TRAVEL INSURANCE
BY SPECIALTY RISK INTERNATIONAL
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WHY YOU NEED THIS PROGRAM
While the United States offers the most comprehensive medical care available, it is often complicated as well as very expensive. For the visitor to the United States or the recent immigrant, finding a program that is easy to understand and reasonably priced is often difficult.
As a solution, Inbound USA was developed to provide a simple program to visitors and immigrants.
This is a brief description of the Inbound USA program. Detailed wording is outlined in the Program Summary, which will be mailed to you once you have enrolled into Inbound USA.
ELIGIBILITY
This program is available to non-United States citizens who come to the U.S. for business, pleasure, to study, or to immigrate. The program must become effective within 12 months of arrival in the United States.
PERIOD OF COVERAGE
You may initially enroll into Inbound USA for between 1 and 12 months. If you initially purchase at least 3 months, you may continue to renew coverage for a minimum 3 months at a time, at the premium rate in force at the time of renewal. Total period of coverage for Inbound USA cannot exceed 36 months.
Effective Date - Your coverage will begin on the latest of the following:
- Your departure from your Home Country; or
- The date your Application and premium are received by SRI; or
- The date your Application and premium are accepted by SRI; or
- The date you request on the Application.
Expiration Date - Your coverage will end on the earlier of the following:
- The date shown on the Insurance Confirmation Card, for which premium has been paid; or
- The date you return to your Home Country; or
- 36 months after your original Effective Date; or
- The day an insured becomes a U.S. citizen or is considered a U.S. resident by the state where they are residing; or
- The date of entry into active military service.
Upon each renewal, rates, benefits, and program in general are subject to change.
RENEWAL
If Inbound USA is initially purchased for at least three months, one month before the expiration date, SRI will send a renewal notice to the Address of Correspondence listed on the application. Coverage may then be renewed for a period of time, depending upon your specific need. If you renew the coverage for 3 or more months (up to 12 months at a time), SRI will continue to send renewal notices to you. If you renew the coverage for only 1 or 2 months, SRI will assume that you no longer require the coverage and will not send another renewal notice. Again, total period of coverage for Inbound USA cannot exceed 36 months.
SCHEDULE OF BENEFITS
When your covered Injury or Sickness requires treatment by a physician, this program will provide benefits for the Usual and Customary (U&C) charges scheduled below which exceed the chosen Per Person Deductible (either $75 or $150, or a $250 deductible for age 70 and over) for each Injury and each Sickness and which are incurred within the 52 weeks following the Injury or Sickness (within 32 weeks for those insureds age 70 and over). Payment for any covered service will be no more than the Benefit Limit shown for it. The total payable by all Benefits will be no more than $50,000 or $100,000 for each Injury and each Sickness.
For persons age 70 and over, the maximum benefit limit is $50,000, the period in which covered expenses must be incurred is 32 weeks following the Injury or Sickness, and a separate schedule applies.
COVERED SERVICES INJURY AND SICKNESS BENEFIT LIMITS
Age 14 days to Age 69 Age 14 days to Age 69 Age 70 and over
Maximum Limit $50,000 Max per Injury / Sickness $100,000 Max per Injury / Sickness $50,000 Max per Injury / Sickness
INPATIENT
INPATIENT Age 14 days to Age 69 Age 14 days to Age 69 Age 70 and over
Hospital Room & Board including miscellaneous $1275/day, 30 day max $1750/day, 30 day max $950/day, 30 day max
Hospital Intensive Care Unit Additional $525/day, 8 day max Additional $750/day, 8 day max Additional $425/day, 8 day max
Surgical Treatment $3000 $5000 $2500
Anesthetist 25% of surgical benefit 25% of surgical benefit 25% of surgical benefit
Assistant Surgeon 25% of surgical benefit 25% of surgical benefit 25% of surgical benefit
Physician's Non-Surgical Visits $50/visit, 1/day, 30 visits $75/day, 1/day, 30 visits $50/visit, 1/day, 30 visits
Consultant Physician, when requested by attending Physician $400 $450 $350
Pre-Admission Tests within 7 days before Hospital admission $1000 $1000 $700
Private Duty Nurse $500 $500 $500
OUTPATIENT
OUTPATIENT Age 14 days to Age 69 Age 14 days to Age 69 Age 70 and over
Surgical Treatment $3000 $5000 $2500
Anesthetist 25% of surgical benefit 25% of surgical benefit 25% of surgical benefit
Assistant Surgeon 25% of surgical benefit 25% of surgical benefit 25% of surgical benefit
Physician's Non-Surgical Visits $50/visit, 1/day, 10 visits $75/visit, 1/day, 10 visits $50/visit, 1/day, 10 visits
Diagnostic X-rays & Lab Services $400
Additional $250 - One Cat scan, PET scan or MRI $450
Additional $750 - One Cat scan, PET scan or MRI $350
Additional $250 - One Cat scan, PET scan or MRI
Hospital Emergency Room 75% of U&C to $300 75% of U&C to $500 75% of U&C to $250
Prescription Drugs $100 $150 $80
Day surgery miscellaneous, related to outpatient scheduled surgery performed at a Hospital or licensed outpatient surgery center; including the cost of operating room, anesthesia, drugs and medicines and medical supplies. $900 $1000 $800
OTHERS
OTHERS Age 14 days to Age 69 Age 14 days to Age 69 Age 70 and over
Ambulance Services $400 $400 $400
Initial Orthopedic Prosthesis / brace $1000 $1200 $800
Chemotherapy and / or radiation therapy $1000 $1250 $800
Dental Treatment for Injury to Sound, Natural Teeth $500 $500 $500
Mental & Nervous Disorder & Substance Abuse Same as any Sickness Same as any Sickness Same as any Sickness
Maternity (conception occurs at least 90 days after your effective date) $2500 Max $2500 Max N/A
Physiotherapy $35/visit, 1/day, 12 visits $35/visit, 1/day, 12 visits $35/visit, 1/day, 12 visits
Emergency Evacuation $10,000 $10,000 $10,000
Repatriation of Remains $7,500 $7,500 $7,500
AD&D Principal Sum $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier
Should an insured person turn 70 during the purchased coverage period, the 70 and over benefit schedule becomes effective upon the day the insured turns 70.
Emergency Medical Evacuation Expenses
If you or any covered dependents become sick or injured during the period of coverage and it has been determined that an Emergency Medical Evacuation is required to either the nearest medical facility, where appropriate medical treatment can be obtained, or to your Country of Residence, all eligible expenses incurred are covered up to $10,000. An Emergency Medical Evacuation must be recommended by a legally licensed physician who certifies that the severity of the Injury or Sickness necessitates such Emergency Medical Evacuation, and agreed to by you or your representative. All arrangements must be coordinated by the Assistance Provider.
Repatriation of Mortal Remains Expenses
If Injury or Sickness commencing during the Period of Coverage results in death, all reasonable expenses incurred for preparation and return of the remains to the Country of Residence are covered up to a maximum of $7,500 provided that all arrangements are coordinated by the Assistance Provider.
Common Carrier Accidental Death and Dismemberment (AD&D)
Accidental Death and Dismemberment shall apply to covered accidents sustained by an insured person while riding as a passenger in or on any land, water or air conveyance operated under a license for the transportation of passengers for hire. A loss must occur within 365 days after the date of accident causing the loss:
For Loss of: Indemnity
Life Principal Sum
Both Hands or Both Feet or Sight of Both Eyes Principal Sum
One Hand and One Foot Principal Sum
Either Hand or Foot and Sight of One Eye Principal Sum
Either Hand or Foot One-Half the Principal Sum
Sight of One Eye One-Half the Principal Sum
DEFINITIONS
"Injury" means: bodily injury: (1) directly and independently caused by specific accident which is unrelated to any pathological, functional, or structural disorder of injury, (2) treated by a Physician within 30 days after the date of accident; and (3) which causes loss during the term of the policy.
"Sickness" means: sickness or disease of the insured Person which causes loss and originates while the Insured Person is covered under the policy. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness.
"Pre-Existing Condition" means: (1) the existence of symptoms within the 6 months (or 12 months for persons 70 and older) immediately prior to the Insured's Effective Date under the policy, or, (2) any condition which originates, is diagnosed, treated or recommended for treatment within the 6 months (or 12 months for persons 70 and older) immediately prior to the Insured's Effective Date under the policy; or (3) congenital conditions.
"Usual and Customary Charges" means: a reasonable charge which is: (1) usual and customary when compared with the charges made for similar services and supplies; and (2) made to persons having similar medical conditions in the locality of the Policyholder. No payment will be made under the policy for any expenses incurred which in the judgment of the Company are in excess of Usual and Customary Charges.
EXCLUSIONS
No benefits will be paid for loss or expense caused by, contributed to, or resulting from:
- Pre-existing Conditions;
- Any loss that occurs while traveling solely for the purpose of obtaining medical treatment while on a waiting list for a specific treatment, or while traveling against the advice of a physician;
- Expense incurred within the Insured Person's Home Country or country of regular domicile;
- Routine physical or other examinations where there are no objective indications of impairment of normal health, or well baby care;
- Eye examinations; prescriptions or fitting of eyeglasses and contact lenses; or other treatment for visual defects and problems. "Visual defects: means any physical defect of the eye which does or can impair normal vision;
- Hearing examinations or hearing aids; or other treatment for hearing defects and problems. "Hearing defects: means any physical defect of the ear which does or can impair normal hearing:
- Dental treatment, except as the result of injury to sound, natural teeth as stated in the Schedule of Benefits:
- Professional services rendered by a Member of the Insured Person's immediate family, or anyone who lives with the Insured Person;
- Services or supplies not necessary for the medical care of the patient's injury or sickness;
- Weak, strained or flat feet, corns, calluses, or toenails;
- Cosmetic surgery, or treatment for congenital anomalies (except as specifically provided), except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or covered Sickness;
- Elective Surgery and Elective Treatment;
- Diagnostic or surgical procedures in connection with infertility unless infertility is a result of a covered Injury or covered Sickness;
- Birth control, including surgical procedures and devices;
- Routine new-born baby care, well-baby nursery and related Physician charges;
- Participation in professional or intercollegiate athletics;
- Injury or Sickness for which benefits are paid or payable under any Worker's Compensation or Occupational Disease Law or Act, or similar legislation;
- Organ transplants;
- War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered);
- Participation in a riot or civil disorder, commission of or attempt to commit a felony in the country in which it was attempted or committed;
- Suicide or attempted suicide (including drug overdose), while sane or insane (while sane in Missouri), or intentionally self-inflected Injury;
- Charges of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;
- Treatment of nervous or mental disorders, except as stated in the Schedule of Benefits, or treatment of alcoholism or drug abuse, except as provided for treatment of mental or nervous disorders, according to the Schedule of Benefits;
- Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;
- Treatment services, supplies or facilities in a hospital owned or operated by: a) The Veteran's Administration; or b) A national government or any of its agencies. (This exclusion does not apply to treatment when a charge is made which the Insured is required by law to pay);
- Duplicate services actually provided by both a certified nurse-midwife and Physician;
- Expenses payable under any prior policy which was in force for the person making the claim;
- Expenses incurred during a hospital emergency room visit which is not of an emergency nature;
- Expenses incurred for outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or sublimation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
- Injury sustained as the result of the Insured operating a motor vehicle while not properly licensed to do so in the jurisdiction the motor vehicle accident occurs;
- Voluntary or elective abortion;
- Expense covered by any other valid and collectible medical, health or accident insurance;
- Expense incurred after the date insurance terminates for an Insured Person except as may be specifically provided;
- Expenses incurred for injuries resulting from the use of alcohol or intoxicants, or any drugs unless prescribed by a Physician;
- Sexually transmitted diseases, including AIDS.
ENROLLING IN INBOUND USA INSURANCE
- Complete entire application.
- Select method of payment.
- If paying by check or money order, make payable to: "SRI" and enclose it together with completed Application.
- If paying by credit card, complete Application and mail or fax to SRI. Be sure to sign Method of Payment section.
Complete and return the Application with your payment for the total premium to:
SRI
9200 Keystone Crossing, Ste 300
Indianapolis, IN 46240
Fax: 317-575-2659(You may fax if paying by credit card only. Originals are not required if applications is faxed to SRI with credit card payment)
MONTHLY RATES (Effective November 1, 2001)
$75 Per Injury / Sickness Deductible Per Person
$50,000 Maximum $100,000 Maximum
Age 2 weeks - 49 $59 $86
Age 50 - 69 $94 $132
Dependent Child (Age 2 weeks through age 18) $49 $74
$150 Per Injury / Sickness Deductible Per Person
$50,000 Maximum $100,000 Maximum
Age 2 weeks - 49 $56 $83
Age 50 - 69 $91 $129
Dependent Child (Age 2 weeks through age 18) $46 $69
$250 Per Injury / Sickness Deductible Per Person
$50,000 Maximum $100,000 Maximum
Age 70 - 79 $101 N/A
Age 80 + $131 N/A
Dependent Child rate is applicable when at least one parent will also be covered under Inbound USA.
Please be aware that this is not a general health insurance policy, but an interim program intended for temporary use. Inbound USA does not guarantee payment to a facility or individual for medical expenses until the Company determines that it is an eligible expense.
Refund of Premium
Refund of premium shall be considered only if written request is received by SRI prior to the Effective Date of Coverage. After the Effective Date of Coverage, the premium is considered fully earned and non-refundable.
What You Will Receive
Upon successful enrollment in Inbound USA, you will receive an information packet from SRI. This packet will include your ID Card and Program Summary. The Program Summary describes all the benefits of Inbound USA in complete detail. In addition, the Program Summary tells you the procedure for submitting claims.
The Insurance Company
Inbound USA is underwritten by The Insurance Company of the State of Pennsylvania, a member company of the American International Group of Companies (AIG) and is rated A++ "Superior" by the A.M. Best Company.
Inbound USA, Copyright 2001, Specialty Risk International, Inc.(SRI)
"Inbound" is a service mark of SRI
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