Patriot GoTravel America

Why Consider Travel Insurance? Traveling abroad can be an exciting experience. But what would happen if you or one of your family members become ill or injured whiled away from home? International travel can quickly turn frightening if you’re not prepared fro a medical emergency.

Most travelers assume they will be covered by their standard medical plan. The truth is, while traditional plans may offer adequate domestic coverage, they may not be designed for international travel. Without even realizing it, you may be putting your health - & that of your family - at risk.

What if you are injured or become ill during your trip? Could you get quality treatment at an unfamiliar hospital? How would you deal with the language and currency barriers? What if the treatment you need isn't available nearby? Who do you call? Imagine trying to call your insurance company at 3:00 a.m. from a foreign country during a medical emergency! Will they be there when you need them the most?

You have enough to worry about when you're traveling. Don't let your medical coverage be an uncertainty. International Medical Group® (IMG®) has developed Patriot GoTravelSM Medical Insurance plans to provide you and your family Coverage Without Boundaries. Each plan offers a complete package of international benefits available 24 hour a day. Simply select the one that best fits your needs.

Patriot GoTravel America Provides coverage for non-U.S. citizens traveling outside their home country for a minimum of 5 days up to a maximum of two years. If the plan is purchased for a minimum of one month, coverage may be renewed (without break in coverage) for a total of up to two years.


Benefits:


PLAN INFORMATION
Plan Maximum $50,000, $100,000, $500,000, $1,00,000, $2,000,000
Deductible Your choice of $0, $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 U.S. & Canada: No coinsurance

In the PPO Network:The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Policy Maximum
Outside the PPO Network: The plan pays 80% of eligible expenses up to $5,000, then 100% up to the Policy Maximum

For treatment received outside the U.S. & Canada: No coinsurance [100% coverage up to the Policy Maximum]
Renewal of Coverage One months

If your Patriot plan is purchased for a minimum of one month, coverage may be renewed (unless there is a break in coverage) for a total of up to two years. Renewals are available in whole month or daily increments and may be completed online or by using a paper application, however, renewals of less than one month are available only online. For each renewal of less than one month completed online, you will be charged an additional $5 processing fee. Each insured person must only satisfy one deductible and coinsurance within each 12 month coverage period.

Please note: Renewal rates may differ from initial rates.

Eligibility to purchase, extend or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including the Patient Protection and Affordable Care Act (PPACA).

Benefit Period Six months
If a covered injury or illness requires continuing treatment after the Period of Coverage expires, the sixmonth Benefit Period may offer continued coverage for that injury or illness. 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 continues. This is subject to the Maximum Limits and the other terms of the plan until there have been six months of continuous coverage for the covered injury or illness.
Sudden and Unexpected Recurrence of a Pre-existing Condition
(Non U.S. citizens only) For those under age 65, the Plan will pay up to a $50,000 lifetime maximum for eligible medical expenses. For those ages 65 and older, the Plan will pay up to $2,500 lifetime maximum.

(U.S. citizens only) For those up to age 65 with a primary health the Plan will pay the Usual, Reasonable and Customary charges of a sudden and unexpected recurrence of a Pre-existing Condition (defined on page 16) up to the plan maximum. For those without a primary health plan, the plan will pay up to a $20,000 lifetime maximum. For those ages 65 and older, with or without a primary health plan, the Plan pay up to a $2,500 lifetime maximum. The primary health plan must have existed prior to the effective date and during coverage of the Plan, and the Pre-existing Condition must be covered under the primary health plan.

In addition, up to $25,000 will be paid to U.S. and non-U.S. citizens 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
SCHEDULE OF BENEFITS (all amounts listed are in U.S. dollars)
MEDICAL BENEFITS Usual, reasonable and customary charges, subject to deductible and coinsurance
Hospital Room and Board Up to Policy Maximum for average semi-private room rate
Intensive Care Up to Policy Maximum
Medical Expenses Up to Policy Maximum
Outpatient Medical Up to Policy Maximum
Local Ambulance Up to Policy Maximum
Prescription Drugs Up to Policy Maximum
Emergency Room Accident Up to Policy Maximum
Emergency Room Illness with
In-patient Admission
Up to Policy Maximum
Emergency Room Illness without
In-patient Admission
Up to the Maximum Limit with
additional $250 deductibl
Dental - Injury Due to Accident Up to the Maximum Limit
Dental - Sudden Dental
Emergency
Up to $100
Hospital Daily Indemnity Up to $100 per night up to a
maximum of 10 days

INTERNATIONAL EMERGENCY CARE (when coordinated through the Plan Administrator)
Emergency Evacuation Up to $500,000 lifetime maximum (independent of policy maximum)
The Patriot plans offer coverage for Emergency Medical Evacuation to the nearest qualified medical facility; expenses for reasonable transportation resulting from the evacuation; and the cost of returning to either the home country or the country where the evacuation occurred, up to a $500,000 lifetime maximum (independent of the Maximum Limit).
Emergency Reunion Up to $50,000
Each Patriot plan also offers Emergency Reunion coverage, up to $50,000 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 home country to be reunited with the insured.
Return of Mortal Remains Or
Cremation/Burial
Up to $50,000
If a covered illness/injury results in death, expenses for Repatriation of bodily remains or ashes to the home country will be covered up to a maximum of $50,000; or up to $5,000 for the preparation, local burial or cremation of your mortal remains at the place of death.
Returning Minor Children Up to $50,000
If a covered illness/injury results in a hospitalization and/or death of the insured person, and he/she is traveling alone with child(ren) 19 or under that otherwise would be left unattended, the Patriot plans will pay up to $50,000 for one way economy fare to their home country, including a chaperone, if necessary, for the safety of the child(ren).
To be eligible for the Evacuation, Reunion and Return benefits, these must be recommended by the attending physician in life-threatening medical situations, and approved in advance and coordinated by IMG.
Political Evacuation Up to $10,000
If the United States Department of State, Bureau of Consular Affairs, or similar government organization of the insured person's home country, orders the evacuation of all non-emergency government personnel from the host country, due to political unrest, that becomes effective on or after the insured person's date of arrival in the host country, the Company pays up to a $10,000 lifetime maximum for transportation to the nearest place of safety or for repatriation to the insured person's home country or country of residence provided that:
  1. The insured person contacts the Company within 10 days of the United States Department of State, Bureau of Consular Affairs, or similar government organization of the insured person's home country, issuance of the evacuation order; and
  2. The evacuation order pertains to persons from the same home country as the insured person; and
  3. Political Evacuation and Repatriation is approved and coordinated by the Company; In no event will the Company pay for a political evacuation if there is a travel warning in effect on or within six (6) months prior to the insured person's date of arrival in the host country.

To be eligible for the Evacuation, Reunion and Return benefits, these must be recommended by the attending physician in critical medical situations, and approved in advance and coordinated by IMG.
ADDITIONAL BENEFITS
Home Country Coverage As described below
Incidental Home Country Coverage - During the Period of Coverage an insured person may return to their home country for incidental visits up to a cumulative two weeks total, subject to:
  1. The insured person must have left their home country,
  2. The total Period of Coverage must be for a minimum of 30 days, and
  3. The return to the home country may not be taken to receive treatment for an illness or injury incurred while traveling.
End of Trip Home Country Coverage For every five 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 calculate your premium on the Application Form to include the additional month(s).
Trip Interruption
If, during a covered trip, there is an unexpected death of an immediate family member (spouse, child, parent or sibling), a breakin at the insured's principle residence, or the substantial destruction of the insured's principal residence due to a fire or natural disaster, each Patriot plan pays to return the insured to the area of principal residence. The plan pays 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 Up to $50 per item of personal property;
maximum of $250 per Period of Coverage
A benefit of $50 per luggage item, up to a maximum of $250, is payable in the event that the Common Carrier permanently loses an insured person's checked luggage while in transit. This coverage is secondary to any other available reimbursement, including the Carrier's.
Common Carrier Accidental Death $50,000 to Beneficiary; maximum of $250,000 per family
If accidental death should occur while traveling on a commercial Common Carrier, $50,000 is payable to the designated beneficiary, to a maximum of $250,000 per family.
Sports and Activities Coverage
Each Patriot plan covers injuries incurred during athletic activities which are non-organized, non-contact and engaged in by the insured person solely for leisure, recreation, entertainment or fitness purposes. Some of these sports and activities include, but are not limited to, motor cycle/motorscooter riding, recreational downhill and/or cross country snow skiing, horseback riding, subaquatic activities (to 10m), wakeboarding, and water skiing. However, activities not covered include amateur or professional sports or other athletic activity which is organized and/or sanctioned by the National Collegiate Athletic Association (and/or any other collegiate sanctioning or government body), or the International Olympic Committee, and or Adventure Sports. Please note this is only a summary of sports and activities and exclusions. For additional information, please refer to the Certificate of Insurance.
Accidental Death & Dismemberment $25,000 principal sum
Each Patriot plan offers a $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.
Terrorism Coverage Up to $50,000 lifetime maximum

Each Patriot plan provides coverage for injuries and illness incurred as a result of an act of Terrorism, limited in amount and by circumstances. If an insured person is injured as a result of an act of Terrorism, and the insured person has no direct or indirect participation in the act, the plan reimburses eligible medical claims subject to a $50,000 lifetime maximum. Terrorism includes criminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provide a state of terror in the general public or in a group of persons or particular persons, intimidate a population, or compel a government or international organization to do or to abstain from doing an act. However, this benefit does not cover an act of Terrorism in any country or location where the United States government has issued a travel advisory that has been in effect within the six months prior to the insured person's date of arrival. In addition, claims incurred as a result of radiological, nuclear, chemical or biological weapons or events are not covered.

This benefit also does not cover an act of Terrorism in the event that an advisory to leave a certain country or location is issued by the United States government after the insured person's arrival date, and the insured person unreasonably fails or refuses to heed such warning or depart the country or location.

Identity Theft Assistance Up to $500 per Period of Coverage

If an imposter obtains key personal information such as a Social Security or Driver's License number, or other method of identifying an insured person in order to impersonate or obtain credit, merchandise or services in the insured person's name, the Patriot plans provide coverage up to $500 for the reasonable, customary and necessary costs incurred by the insured for: refiling a loan or other credit application that is rejected solely as a result of the stolen identity event; notarization of legal documents, long distance telephone calls, and postage that has resulted solely as a result of reporting, amending and/or rectifying records as a result of the stolen identity event; up to three credit reports obtained within one year of the insured person's knowledge of the stolen identity event; and stop payment orders placed on missing or unauthorized checks as a result of the stolen identity event.

The identity theft event must occur during the Period of Coverage.

Hospital Daily Indemnity
Each plan pays $100 directly to the insured person for each night of a required overnight stay in a hospital up to a maximum of 10 days. The hospital stay must be covered under this plan in order to receive this benefit. This benefit is not available for Patriot America (non-U.S. citizens) if the hospitalization is due to the Sudden Recurrence of a Pre-existing Condition.
Natural Disaster $100 per day for five days
This benefit is available in the event an insured person is required to depart his/her destination due to an evacuation order issued by prevailing authorities in connection with a Natural Disaster. Natural Disaster is defined as widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe or event resulting in migration of the population for its safety.

Exclusions:


Charges for certain services, treatments and/or conditions, among others, are excluded from coverage under the Patriot plans and include but are not limited to:
  1. A Pre-existing Condition which is any injury, illness, sickness, disease, or other physical, medical, mental or nervous condition, disorder or ailment that, with reasonable medical certainty, existed at the time of application or at any time during the three years prior to the effective date of the insurance, including any subsequent, chronic or recurring complications or consequences related thereto or arising therefrom, whether or not previously manifested or known, diagnosed, treated, or disclosed.
  2. Treatment or surgeries which are elective, investigational, experimental or for research purposes.
  3. War, military action, terrorism, political insurrection, protest, or any act thereof. The Company will not pay for a Political Evacuation if there is a travel advisory in effect on or within six (6) months prior to the Insured Person's date of arrival in the Host Country.
  4. Immunizations and routine physical exams.
  5. Treatment of Temporomandibular Joint or dental treatment, except as expressly provided for in the Certificate of Insurance.
  6. Venereal disease, AIDS virus, AIDS related illness, ARC Syndrome, or AIDS, and the cost of testing for these conditions, and charges for treatment or surgeries which are incurred by any Insured who was HIV+ at time of enrollment into this insurance.
  7. Pregnancy, childbirth, birth control, artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
  8. Any illness or injury sustained while taking part in: Amateur Athletics, Professional Athletics, or other athletic activity that is sponsored or sanctioned by the National Collegiate Athletic Association (and/or any other collegiate sanctioning or governing body), or the International Olympic Committee. The following Adventure Sports are excluded unless the Adventure Sports Rider is purchased: abseiling, BMX, bobsledding, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, hot air ballooning, inline skating (with proper use of helmet and pads), jet skiing, jungle zip lining, kayaking, mountain biking, parachuting, paragliding, parascending, piloting a non-commercial aircraft, rappelling, rock climbing or mountaineering (ropes and guides to 4500m from ground level), scuba diving (to 50m), skydiving, snowboard-ing, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), wildlife safaris, and windsurf-ing. All such activities must be carried out in strict accordance wit the rules, regulations and guidelines of the applicable Governing Body or Authority of each such activity.

    Injury sustained while participating in contact sports of any kind, racing of any kind, any rodeo activity, BASE jumping, kiteboarding, mountaineering or climbing or trekking above elevation 4500 meters above ground level or without proper ropes or guides; luge, motocross, Moto-X, ski jumping, sub-aquatic activities below 50 meters, whitewater rafting exceeding Class V difficulty; and/or adventure sports activity not expressly covered hereunder are excluded regardless of which plan or rider is selected.
  9. Vision or ear tests and the provision of visual or hearing aids.
  10. Vocational, recreational, speech or music therapy.
  11. Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services.
  12. Charges, injuries and/or illnesses resulting or arising from or occurring during the commission or continuing perpetration of a violation of law by the insured, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
  13. Treatment for, and injuries and/or illnesses resulting or arising from, substance abuse or drug addiction.
  14. Injury and/or illness resulting or arising from being under the influence of alcohol or drugs; and injury or illness resulting from operating any type of vehicle after consuming any alcohol or drugs.
  15. Willful self-inflicted injury or illness.
  16. Treatment required as a result of or arising from complications from a treatment or condition not covered under the certificate.
  17. Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured.
  18. Treatment for mental and nervous disorders.
  19. Organ or tissue transplants or related services.
  20. Illness or injury where the trip to the host country is undertaken for treatment or advice for such illness or injury, except as expressly provided for in the certificate of insurance.
  21. Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).
  22. Any infection of the urinary tract (or Illness arising therefrom), that occurs within ninety (90) days of the Effective Date of coverage and that requires Treatment of the Insured Person in a Hospital; provided that any such Illness will be deemed by the Company to be a Pre-existing Condition. See Sudden and Unexpected Recurrence of a Pre-existing Condition, on brochure pdf page 11
This web page contains only a consolidated and summary description of all current Patriot GoTravel benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate 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 Certificate Wordings are available upon request.

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 will require U.S. citizens and certain U.S. residents to obtain PPACA compliant insurance coverage unless they are exempt from PPACA. Penalties may be imposed on U.S. citizens and U.S. residents who are required to maintain PPACA compliant coverage but do not do so. Please note that it is solely your responsibility to determine if PPACA is applicable to you.


Nationwide PPO Network:


Click here to ACCESS THE PPO DIRECTORY

You may seek treatment under Patriot GoTravel Medical Insurance Plan worldwide, including in the United States, with the hospital or doctor of your choice. When seeking treatment in the U.S., you may use the independent Preferred Provider Organization (PPO) contracted by IMG, a separately organized network (First Health Group) of approximately 500,000 physicians and 4,700 privately owned and operated hospitals. * This PPO network includes a large number of hospitals including some of the most well recognized university medical centers and transplant facilities.

Using this provider network could significantly reduce your out-of-pocket expenses.

When a U.S. hospital outside the network is used, a co-payment of US $250 is required in addition to the regular deductible and coinsurance. This co-payment is waived, however, if there is not a network provider within 50 miles of the location of treatment.

Each proposed hospital admission, inpatient or outpatient surgery, and certain other medical procedures must be Pre-certified for medical necessity. This means the insured person or their attending physician must call the number listed on the IMG identification card prior to admittance to a hospital or performance of a surgery, or medical procedure. In the case of an emergency hospital admission, the Pre-certification call must be made within 48 hours of the admission, or as soon as reasonably possible. For a complete list of procedures requiring Pre-certification, please refer to your certificate wording.

If Pre-certification guidelines are not followed, eligible claims and expenses will be reduced by 50%.


Rates - Patriot GoTravelSM America Insurance (Foreign National Visiting USA or worldwide)


Patriot GoTravel America: The following rates are based on a $250 deductible in all the policy maximum options.

Options: Other lower and Higher deductible options available as follows to improve the deductible or reduce the cost. please use these rate factors.
Deductible Rate Factors. Deductible Rate Factors.
US $ Zero 1.25 US $500 .90
US $100 1.10 US $1,000 .80
US $250 1.00 US $2,500 .70

ONE MONTH RATES
(Four Policy Maximum options. Maximums are per insured per certificate period.)

Option 1 Option 2 Option 3 Option 4
$50,000 $100,000 $500,000 $1,000,000
Age Monthly Rates
18-29 $42 $49 $63 $74
30-39 $55 $66 $82 $95
40-49 $82 $94 $123 $139
50-59 $118 $144 $174 $202
60-64 $139 $171 $203 $243
65-69 $159 $204 $221 $265
70-79 $215 N/A N/A N/A
80+* $373 N/A N/A N/A
Dep. Child $36 $43 $55 $62
ChildAlone $38 $45 $58 $65
DAILY RATES (5 day minimum)
(Four Policy Maximum options. Maximums are per insured per certificate period.)

Option 1 Option 2 Option 3 Option 4
$50,000 $100,000 $500,000 $1,000,000
Age Daily Rates (Minimum length of coverage is 5 days)
18-29 $1.42 $1.72 $2.16 $2.50
30-39 $1.86 $2.21 $2.79 $3.19
40-49 $2.79 $3.19 $4.17 $4.70
50-59 $3.97 $4.85 $5.88 $6.76
60-64 $4.70 $5.73 $6.81 $8.18
65-69 $5.34 $6.86 $7.45 $8.87
70-79 $7.20 N/A N/A N/A
80+* $12.50 N/A N/A N/A
Dep.Child $1.20 $1.45 $1.85 $2.10
ChildAlone $1.32 $1.57 $1.96 $2.21


Riders:

EXTREME SPORTS RIDER:
The Extreme Sports Rider is available on both Patriot plans for those up to the age of 65. The following activities are covered to the lifetime maximum amounts: abseiling, aviation, BMX, bobsleigh, bungee jumping, canyoning, caving, flying (private plane), hang gliding, heli-skiing, high diving, hot air ballooning, inline skating, jet skiing, kayaking, mountain biking, paragliding, parascending, rappelling, rock climbing (ropes and guides to 4500m from ground level), skydiving, snow boarding, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), wind-surfing. These extreme activities must be engaged in solely for leisure, recreation, or entertainment purposes.
Age Lifetime Maximum
0 - 49 $50,000
50 - 59 $30,000
60 - 64 $15,000
PATRIOT GoTravel RETURN RIDER:
(Non-U.S. citizens only) When purchased at the time of application, the Patriot GoTravel Return Rider provides temporary medical coverage for non-U.S. citizens returning to their home country.
Up to Policy Maximum
ENHANCED AD&D RIDER:
When purchased at the time of application, the Citizenship Return Rider provides temporary medical coverage for non-U.S. citizens returning to their country of citizenship. For U.S. citizens, the rider provides up to 60 days of coverage for brief returns to the U.S. provided you have a current health plan in force and have resided outside the U.S. continuously for the past six months. Coverage for sudden recurrence of pre-existing conditions is excluded if the rider is selected. For premium information, please see the back of the Application Form.
PERSONAL LIABILITY RIDER:
This optional coverage is available for the primary insured person only. This coverage is in addition to the Accidental Death and Dismemberment already included in the Patriot GoTravel plans. Coverage must be purchased for a minimum of one month.
Up to an Additional $400,000