International travel medical and health insurance

SCHEDULE OF BENEFITS
MEDICAL BENEFITS	Usual reasonable and customary charges, subject to deductible and coinsurance
Hospital Room and Board	To Policy Maximum for average semi-private room rate

Intensive Care	To Policy Maximum

Medical Expenses	To Policy Maximum

Outpatient Medical	To Policy Maximum

Local Ambulance	To Policy Maximum

Emergency Room	As described below
Charges incurred for the use of the Emergency Room due to an accident are covered up to the Policy Maximum. Charges incurred for the use of the Emergency Room for treatment of an illness are subject to an additional (extra) US$250 deductible if treatment does not require admittance to the hospital.

Dental	As described below
Injury due to an accident: Each Outreach 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 Policy Maximum. Sudden dental pain: Each plan will pay up to US$100 for the necessary treatment of sudden, unexpected pain to sound natural teeth.

INTERNATIONAL EMERGENCY CARE
Emergency Evacuation	To Policy Maximum when coordinated through the Plan Administrator
Each Outreach Travel Medical Insurance 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 country of residence or the country where the evacuation occurred, up to the policy limit.
Emergency Reunion	To US$15,000 when coordinated through the Plan Administrator
Each Outreach plan also provides emergency reunion coverage, up to US$15,000 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 country of residence to be reunited with the insured.
Repatriation	To US$25,000 when coordinated through the Plan Administrator
If a covered illness/injury results in death, expenses for Repatriation of bodily remains or ashes to the country of residence will be covered up to a maximum of US$25,000.
Returning Minor Children	To US$5,000 when coordinated through the Plan Administrator
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 Outreach plans will pay up to US$5,000 for one way economy fare to their home country, including a chaperone, if necessary, for the safety of the child(ren).

PLAN INFORMATION
Deductible	Your choice of US$100, $250, $500, $1,000 or $2,500
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.
Coinsurance	As described below
For treatment received outside the US & Canada: No coinsurance For treatment received within the US & Canada: The plan pays 80% of eligible expenses up to US$5,000, then 100% up to the Policy Maximum
Benefit Period	Six months
If a covered injury or illness requires continuing treatment after the Period of Coverage expires, the six-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 six months before the Period of Coverage expired, benefits for the covered injury or illness will continue subject to the Policy Limits and the other terms of the plan until there have been six months of continuous coverage for the covered injury or illness.

SPECIAL COVERAGES
Home Country Coverage	As described below
Incidental Home Country Coverage - During the Period of Coverage an insured person may return to their country of residence for incidental visits up to a cumulative two weeks total, subject to: a. The insured person must have left their country of residence, b. The total Period of Coverage must be for a minimum of 30 days, and c. The return to the country of residence may not be taken to receive treatment for an illness or injury incurred while traveling. End of Trip Home Country Coverage - For every six 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 two 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	To US$5,000
If, during a covered trip, there is a death of an immediate family member (spouse, child, parent or sibling) or the substantial destruction of the insured’s principal residence, each Outreach 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.
Lost Luggage	To US$50 per item or personal property; maximum of US$250 per Period of Coverage
This benefit will be paid in the event that the Common Carrier permanently loses an insured person’s checked luggage. This coverage is secondary to any other available coverage, including the Carrier’s.
Common Carrier Accidental Death	US$50,000 to Beneficiary; maximum of US$250,000 per family
If accidental death should occur while traveling on a commercial Common Carrier, US$50,000 will be paid to the designated beneficiary, to a maximum of US$250,000 per family.

Sports & Activities Coverage	To Policy Maximum for basic sports Coverage as described below
Each Outreach 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. 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: racing of any kind, aviation (except when traveling as a passenger in a commercial aircraft), BMX, BASE jumping, bobsleigh, bungee jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning, inline skating, jet skiing, kayaking, luge, motocross (moto-x), mountain biking, mountaineering, parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping, sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling, surfing, wakeboarding, water skiing, windsurfing and whitewater rafting. Optional Sports Rider: This rider adds coverage for jet skiing, scuba diving, snow skiing, snowboarding, snowmobiling, snorkeling, surfing, wakeboarding, water skiing and windsurfing. For more sports coverage, please review IMG’s Patriot Extreme^SM plan.
Accidental Death & Dismemberment	US$25,000 principal sum
Each Outreach plan includes US$25,000 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. For more information, see the Conditions of Coverage section on page 14.

Additional Benefits for U.S. Citizens
Sudden Recurrence of a Pre-existing Condition
Up to US$15,000 will be paid for the eligible expenses of a sudden and unexpected recurrence of a Pre-existing Condition while traveling outside of the US. In addition, up to US$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. For the definition of a Pre-existing Condition, please see Exclusion number 1 on page 12.
Indemnity
Outreach International will pay directly to the insured person US$100 for each night of a required overnight stay in a hospital. However, the hospital stay must be covered under this plan in order to receive this benefit.

This web page contains only a consolidated and summary description of all current Outreach Travel Medical Insurance benefits, conditions, limitations and exclusions. A certificate containing the complete Policy Wording with all terms, conditions and exclusions will be included with the fulfillment kit. IMG reserves the right to issue the most current Policy Wording for this insurance plan in the event this application and/or brochure has expired, is modified, or is replaced with a newer version. Current Policy Wordings are available upon request.