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Certificate of Insurance
This is your Certificate of Insurance. Read it carefully in order to understand your benefits. Please carry this document with you at all times and, if necessary, present it along with your passport to the doctor or hospital if you seek medical care. If you have any questions, please call the Administrator.
The coverage is available only to a foreign visitor while visiting or traveling In the USA, Canada or the Caribbean Islands. Citizens of the USA are not eligible to be covered under this insurance.
The person named on the insurance I.D. card has been issued this Certificate of Insurance, which provides certain hospital and outpatient benefits. That person is eligible for the benefits described in this Certificate of Insurance, within the USA, Canada or the Caribbean Islands. Physicians and hospitals should immediately contact the Administrator to confirm benefits and to arrange direct payment. Only the person named on the I.D. card is eligible for benefits. Please verify the person's identity with their passport. Should this person require hospitalization or surgery, or if the total cost of treatment is expected to exceed $500, you must notify the MEDEX Emergency Response Center immediately.
(800) 527-0218 or (410) 453-6330
The Company will pay up to the benefit limit for those medical expenses incurred within the USA during the Period of Insurance which are the direct result of each Covered Injury or Sickness which first manifests itself during the Period of Insurance. Covered expenses include, but are not limited to, the necessary medical or surgical treatment, services and supplies, hospital services, local ambulance, prescriptions, x-rays, laboratory fees and visits to a physician's office. There is a $100 deductible per claim.
Benefits for claims resulting from: (1) downhill (alpine) skiing; and (2) cardiovascular/circulatory related conditions are limited to $10,000.
The Accident & Sickness Benefit also includes:
Medical EvacuationIf a Covered Injury or Sickness occurs during the Period of Insurance and requires a medical evacuation; upon the recommendation of the attending Physician, authorization from the MEDEX Physician Advisor and the concurrence of the Insured Person; the Company may:
a. medically evacuate the Insured Person to a more suitable medical facility; or
b. after five or more consecutive days of hospitalization, evacuate the Insured Person to their home, or an appropriate medical facility near their home. Medical evacuation to the Insured Person's home or nearby medical facility will terminate all benefits under this policy.
All medical evacuations must be approved (in advance) and coordinated by the MEDEX Assistance Corporation.
Repatriation of RemainsIf a Covered Injury or Sickness results in the loss of life during the Period of Insurance, the Company will pay the expenses for the preparation and transportation of the body to the Insured Person's home:
All repatriations of remains must be approved (in advance) and coordinated by the MEDEX Assistance Corporation.
The Company will pay up to $200 per tooth (subject to a $1000 maximum) for dental treatment resulting from a covered accident.
The principal sum benefit is $25,000.
If a Covered Injury occurs to you during the Period of Insurance, which is independent of all other causes, and results in one of the following losses within 180 days of the Covered Injury, the Company will pay the sum indicated below:
| Loss of | Benefit | |
| Life | Principal Sum | |
| Any two limbs (above the elbow/knee) | Principal Sum | |
| Sight in both eyes (irrecoverable) | Principal Sum | |
| Sight in one eye and loss of one limb | Principal Sum | |
| Sight in one eye or loss of one limb | One-half Principal Sum |
Coverage begins: (a) at 12:01 a.m. on the date requested on the application; (b) 12:01 a.m. on the day your mailed application is received by the Administrator; (c) 12:01 a.m. on the day after your electronically submitted application is received by the Administrator; or (d) when you arrive in the USA, whichever occurs last. Coverage terminates: (a) at 11:59 p.m. on the last day of coverage requested on the application; or (b) when you leave the USA, whichever occurs first.
This insurance does not cover, nor has premium been charged for losses resulting from:
A. A Pre-existing Condition; Since this is short-term travel insurance, no claim for cancers or tumors (malignant or benign), tuberculosis or organ transplants are eligible to be covered.
B. Any claim in respect of:
1. Congenital conditions; suicide, self-inflicted injury or any attempt thereat; cosmetic surgery, including treatment for a deviated nasal septum and dental care, except if required by a Covered Injury;
2. Expenses incurred after the Period of Insurance or in the Insured Person's home country;
3. Expenses not recommended and approved as necessary by an attending physician; examinations or treatment where there is no objective impairment of normal health;
4. Eyeglasses, contact lenses or hearing aids;
5. Sexually transmittable diseases (this exclusion does not apply to HIV, AIDS, ARC or any derivative thereof);
6. Alcohol, drug or intoxicant related treatment;
7. Birth control, fertility or infertility treatment, or pregnancy including miscarriage or abortion;
8. Emotional or mental disorders of any kind;
9. "Off-Road", All-Terrain Vehicle accidents; mountaineering (where ropes or guide persons are customarily used); or
10 . Other vehicle accident, if such expenses are recoverable under any other valid and collectible insurance, regardless of whether the Insured Person asserts his rights to obtain benefits from these sources. Nor will this insurance cover the Insured Person while operating the vehicle unless the Insured Person is properly licensed to operate the vehicle at the place and time of the accident.
A. Any claim arising from war, declared or undeclared, or any act of war or while in the military service. An act of terrorism shall not be considered an act of war.
B. Participation in professional sports, scuba diving; or aviation other than as a passenger in powered aircraft currently licensed for the carrying of passengers.
C. Amounts covered under any occupational or other benefit plan, or any other insurance or public assistance program.
D. A claim or loss that occurs:
1. Anywhere in the world except in the USA, Canada and the Caribbean Islands;
2. While traveling against the advice of a Physician;
3. While on a waiting list for a specific treatment; or
4. When traveling for the purpose of obtaining medical treatment.
1. TravMed America provides insurance for foreign nationals visiting the United States and will also cover incidental travel from the United States to Canada or the Caribbean Islands. Foreign nationals who are permanent residents of the United States or intend to live in the United States are not eligible for this insurance. The insurance must be purchased and in effect within the first 20 days of arrival in the U.S. The Administrator may require the applicant to provide proof of entry (copy of the 1-94 Arrival/Departure Record) into the United States.
2. TravMed America is temporary insurance for protection against unanticipated injuries and sicknesses. Therefore, it does not provide coverage for medical expenses which are the result of a pre-existing medical condition. Nor will TravMed America provide coverage for cancer, tumors, organ transplants, or tuberculosis related conditions.
3. Eligible applicants must be between the ages of 3 and 60 years of age with a premium of $5.25 per day. For applicants from age 61 to 70, the premium is $10.50 per day. No coverage is available on or after your 71st birthday.
4. The TravMed America policy cannot be renewed or extended. If additional insurance is required, one more policy may be purchased if requested before the expiration of the first policy. Any injury or sickness incurred during the first policy will be considered a Pre-existing Condition under the new policy and therefore not covered.
5. Refund policy: If the Administrator receives a written request to cancel the insurance prior to the beginning of the Period of Insurance, the premium (less the $15 enrollment fee) will be refunded. After the Period of Insurance has begun, the premium will be considered fully earned and will not be refunded.
6. Right of Subrogation: If you are injured or become sick as a result of another person's negligence, the Company has the right to seek reimbursement on your behalf against the negligent part for any claims paid under this insurance.
A. Covered Expense
The Usual and Customary expense incurred during the Period of Insurance for medical care, treatment, services or supplies, recommended and approved by the attending Physician which is the direct result of a Covered Injury or Sickness.B. Covered Injury
A bodily injury which results directly and independently of all other causes, from an accident occurring while an Insured Person is covered under the Policy.C. Covered Sickness
A sickness, illness or disease which first manifests itself while an Insured Person is covered under the Policy. For the purposes of this insurance a Covered Sickness does not include any cancers, tumors or tuberculosis related conditions.D. Insured Person
An eligible foreign national between the ages of 3 and 70 (not yet attained their 71st birthday) while visiting the USA, for whom the applicable premium has been received and accepted by the Administrator.E. Medically Necessary
Any services or supplies provided for the diagnosis and treatment of a specific Covered Injury or Sickness which are: (a) ordered or recommended by a Physician; and (b) required for the treatment or management of a medical condition or symptom; and (c) the most appropriate supply or level of service which can safely be provided to the Insured Person; and (d) provided in accordance with approved and generally accepted medical or surgical practice; and (e) not for the convenience of the Insured Person, his Physician, or another provider; and (f) not for services or supplies which are experimental or investigational; and (g) furnished in the least intensive type of medical care setting required by the Insured Person's condition. Services and supplies will not automatically be considered Medically Necessary because they were ordered by a Physician.F. Physician
A person properly licensed to practice medicine in the jurisdiction and/or country where the treatment is provided and includes doctors of medicine, general practitioners, specialists and medical consultants other than the Insured Person and his/her immediate family.G. Pre-existing Condition
Means any injury or sickness, or complications arising therefrom, for which symptoms were manifested during the 12 months immediately prior to the Period of Insurance; or for which a Physician was consulted, treatment was received or medicines/drugs were taken, in the 12 months immediately prior to the Period of Insurance.
H. Usual and Customary
An amount not to exceed the charge routinely made by providers in the locality where the charge is incurred for similar services or supplies. Consideration will be given to: (a) the Insured Person's condition; and (b) unusual circumstances or complications; and (c) requirements for additional time, skill or experience. The Company will determine the Usual and Customary charge and if it is covered by the Policy.
A. Law and Conformity to Statutes
Any provision of the Policy which, on its effective date, is in conflict with the statutes of the legal jurisdiction of the Insured Person, is hereby amended to conform to the minimum requirements of such statutes.
B. Entire Contract: Changes
The Policy, and individual application of the Insured Person constitute the entire contract between the parties. No change in the Policy shall be valid unless approved by an executive officer of the Company and unless such approval be endorsed hereon or attached hereto.
C. Notice of Claim
Written notice of claim must be given to the Administrator within 45 days after the occurrence or commencement of any loss covered by the Policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the claimant to the Administrator at its offices, or to any authorized agent of the Company, with information sufficient to identify the Insured Person, shall be deemed notice of claim.
D. Claim Forms
Upon receipt of a written notice of claim, the Company or Administrator will furnish to the claimant such forms as are usually furnished for filing Proof of Loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of the Policy as to Proof of Loss upon submitting within the time fixed in the Policy for filing Proofs of Loss.
E. Proof of Loss
Written Proof of Loss must be furnished to the Company within 45 days after the date of such loss, or as soon thereafter as reasonably possible. The completed claim form must be accompanied by the original Proofs of Loss such as bills, receipts, etc. for all expenses. Photocopies are not acceptable.
F. Payment of Claims
Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed therein and effective at the time of payment.
G. Beneficiary Designation
The beneficiary designation for Insured Persons shall be "ESTATE." An Insured Person may name a beneficiary or change a named beneficiary by written request to the Company. The request takes effect on the date it is executed regardless of whether or not the Insured Person is living when the Company receives it. The Company will be relieved of further responsibility to the extent of any payment made in good faith before receiving said request.
H. Not in Lieu of Workers' Compensation
The Policy is not in lieu of and does not affect any requirement for coverage by Workers' Compensation Insurance, or any other occupational benefit plan or public assistance program.
I. Change of Premiums
The Company has the right to change the rate at which premiums will be calculated for any time period or Period of Insurance under the Policy.
J. Exposure and Disappearance
If by reason of an accident covered by the Policy the Insured Person is unavoidably exposed to the elements and as a result suffers (within six months after the accident), a loss attributable to such exposure, the loss will be covered. If the body of an Insured Person has not been found within six months of an accident or disappearance of the aircraft or vessel on which the Insured Person was known to be a passenger, then it shall be deemed (subject to all other terms and conditions of this insurance), that the Insured Person shall have suffered loss of life at the time of the incident.
K. Physical Examinations and Autopsy
While a claim is pending, the Company has the right at their expense: (a) to have the Insured Person who has a loss, examined by a Physician when and as often as is reasonably necessary; and (b) in case of death to make an autopsy, unless forbidden by law or local custom.
L. Legal Action
No legal action may be taken against the Company: (a) before 90 days following the date the fully completed Proof of Loss is sent to the Company; or (b) after three years following the date Proof of Loss is due.
M. Assignment
The coverages under the Policy are not generally assignable. However, benefits payable for services received under the Medical Expense Benefits provision may be assigned to the provider of those services in accordance with the Payment of Claims provision of the Policy.
N. Payment of Premium
If payment of a premium is not honored by the bank or credit card drawn upon, the insurance is deemed to have not been purchased.
O. Extension of Benefits
If on the last day of the Period of Insurance, the Insured Person is hospitalized (as an inpatient) for a Covered Injury or Sickness, the Period of Insurance will be extended until it is medically confirmed that further inpatient hospitalization is no longer necessary, subject to an overall maximum of 30 days beyond the last day of the Period of Insurance
P. Termination of Coverage
All coverage provided to an Insured Person under the Policy will automatically terminate on the earliest of: (a) the end of the Period of Insurance; (b) the beginning of any period for which any required premium has not been paid; (c) the date the Policy is cancelled; or (d) the date the Insured Person cancels his/her coverage under the Policy. Should the Policy be cancelled by the Policyholder or the Company, the Insured Person's coverage will continue through the end of their Period of Insurance, provided the applicable premium has been received by the Company.
The Master Policy is issued to the International Sojourners Insurance Trust of Washington, D.C. by Pan-American life
Insurance Company, 601 Poydras Street, New Orleans, Louisiana 70130.
Requests for policy cancellations and refunds must be in writing and the effective date of the cancellation cannot be prior to the date the request to cancel is received by the Administrator.Policies cancelled before the Period of Insurance begins are eligible for a full refund less the enrollment fee.
Policies cancelled after the Period of Insurance begins are not eligible for any refund.
Pan-American life Insurance Company collects nonpublic information about you from the following sources: (a) Information we receive from you in applications or other forms; (b) Information about your transactions with us, our affiliates or others; and (c) Information we receive from a consumer reporting agency.We do not disclose any nonpublic information about our customers or former customers to anyone, except as permitted by law.We restrict access to your nonpublic personal information to those employees who need to know that information to provide products or services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.
All claims and correspondence relating to sales and general policy information should be directed to the Administrator:
MEDEX Insurance Services, Inc.
8501 LaSalle Road,
Suite 200
Towson, MD 21286
410-453-6380
800-132-5309
Email: info@medexassist.com
Internet: www.medexassist.com
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