Scheduled Benefits for Travel Medical Coverage
- INCLUDING coverage for COVID-19 and SARS-CoV2
- Emergency Medical Evacuation and Repatriation of Mortal Remains coverage
- Eligible to non-U.S. citizens traveling from their Home Country to the U.S. or worldwide including the U.S.
- Plans available for ages up to 89 years
- Coverage duration is a minimum of 5-days and a maximum of 364-days
Plan Benefits | Safe Travels Elite Economy | Safe Travels Elite Basic | Safe Travels Elite Silver | Safe Travels Elite Gold | Safe Travels Elite Platinum | Safe Travels Elite Diamond | Safe Travels Elite Diamond Plus |
---|---|---|---|---|---|---|---|
Medical Maximum per Incident | $25,000 | $50,000 | $75,000 | $100,000 | $175,000 | $50,000 | $100,000 |
Deductible Per Incident | $0 | $0 | $0 | $0 | $0 | $100 or $200 | $100 or $200 |
Ages | 0-69 | 0-69 | 0-69 | 0-69 | 0-69 | 70-89 | 70-89 |
Inpatient Hospital Expense | |||||||
Hospital Room and Board Expenses | $1,400/day (30-day max.) | $2,000/day (30-day max.) | $2,000/day (30-day max.) | $2,000/day (30-day max.) | $3,000/day (30-day max.) | $1,500/day (15-day max.) | $1,500/day (15-day max.) |
Inpatient Ancillary Hospital Services | Included under the Hospital Room and Board | Included under the Hospital Room and Board | Included under the Hospital Room and Board | Included under the Hospital Room and Board | Included under the Hospital Room and Board | Included under the Hospital Room and Board | Included under the Hospital Room and Board |
Hospital Intensive Care Unit Expenses | $2,100/day (10-day max.) | $2,500/day (10-day max.) | $2,500/day (8-day max.) | $3,000/day (8-day max.) | $4,500/day (8-day max.) | $2,300/day (8-day max.) | $2,300/day (8-day max.) |
Physician's Surgical Treatment | $3,500 per Incident | $5,000 per Incident | $5,000 per Incident | $6,000 per Incident | $7,500 per Incident | $3,500 per Incident | $3,500 per Incident |
Anesthesiologist Expense | $850 per Incident | $850 per Incident | $1,200 per Incident | $1,400 per Incident | $1,800 per Incident | $850 per Incident | $850 per Incident |
Assistant Physician’s Surgical Expenses | $850 per Incident | $850 per Incident | $1,200 per Incident | $1,400 per Incident | $1,800 per Incident | $850 per Incident | $850 per Incident |
Physician's Non-Surgical Visits | $55/visit (1 visit/day; 30 visits max.) | $75/visit (1 visit/day; 30 visits max.) | $75/visit (1 visit/day; 30 visits max.) | $100/visit (1 visit/day; 30 visits max.) | $130/visit (1 visit/day; 30 visits max.) | $75/visit (1 visit/day; 30 visits max.) | $75/visit (1 visit/day; 30 visits max.) |
Consulting Physician | $450 per Incident | $450 per Incident | $550 per Incident | $550 per Incident | $700 per Incident | $450 per Incident | $450 per Incident |
Private Duty Nurse | $450 per Incident | $450 per Incident | $550 per Incident | $550 per Incident | $700 per Incident | $450 per Incident | $450 per Incident |
Pre-Admission Test within 7 days of Admission | $1,100 per Incident within 7-day of Admission | $1,100 per Incident within 7-day of Admission | $1,100 per Incident within 7-day of Admission | $1,200 per Incident within 7-day of Admission | $1,500 per Incident within 7-day of Admission | $1,100 per Incident | $1,100 per Incident |
Outpatient - Maximum Daily Benefit All Services $10,000 - up to the selected Policy Maximum | |||||||
Outpatient Surgical Facility | $1,000 per Incident | $1,100 per Incident | $1,150 per Incident | $1,275 per Incident | $1,400 per Incident | $1,100 per Incident | $1,100 per Incident |
Physician's Surgical Treatment | $3,500 per Incident | $5,000 per Incident | $5,000 per Incident | $6,000 per Incident | $7,500 per Incident | $3,500 per Incident | $3,500 per Incident |
Anesthesiologist Expense | $850 per Incident | $850 per Incident | $1,200 per Incident | $1,400 per Incident | $1,800 per Incident | $700 per Incident | $700 per Incident |
Assistant Physician’s Surgical Expenses | $850 per Incident | $850 per Incident | $1,200 per Incident | $1,400 per Incident | $1,800 per Incident | $700 per Incident | $700 per Incident |
Physician's Visits/Urgent Care | $55/visit (1 visit/day; 30 visits max.) | $75/visit (1 visit/day; 30 visits max.) | $75/visit (1 visit/day; 30 visits max.) | $100/visit (1 visit/day; 30 visits max.) | $130/visit (1 visit/day; 30 visits max.) | $75/visit (1 visit/day; 30 visits max.) | $75/visit (1 visit/day; 30 visits max.) |
Diagnostic X-Rays and Lab Services | $450 per Incident | $750 per Incident | $750 per Incident | $750 per Incident | $1,000 per Incident | $750 per Incident | $750 per Incident |
Chemotherapy &/or radiation therapy | $1,100 per Incident | $1,100 per Incident | $1,225 per Incident | $1,350 per Incident | $1,750 per Incident | $1,100 per Incident | $1,100 per Incident |
Scans, PET Scan or MRI | $650 per Incident | $650 per Incident | $875 per Incident | $1,050 per Incident | $1,300 per Incident | $650 per Incident | $650 per Incident |
Emergency Room Sickness with no direct Hospital Admission | $350 ($200 Deductible per visit) | $500 ($200 Deductible per visit) | $500 ($200 Deductible per visit) | $600 ($200 Deductible per visit) | $800 ($200 Deductible per visit) | $500 ($200 Deductible per visit) | $500 ($200 Deductible per visit) |
Emergency Room injury/Accident or Sickness with direct Hospital Admission | $350 per Incident | $500 per Incident | $500 per Incident | $600 per Incident | $800 per Incident | $500 per Incident | $500 per Incident |
Prescription drugs and medications | $250 per Incident | $350 per Incident | $350 per Incident | $350 per Incident | $350 per Incident | $250 per Incident | $250 per Incident |
Additional Medical Treatment and Services | |||||||
Acute Onset of Pre-Existing Condition Expenses | Up to Medical Maximum (Coverage related to Cardiac Conditions or Stroke are limited to $25,000) | Up to Medical Maximum (Coverage related to Cardiac Conditions or Stroke are limited to $25,000) | Up to Medical Maximum (Coverage related to Cardiac Conditions or Stroke are limited to $25,000) | Up to Medical Maximum (Coverage related to Cardiac Conditions or Stroke are limited to $25,000) | Up to Medical Maximum (Coverage related to Cardiac Conditions or Stroke are limited to $25,000) | $25,000 (ages 70-79), $15,000 (ages 80+) Coverage related to Cardiac Conditions or Stroke are limited to $15,000 | $25,000 (ages 70-79), $15,000 (ages 80+) Coverage related to Cardiac Conditions or Stroke are limited to $15,000 |
Cardiac Conditions and Stroke Expenses | $25,000 | $25,000 | $25,000 | $25,000 | $25,000 | $15,000 | $15,000 |
Covid-19, SARS-CoV-2 | Covered the same as any other Sickness | Covered the same as any other Sickness | Covered the same as any other Sickness | Covered the same as any other Sickness | Covered the same as any other Sickness | Covered the same as any other Sickness | Covered the same as any other Sickness |
Well Doctor Visit | $125 - 1 visit | $125 - 1 visit | $125 - 1 visit | $125 - 1 visit | $125 - 1 visit | $125 - 1 visit | $125 - 1 visit |
Dental Treatment for Injury of Sound Natural Teeth | $600 per Incident | $750 per Incident | $750 per Incident | $750 per Incident | $750 per Incident | $750 per Incident | $750 per Incident |
Mental or Nervous Disorder | $5,000 per Incident | $5,000 per Incident | $5,000 per Incident | $5,000 per Incident | $20,000 per Incident (30-day max.) | $5,000 per Incident | $5,000 per Incident |
Physiotherapy Physical Medicine/Chiropractic Expenses | $40/visit (1 visit/day; 12 visits max.) | $50/visit (1 visit/day; 12 visits max.) | $50/visit (1 visit/day; 12 visits max.) | $60/visit (1 visit/day; 12 visits max.) | $60/visit (1 visit/day; 12 visits max.) | $50/visit (1 visit/day; 12 visits max.) | $50/visit (1 visit/day; 12 visits max.) |
Initial Orthopedic Prosthesis/brace | $1,100 per Incident | $1,100 per Incident | $1,225 per Incident | $1,350 per Incident | $1,750 per Incident | $1,100 per Incident | $1,100 per Incident |
Return to Home Country Coverage | $2,000 (Up to 30-days per 12 months purchased) | $2,000 (Up to 30-days per 12 months purchased) | $2,500 (Up to 30-days per 12 months purchased) | $2,500 (Up to 30-days per 12 months purchased) | $7,500 (Up to 90-days per 12 months purchased) | N/A | N/A |
Transportation Expenses | |||||||
Ambulance Service Benefits | $500 per Incident | $650 per Incident | $650 per Incident | $650 per Incident | $750 per Incident | $650 per Incident | $650 per Incident |
Emergency Medical Evacuation* | $100,000 | $100,000 | $100,000 | Unlimited | Unlimited | $50,000 ($25,000 Lifetime Maximum for Acute Onset over age of 80) | $50,000 ($25,000 Lifetime Maximum for Acute Onset over age of 80) |
Medically Necessary Repatriation* | $15,000 | $15,000 | $15,000 | $15,000 | $15,000 | $15,000 | $15,000 |
Political Evacuation* | $500 | $500 | $1,000 | $1,500 | $2,000 | $500 | $500 |
Natural Disasters Evacuation* | $25,000 | $25,000 | $25,000 | $25,000 | $25,000 | $15,000 | $15,000 |
Return of Minor Children or Grandchildren* | $5,000 | $5,000 | $7,500 | $7,500 | $10,000 | $5,000 | $5,000 |
Repatriation of Mortal Remains* | $7,500 | $7,500 | $10,000 | $20,000 | $25,000 | $7,500 | $7,500 |
Local Burial/Cremation* | $5,000 | $5,000 | $5,000 | $5,000 | $5,000 | $5,000 | $5,000 |
Additional Benefits | |||||||
Common Carrier Accidental Death & Dismemberment (AD&D)* | $25,000 | $25,000 | $35,000 | $35,000 | $35,000 | N/A | N/A |
Felonious Assault AD&D* | $5,000 | $5,000 | $7,500 | $7,500 | $10,000 | $5,000 | $5,000 |
Additional Services | |||||||
Telemedicine** | Included | Included | Included | Included | Included | Included | Included |
Travel Assistance** | Included | Included | Included | Included | Included | Included | Included |
*Not subject to the Medical Deductible
**This is a non-insurance service and is not a part of the insurance underwritten by Zurich Insurance Europe AG Belgian branch.
This is brief summary of the features available in this plan. It is not a contract of insurance. This plan includes both insurance and non-insurance benefits. Limitations and exclusions apply.
Rates
Safe Travels Elite Rates Per Person Per Day | Economy | Basic | Silver | Gold | Platinum | Diamond | Diamond | Diamond Plus | Diamond Plus |
---|---|---|---|---|---|---|---|---|---|
Policy Max | $25,000 | $50,000 | $75,000 | $100,000 | $175,000 | $50,000 | $50,000 | $100,000 | $100,000 |
Deductible | $0 | $0 | $0 | $0 | $0 | $100 | $200 | $100 | $200 |
0-17 | $0.73 | $1.18 | $1.48 | $1.64 | $2.37 | N/A | N/A | N/A | N/A |
18-29 | $0.73 | $1.18 | $1.48 | $1.64 | $2.22 | N/A | N/A | N/A | N/A |
30-39 | $0.82 | $1.36 | $1.64 | $1.82 | $2.36 | N/A | N/A | N/A | N/A |
40-49 | $0.85 | $1.41 | $1.67 | $1.85 | $2.45 | N/A | N/A | N/A | N/A |
50-59 | $1.21 | $1.96 | $2.36 | $2.62 | $3.67 | N/A | N/A | N/A | N/A |
60-64 | $1.60 | $2.47 | $2.92 | $3.25 | $4.31 | N/A | N/A | N/A | N/A |
65-69 | $1.60 | $2.47 | $2.92 | $3.25 | $4.31 | N/A | N/A | N/A | N/A |
70-74 | N/A | N/A | N/A | N/A | N/A | $3.51 | $3.32 | $5.00 | $4.87 |
75-79 | N/A | N/A | N/A | N/A | N/A | $3.51 | $3.32 | $5.00 | $4.87 |
80-84 | N/A | N/A | N/A | N/A | N/A | $9.14 | $7.63 | $17.85 | $14.70 |
85-90 | N/A | N/A | N/A | N/A | N/A | $11.20 | $9.52 | $25.20 | $22.05 |
Pre-certification Requirements and Procedures
Pre-certification is a general determination of Medical Necessity only.
- Inpatient Hospitalization, Surgery or Surgical procedure: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
- Deductible is taken after reduction.
- Coinsurance and Out of Pocket Maximum are applied to remainder of the reduced amount.
- Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met.
- Emergency Medical Evacuation or Medically Necessary Repatriation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION or MEDICALLY NECESSARY REPATRIATION provisions for complete requirements and coverage.
- Refer to the PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification.
All such determinations are made by the Company (acting through its authorized agents and representatives) in reliance and based upon the completeness and accuracy of the information provided by the Covered Person and/or their Relatives, guardians and/or healthcare providers at the time of Pre-certification. The Company reserves the right to challenge, dispute and/or revoke a prior determination of Medical Necessity based upon subsequent information obtained. Pre-certification is not an assurance, authorization, preauthorization, or verification of Treatment or coverage, a verification of benefits, or a guarantee of payment. The fact that Treatment or supplies are Pre-certified by the Company does not guarantee the payment of benefits, the availability of coverage, or the amount of or eligibility for benefits. The Company’s consideration and determination of a Pre-certification request, as well as any subsequent review or adjudication of all medical claims submitted in connection therewith, shall remain subject to all of the Terms of this insurance, including exclusions for Pre-existing Conditions and other designated exclusions, benefit limitations and sub-limitations, and the requirement that claims be Usual and Customary Charge. Any consideration or determination of a Pre-certification request shall not be deemed or considered as the Company’s approval, authorization, or ratification of, recommendation for, or consent to any diagnosis or proposed course of Treatment. Neither the Company nor the Plan Administrator (nor anyone acting on their respective behalf) has any authority or obligation to select Physicians, Hospitals, or other healthcare providers for the Covered Person, or to make any diagnosis or medical Treatment decisions on behalf of the Covered Person, and all such decisions must be made solely and exclusively by the Covered Person and/or their family members or guardians, Treating Physicians and other healthcare providers. If the Covered Person and their healthcare providers comply with the Precertification requirements of this coverage, and the Treatment or supplies are Pre-certified as Medically Necessary, the Company will reimburse the Covered Person for Eligible Medical Expenses up to the amount shown in the SCHEDULE OF BENEFITS incurred in relation thereto, subject to all Terms of this insurance. Eligibility for and payment of benefits are subject to all of the Terms of this insurance.
- SPECIFIC REQUIREMENTS: The following must always be Pre-certified for Medical Necessity by the Company through the Plan Administrator before admission or receiving the Treatments and/or supplies: (a) Inpatient Hospitalization (b) Surgery or Surgical procedure.
- GENERAL REQUIREMENTS: To comply with the Pre-certification requirements of this insurance for the Treatments and/or supplies or services listed in the SPECIFIC REQUIREMENTS provision, above, the Covered Person or their Physician or healthcare provider must perform all of the following: (a) contact the Company through the Plan Administrator at the contact information below and on the Covered Person's ID card as soon as possible and before the Treatment or supply is to be obtained (b) comply with the instructions of the Company and submit any information or documents required by the Company (c) notify all Physicians, Hospitals, and other healthcare providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with the Company.
- LOSS OF COVERAGE/ BENEFITS FOR NON-COMPLIANCE OF PRE-CERTIFICATION REQUIREMENTS: If the Covered Person or their healthcare providers do not comply with the Pre-certification requirements for the Treatment or supplies identified in the SPECIFIC REQUIREMENTS subparagraphs above, or if such Treatment or supplies are not Pre-certified then (a) Eligible Medical Expenses incurred with respect to said Treatment and/or supplies will be reduced by the amount shown in the BENEFIT SUMMARY (b) any Deductible will be subtracted from the remaining amount (c) Coinsurance will be applied.
- EMERGENCY PRE-CERTIFICATION: In the event of an Emergency Hospital admission, Pre-certification must be completed within forty-eight (48) hours after the admission, or as soon as is reasonably possible.
- CONCURRENT REVIEW: For Inpatient Treatment of any kind, the Company will Pre-certify a limited number of days of confinement based upon the disclosed medical condition. Thereafter, Pre-certification must again be requested and approved if additional days of Inpatient Treatment are necessary.
Pre-existing Condition Limitation
This coverage contains a Pre-Existing Condition limitation. "Pre-Existing Condition" means any Injury, Illness, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existing at the time of Application or at any time during the three (3) years prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all subsequent, Chronic or recurring complications or consequences related thereto or resulting or arising therefrom.
Pre-Existing shall also include any Acute Onset of a Pre-existing Condition; meaning, a sudden and Unexpected outbreak or reoccurrence that is of short duration, is rapidly progressive, and requires urgent medical care. A Pre-existing Condition that is chronic or congenital, or that gradually becomes worse over time is not an Acute Onset of a Pre-existing Condition. An Acute Onset of Pre-existing Condition does not include any condition for which, as of the Effective Date, the Covered Person (i) knew or reasonably foresaw he/she would receive, (ii) knew he/she should receive, (iii) had scheduled, or (iv) were told that he/she must or should receive, any medical care, drugs, or Treatment.
Cancellation and Refund Procedure Provisions
Full cancellation and refund will only be considered if We receive written request prior to or on the Effective Date of the Coverage. If We receive a written request for cancellation and refund after the Effective Date of Coverage, a partial cancellation and refund may be allowed.
The following conditions apply:
a) If any claims have been filed with Us, the premium is fully earned and is non-refundable. If no claims have been filed with the Company, then (i) a cancellation fee of US $50 will be charged; and only unused days b) Premiums will be considered as refundable; and c) If after a refund is made, it is determined that a claim was presented to Us on a Covered Person’s behalf, the Covered Person will be fully responsible for that claim in its entirety. Upon effectuation of such cancellation and refund, neither the Company nor the Covered Person shall have any further rights, liabilities, or obligations under this insurance.
Privacy Statement:
We know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public personal information about our Covered Persons or former Covered Persons to anyone, except as permitted or required by law. We maintain appropriate physical, electronic and procedural safeguards to ensure the security of your non-public personal information.
Complaints:
In the event that you remain dissatisfied and want to make a complaint you can do so to the Complaints team at SureGo Administrative Services.
Data Protection:
If you are ordinarily resident in the European Economic Area (EEA), you should be aware that we may need to transfer your personal information to some of our recipients (e.g., our appointed agent (Trawick International, GmbH), claims handler (SureGo Administrative Services) and affiliates). Some of these recipients are located outside the EEA in countries which may not have laws that protect your personal information in the same way as the data protection laws in the EEA. Where these transfers occur, we ensure that: (a) they do not occur without our prior written authority (where applicable); and (b) an appropriate transfer mechanism or agreement is in place to protect your personal information (e.g. the European Commission's Standard Contractual Clauses, the EU-US Data Privacy Framework or the Swiss-EU Privacy Shield). For more information on these transfers, please contact the Data Protection Officer.
Administrator
Trawick International Inc.Post Office Box 2284
Fairhope, AL 36533
FOR ADDITIONAL INFORMATION
PersfinsureC1-202 Shriram Shreyas Telecom Colony Kodigehalli
Bengaluru, Karnataka 560092
India
Phone: +91-7028016146
Website: persfinsure.brokersnexus.com
Version: 10/15/2024