evacuation ......................................................................................... 16 K. Emergency Reunion ........................................................................................................... 17 L. Recreational Sports ............................................................................................................ 17 M. Repatriation for Medical Treatment .................................................................................... 18 N. Return of Mortal Remains................................................................................................... 18 O. Trip Interruption .................................................................................................................. 18 P. Exclusions .......................................................................................................................... 18 Q. Definitions ........................................................................................................................... 22 BENEFIT SUMMARY Coverage Limit / Maximum Amount for Eligible Medical Expenses Period of Coverage Maximum Limit: 365 days Maximum Limit $5,000,000 Maximum Limit per Illness or Injury $1,000,000 Area of Coverage Worldwide excluding Country of Residence Deductible for Eligible Medical Expenses Deductible $50 • Per Injury or Illness Coinsurance for Eligible Medical Expenses Coinsurance Plan pays 100% • In addition to Deductible Insured pays 0% Pre-certification • Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met. • Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage. • All other Treatments & supplies: fifty percent (50%) reduction of Eligible Medical Expenses if Pre-certification requirements are not met. Maximum Penalty: $1,000 • Deductible is taken after reduction. • Coinsurance is applied to remainder of the reduced amount. • Refer to PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification. Pre-existing Conditions Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded under this insurance. Inpatient or Outpatient Services Subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit Benefit Coverage Eligible Medical Expenses 100% Physician / Specialist Visit • Maximum Visits per day: 1 100% (unless visit is for a different medical/surgical specialty) Urgent Care 100% Walk-in Clinic 100% Hospital Emergency Room • Injury: Not subject to Emergency Room Deductible • Illness: Subject to a $250 Deductible for each 100% Emergency Room visit for Treatment that does not result in a direct Hospital admission. Hospitalization / Room & Board • Average semi-private room rate 100% • Includes nursing, miscellaneous and Ancillary Services CCUSA – Premium 11.05.19 v1.0 1 Patriot Exchange Program Group (EECPP) 01.01.20 Inpatient or Outpatient Services Subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit Benefit Coverage Intensive Care 100% Outpatient Surgical / Hospital Facility 100% Laboratory 100% Radiology / X-ray 100% Pre-admission Testing 100% Surgery 100% Reconstructive Surgery • Surgery is incidental to or follows Surgery that was 100% covered under the Plan Assistant Surgeon 100% • 20% of the primary surgeon’s eligible fee Anesthesia 100% Durable Medical Equipment 100% Chiropractic Care 100% • Medical order or Treatment plan required Physical Therapy • Maximum Visits per day: 1 100% • Maximum Limit per Visit: $50 • Medical order or Treatment plan required Extended Care Facility 100% • Upon direct transfer from acute care Hospital Home Nursing Care • Provided by a Home Health Care Agency 100% • Upon direct transfer from acute care Hospital Prescriptions Subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit Prescriptions 100% • Dispensing Day Maximum: 90 Emergency Services NOT Subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit Emergency Local Ambulance • Subject to Deductible 100% • Injury • Illness resulting in a Hospitalization admission CCUSA – Premium 11.05.19 v1.0 2 Patriot Exchange Program Group (EECPP) 01.01.20 Emergency Services NOT Subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit Benefit Coverage Emergency Medical Evacuation • Maximum Limit: $1,000,000 100% • Must be approved in advance and coordinated by the Company Emergency Reunion • Maximum Limit: $1,000,000 • Maximum Days: 15 100% • Reasonable and necessary travel costs and accommodations • Must be approved in advance by the Company Interfacility Ambulance Transfer • Services rendered in the United States 100% • Transfer must be a result of an Inpatient Hospital admission Repatriation for Medical Treatment • Maximum Limit: $100,000 • Approved in advance