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Note: This is an Inpatient Hospital Expense Program
Only
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 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.
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 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).
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
- 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.
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
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.
COVERED SERVICES INJURY AND SICKNESS BENEFIT
MAXIMUMS
| |
Age 14 days to Age 69 |
Age 14 days to Age 69 |
|
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 |
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.
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.
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
303 Congressional
Boulevard
Carmel, IN 46032
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 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.
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