Inbound hospital Brochure and Application for the year 2005
Note: This is an Inpatient Hospital Expense Program Only
WHY YOU NEED INBOUND HOSPITAL 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 Hospital was developed to provide a simple program to visitors and immigrants.
This is a brief description of the Inbound Hospital program. Detailed wording is outlined in the Program Summary, which will be mailed to you once you have enrolled into Inbound Hospital.
INBOUND HOSPITAL 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. You may only be eligible for one Inbound Hospital program during any period of coverage.
PERIOD OF INBOUND HOSPITAL COVERAGE
You may initially enroll into Inbound Hospital 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 Hospital cannot exceed 12 months (in order to reapply after the 12 months, you must first return to your home country).
Inbound Hospital 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.
Inbound Hospital 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
- 12 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.
INBOUND HOSPITAL RENEWAL If Inbound Hospital 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 in total), 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 Hospital cannot exceed 12 months
INBOUND HOSPITAL SCHEDULE OF BENEFITS
When your covered Injury or Sickness requires overnight, Inpatient treatment in a Hospital, 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 26 weeks following the Injury or Sickness. Payment for any covered service will be no more than the Benefit Maximum shown. The maximum amount payable for all benefits will be no more than $50,000 or $100,000 (depending upon program purchased and availability) 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 26 weeks following the Injury or Sickness, and a separate schedule applies.
INBOUND HOSPITAL COVERED SERVICES INJURY AND SICKNESS BENEFIT MAXIMUMS
| |
Age 14 days to Age 69 |
Age 14 days to Age 69 |
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Age 70 and over |
| INPATIENT |
$50,000 Max per Policy Period |
$100,000 Max per Policy Period |
$50,000 Max per Policy Period |
| Hospital Room & Board including other expenses relating to an overnight hospital admission |
Up to $2000/day, 30 day max | Up to $2500 per day, 30 day max |
Up to $1450/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 |
| 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 |
INBOUND HOSPITAL PRE-EX BENEFIT
| |
Age 14 days to Age 69 |
Age 14 days to Age 69 |
|
Age 70 and over |
| PRE-EXISTING CONDITIONS(the above maximum schedule still applies) |
Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke |
Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke |
Up to $3,000 in coverage for Myocardial Infarction (heart attack) or Stroke |
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
The program will pay up to $10,000 in Covered Expenses incurred if any covered Injury or Illness commencing during the Period of Coverage results in the Medically Necessary Emergency Medical Evacuation or Repatriation of the Insured Person (the Insured Person's medical condition warrants immediate transportation from the medical facility where the Insured Person is located to the nearest adequate medical facility where medical treatment can be obtained). The benefit must be ordered by the Assistance Company in consultation with the Insured Person's local attending Physician. *
Repatriation of Mortal Remains Expenses
The program will pay the reasonable Covered Expenses incurred up to a maximum of $7,500 to return the Insured Person's remains to his/her Home Country, if he or she dies.*
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 |
* NOTE: In the event of an Emergency Medical Evacuation or Repatriation of Mortal Remains benefit is needed or utilized, arrangements must be made by the Assistance Service Provider.
INBOUND HOSPITAL DEFINITIONS
The term "Hospital" shall mean a place that 1.) Is legally operated for the purpose of providing medical care and Treatment to Sick or Injured persons for which a charge is made that the Insured Person is legally obligated to pay in the absence of insurance 2.) Provides such care and Treatment in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) Provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) Operates under the supervision of a staff of one or more Physicians. Hospital also means a place that is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Heath Care Organizations (JCAHO). Hospital does not mean: -A Convalescent, nursing, or rest home or facility, or a home for the aged; A place mainly providing Custodial, Educational, or Rehabilitative Care; or -A facility mainly used for the Treatment of drug addicts or alcoholics.
The term "Injury" shall mean bodily Injury listed in the most recent edition of the International Classification of Diseases and caused solely and directly by Accidental, external, and visible means occurring while this Certificate is in force and resulting directly and independently of all other causes resulting in a Covered Event under this Program.
The term "Inpatient" shall mean a person who is confined in an institution for a period of 24 hours or more and is charged for room and board.
The term "Myocardial Infarction" shall mean an acute and emergent onset of any of the conditions and/or diseases described and coded in the International Coding of Diseases version 9 (ICD9), code sequences 410.0 - 410.9 and 414.1 - 419.9.
The term "Outpatient" shall mean a person who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician's office, for an Illness or Injury, but who is not confined and is not charged for room and board.
The term "Pre-Existing Condition" shall mean 1) A condition that would have caused a person to seek medical advice, diagnosis, care or Treatment within the 6 months (or 12 months for persons 70 and older) prior to the Individual Effective Date of Coverage under this program; 2) A condition for which medical advice, diagnosis, care or Treatment, including Medication, was sought, recommended or received within the 6 months (or 12 months for persons age 70 and older) prior to the Individual Effective Date of Coverage under this program; 3) the symptoms which occurred within the 6 months (or 12 months for persons 70 and older) prior to the Individual Effective Date of the Coverage under this Certificate would have allowed a person trained in medicine to make a diagnosis of the condition producing the symptoms: 4) a condition which manifested within the 6 months (or 12 months for persons 70 and older) prior to the Individual Effective Date of Coverage under this Certificate; Should the Insured Person suffer a Myocardial Infarction or Stroke during the Period of Coverage and it is determined to be a "Pre-Existing Condition", coverage for those expenses will be covered up to the Pre-Existing Condition Benefit maximum, according to the Schedule of Benefits.
The term "Sickness" shall mean Illness or Disease of any kind listed in the most recent edition of the International Classification of Diseases. All related conditions and recurrent symptoms of the same or a similar condition will be considered one Sickness.
The term "Stroke" shall mean an acute and emergent onset of any of the conditions and/or diseases described and coded in the International Coding of Diseases version 9 (ICD9), code sequence 430-438.9.
INBOUND HOSPITAL EXCLUSIONS
No benefits will be paid for loss or expense caused by, contributed to, or resulting from:
- Pre-existing Conditions, as defined;
- Any expenses incurred when travel was undertaken solely for the purpose of obtaining medical treatment or while traveling against the advise of a Physician;
- Expense incurred within the Insured Person's Home Country or country of regular domicile;
- Routine physicals, inoculations, or other examinations where there are no objective indications of impairment of normal health, or well baby care, new-born baby care; well-baby nursery and related Physician charges;
- Prescriptions or fitting of eyeglasses and contact lenses; eye examinations; 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;
- Services or supplies performed or provided by a Member of the Insured Person's family, or anyone who lives with the Insured Person;
- Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
- 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;
- Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth;
- Injury sustained while participating in professional, sponsored and/or organized Amateur or Interscholastic Athletics;
- Organ transplants;
- Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war;
- 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;
- Expenses 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, or treatment of alcoholism or drug abuse;
- 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);
- Expenses incurred during a hospital emergency room visit, except as covered as an eligible Pre-Admission expense for an eligible Inpatient Hospital stay;
- 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 while taking part in mountaineering where ropes or guides are normally used, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snow boarding;
- Treatment paid for or furnished under any other individual, government, or group policy; previous policy; payable under any Worker's Compensation or Occupational Disease Law or Act; or charges provided at no cost to the Insured Person;
- Expense incurred after the Expiration Date for an Insured Person except as may be specifically provided;
- Expenses for treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent or for Injury or Sickness due wholly or partly to the effects of intoxicating liquor or drugs, unless prescribed by a Physician;
- Sexually transmitted diseases, including AIDS.
- Pregnancy expenses or Sickness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from Injury; or voluntary or elective abortion;
- Treatment while confined primarily to receive custodial care, educational or rehabilitative care and nursing services in a long term facility, spa, hydroclinic, weight loss clinic, sanatorium, nursing home or similar facilities;
- Expenses for Speech therapy, Occupational therapy or Vocational Rehabilitation;
- Any Outpatient Expenses;
- Any non-Inpatient Hospital related expenses including separate charges, invoices and bills made by or for services provided by a physician, surgeon, or for physiotherapy.
ENROLLING IN INBOUND HOSPITAL
- 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)
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Inbound Hospital Monthly Rates (Effective February 1, 2005)
| $75 Per Injury / Sickness Deductible Per Person |
| | $50,000 Maximum | $100,000 Maximum |
| Age 2 weeks - 49 | $36 | $52 |
| Age 50 - 69 | $54 | $79 |
| Dependent Child (Age 2 weeks through age 18) | $28 | $44 |
| $150 Per Injury / Sickness Deductible Per Person |
| | $50,000 Maximum | $100,000 Maximum |
| Age 2 weeks - 49 | $33 | $49 |
| Age 50 - 69 | $50 | $77 |
| Dependent Child (Age 2 weeks through age 18) | $26 | $41 |
| $250 Per Injury / Sickness Deductible Per Person |
| | $50,000 Maximum | $100,000 Maximum |
| Age 70 - 79 | $76 | N/A |
| Age 80 + | $99 | N/A |
Dependent Child rate is applicable when at least one parent will also be covered under Inbound Hospital.
Please be aware that this is not a general health insurance policy, but an interim program intended for temporary use. Inbound Hospital 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 Hospital, 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 Hospital in complete detail. In addition, the Program Summary tells you the procedure for submitting claims.
The Insurance Company
Inbound Hospital is underwritten by Certain Underwriters at Lloyd's, London and is rated A- "Excellent" by A.M. Best. In addition to being one of the largest insurance entities in the world, Lloyd's has over 300 years of experience in the international insurance business.
| Inbound HOSPITAL Application - 2005 |
| OFFICIAL USE ONLY: | Cert#: | Processed: | Eff. Date: | Agent: 7076 |
| Effective February 1, 2005 |
|
All sections must be completed. Incomplete applications will be returned to the applicant without coverage.
Applicant Information
Mr. Mrs. Miss Ms. Last Name: __________________________________ First Name: _______________________
U.S. Correspondence Address
Name: ________________________________________________________________
Address: ____________________________________________ City: _________________ State: ___ Zip: _________
(Address must be in the United States)
Phone Number: _______________________________________ Email: ______________________________________
AD&D Beneficiary: ____________________________________ Relationship: _________________________________
Passport & Travel Information
Passport Number: _________________________ Country Issuing Passport: __________________________________
When did or will you arrive in the United States? ___ / ___ / ____
Date you would like coverage to begin: ___ / ___ / ____
Note: This program is not available to United States citizens. Your coverage must begin within twelve (12) months of your arrival in the United States. The minimum period of coverage is 1 month, maximum is 12. If 3 or more months of premium is sent, an automatic renewal notice will be sent to the address above. Total program length available is 12 months. Coverage cannot begin until you depart from your Home Country and SRI both receives and accepts your application and correct premium.
Coverage Requested
Have you purchased insurance through SRI before? ___No ___Yes If Yes, ID Number: _____________________
Selected Medical Policy Maximum: [ ] Plan A: $50,000 [ ] Plan B: $100,000
Selected Per Injury/Sickness Deductible: [ ] $75 [ ] $150 (or 70 and over at $250)
If there are one or more applicants below age 70 and one ore more applicants age 70 and above, separate applications must be submitted.
| Name of Persons to be Insured | Date of Birth | Monthly Premium |
| Applicant: ______________________ | ____ / ____ / ____ | _____________ |
| Spouse: _______________________ | ____ / ____ / ____ | _____________ |
| Child: _________________________ | ____ / ____ / ____ | _____________ |
| Child: _________________________ | ____ / ____ / ____ | _____________ |
| Child: _________________________ | ____ / ____ / ____ | _____________ |
| Totals: | _____________ |
| A |
x |
|
= |
B |
+ |
$5 |
= |
C |
| Total from Above |
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Number of months |
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Administrative Fee (required) |
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Total Payment Enclosed |
Method of Payment
[ ] Check [ ] Money Order [ ] MasterCard [ ] Visa [ ] Discover
Card Number: ________________________________ Name on Card: _______________________________
Expiration Date: _______________________________ Daytime Phone: ______________________________
Billing Address: ____________________________________________________________________________
Signature (Required) ______________________________________________________________________
Make Check or Money Order Payable to: "SRI". Total Payment for the Full Term of coverage requested on this application must be paid in U.S. Dollars at the time application for coverage is made. Coverage purchased by credit card is subject to validation and acceptance by credit card company. I declare that I agree and I agree to read and understand the terms and conditions of this product as outlined in this brochure and the program summary, including coverage is not available to any U.S. citizen. I understand that pre-existing conditions, as defined in this brochure, are not covered. I understand that this is not a general health insurance product, but a limited benefit program designed to provide basic benefits under certain circumstances. I also understand that Lloyds operates as an approved but non-admitted insurer in most US states and that claims may not be made against any state guarantee fund. I understand and agree that this program does not comply with any US state insurance law. I also understand any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an enrollment form, or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
I hereby subscribe to the Global International Trust and enroll in the group coverage for which I am eligible under the group contract issued by Certain Underwriters at Lloyd's, London. As signatory, I declare that I am affirming all statements for all persons listed on the application (and declare that I have the authority to do so).
__________________________________________________________________________________________
Signature of Insured or Proxy (Required) Date
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