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.
All Claims and correspondence in relation to sales and general policy information should be directed to the Administrator:
MEDEX Insurance Services, Inc.
8501 LaSalle Road, Suite 200
Baltimore, MD 21286
+1 410 453 6380
+1 800 732 5309
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
This is your Certificate of Insurance which describes the coverages available under the TravMed Global Master Policy. Your Identification Card specifies which coverage(s) you have purchased.
This insurance is not renewable. If the Period of Insurance needs to be extended, another policy may be purchased. Any injury or sickness covered under the first policy will be considered a Pre-existing Condition under the new policy and therefore not covered.
Your Identification Card will indicate which coverages you have purchased.
$250,000 Medical Expense Benefits includes benefits for
Accident and Sickness
Repatriation of Remains
Subject to the deductible you selected ($100, $500, or $1,000).
$25,000 Accidental Death & Dismemberment Benefit
$500 - $10,000 Trip Cancellation and Curtailment Benefits
$100,000 Additional Accidental Death & Dismemberment Benefit
Medical Expense Benefits
Accident & Sickness Benefit ($250,000 Limit)
The company will pay up to the benefit limit (in excess of the deductible you selected) for those medical expenses incurred outside the USA during the Period of Insurance which are the direct result of a 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.
Benefit limits for downhill (alpine) skiing and scuba diving (certification by PADI or NAUI required) are $10,000.
The Accident and Sickness Benefit also includes:
If a covered injury or Sickness occurs during the Period of Insurance and requires a medical evacuation; upon the recommendation of the attending Physician and MEDEX Physician Advisor, authorization from the MEDEX Medical Director 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 MEDEX Corporation.
Repatriation of Remains
If 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 and managed by MEDEX.
Emergency Expense Benefit
The company will pay up to $200 for the immediate relief of dental pain; or up to $200 per tooth (subject to a $1,000 maximum for dental treatment resulting from a covered accident.
Accidental Death & Dismemberment Benefit
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:
|Any two limbs (above the elbow/knee)
|Sight in both eyes (irrecoverable)
|Sight in one eye and loss of one limb
|Sight in one eye or loss of one limb
||One-half Principal Sum
Period of Insurance
Coverage for Medical Expense Benefits and Accidental Death & Dismemberment Benefit starts; (a) at 12:01 a.m. local time on the departure date requested by you on the application; (b) when your application and premium are received by the Administrator; or (c) when you board a conveyance at the actual start of the planned trip, whichever occurs later. The Period of Insurance ends: (a) when you alight from a conveyance at the completion of your trip; or (b) at 11:59 p.m. local time on the last day of coverage specified on your application, whichever occurs earlier.
$500-$10,000 Trip Cancellation and Curtailment Benefit
The Company will pay you up to the benefit limit selected on the application for the loss of unrecoverable deposits or charges paid in advance, due to the necessary cancellation of the entire trip prior to the scheduled departure; provided that the Covered Injury, Sickness or death giving rise to the cancellation begins within the Period of Insurance.
The company will pay you up to the benefit limit selected on the application for either; (a) any additional reasonable transportation and/or lodging expenses for the emergency return trip home; or (b) the balance of unrecoverable trip costs; whichever is lesser, provided that the Covered Injury, Sickness or death giving rise to the curtailment occurs after your trip commenced and prior to the termination of the coverage as specified on the application.
Trip Cancellation and Curtailment Benefits may also be applicable if a Covered Injury, Sickness or death are sustained by the insured Person’s traveling companion (named on the application), immediate family (spouse, children, mother, father, sister, brother) and immediate family in-laws. See Exclusion A.
Period of Insurance
Coverage for the Trip Cancellation and Curtailment Benefits begins at 12:01 a.m. local time 30 days prior to your scheduled departure, but no sooner than the date your application and premium are received by the Administrator. Coverage ends at; (a) the completion of your trip; or (b) 11:59 p.m. local time on the last day of coverage specified on your application, whichever occurs earlier.
$100,000 Additional Accidental Death & Dismemberment Benefit
The Accidental Death & Dismemberment Benefit (as previously defined) may be optionally increased from the included $25,000 benefit to a total benefit of $125,000.
$250,000 Medical Expense Benefits
Premium is based on the deductible you select
Definitions and Policy Provisions
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.
D. Home Country
The insured Person's home Country is that country from which a valid passport is held. If the Insured Person holds more than one valid passport, the Home Country will be the country declared on the application. There can only be one Home Country declared on each application.
E. Insured Person
An eligible person for whom the applicable premium has been received and accepted by the Company. The maximum age of an eligible person is 70 years (not yet attained their 71st birthday).
F. 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.
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.
H. Pre-existing Condition
Any injury or sickness, or complications arising there from, which manifests itself, or for which a physician was consulted or for which treatment or medication was prescribed or taken in the 180 days immediately prior to the Period of Insurance.
I. 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. Additional premium may be required to cover certain war risks otherwise excluded. Persons traveling to an area where a state of war exists, that is faced with the threat of war, or is in a state of civil unrest must include that information on the application.
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.
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) outside their Home Country 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.
Exclusions and Limitations
This insurance does not cover, nor has premium been charged for losses resulting from:
- A pre-existing condition is defined as: Any injury or sickness or complications arising therefrom, which manifests itself, or for which a physician was consulted or for which treatment or medication was prescribed or taken in the 180 days immediately prior to the Period of Insurance. With reference to the Trip Cancellation/Curtailment Benefit this exclusion also applies to any condition or set of circumstances known to you at the time of purchasing the insurance where such condition or set of circumstances could reasonably have been expected to give rise to the cancellation or curtailment of the trip.
- Any claim in respect of:
- Congenital conditions; cosmetic surgery and/or dental care (except as covered under the Dental Expense Benefit; suicide; self-inflicted injury or any attempt thereat;
- Examinations/treatment where there is no objective impairment of normal health;
- Eyeglasses, contact lenses or hearing aids;
- Sexually transmittable diseases (this exclusion does not apply to HIV, AIDS, or ARC or any derivative or variation thereof);
- Birth control, fertility or infertility treatment, or pregnancy including miscarriage or abortion;
- “Off-Road”, All-Terrain Vehicle accidents; mountaineering (where ropes or guide persons are customarily used);or
- Other vehicle accident, if such expenses are recoverable under any other valid and collectible insurance, regardless of whether the Insured Person asserts their rights to obtain benefits from these sources. Nor will this plan cover the Insured Person while operating a vehicle unless the Insured Person is properly licensed to operate said vehicle at the time and place of the accident.
- Any claim arising from war, declared or undeclared, or any act of war or while in military service. An act of terrorism shall not be considered an act of war.
- Participation in professional sports; or involving aviation other than as a passenger in a powered aircraft currently licensed for the carrying of passengers.
- Expenses not considered Medically Necessary; or not recommended and approved by the attending Physician.
- Amounts covered under any occupational or other benefit plan or any other insurance or public assistance program.
- Those claim expenses incurred after the Period of Insurance or in the Insured Person’s Home Country.
- Any loss that occurs;
- From medical expenses incurred within the United States;
- While traveling against the advice of a physician’
- While on a waiting list for specific treatment; or
- When traveling for the purpose of obtaining medical treatment.
Subrogation means the Company has the right to request a refund of payments made under the following conditions;
The company will be subrogated to any claim you have against a third party provided:
- You were injured or became ill due to the act or omission of the third party; and
- The company paid benefits to you under this insurance for such Covered Injury or Sickness
The company can only seek repayment of the amount of benefits paid.
If you collect any sums for damages from the third party, you will be liable to the Company for the benefits already paid by the Company. If you sue to recover expenses, the Company can join the suit. If you do not sue, the Company can do so in your name.
You are obligated to:
- Avoid doing anything that would prejudice the Company’s Right of Subrogation; and
- Execute any documents required to enforce the Company’s right. (Failure to execute the required documents does not waive the Company’s right to collect any sums for damages from the third party.)
Once settlement has been made and the Company has been reimbursed the amounts of benefits paid, no other benefits are payable for the condition or related condition which gave rise to the claim.
Requests for policy cancellations and refunds must be in writing.
Policies cancelled before the Period of Insurance begins are eligible for a full refund. After the Period of Insurance begins the entire premium is considered fully earned and none will be funded.
NOTE: The Period of Insurance for Trip Cancellation and Curtailment Coverage begins 30 days before the departure date on the application.
Notice Concerning Your Right of Privacy as a Consumer
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 non public 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.