International Medical Group - Patriot Travel Medical Insurance

Schedule of Benefits

PLAN INFORMATION

Deductible	Your choice of US$0, $100, $250, $500, $1000 or $2,500
Coinsurance For treatment received outside the U.S. & Canada	No Coinsurance

For treatment received within the U.S. & Cananda

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

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
Emergency Room Accident	Up to Policy Maximum
Emergency Illness- with in-patient admission	Up to Policy Maximum
Emergency Illness- without in-patient admission	Up to Policy Maximum with additional US$250 deductible
Dental Injury due to accident	Up to Policy Maximum
Sudden dental pain	Up to US$100

INTERNATIONAL EMERGENCY CARE

When coordinated through the Plan Administrator

Emergency Evacuation	Up to Policy Maximum
Emergency Reunion	Up to US$15,000
Return of Mortal Remains	Up to US$25,000
Returning Minor Children	Up to US$5,000
Political Evacuation	Up to US$10,000

ADDITIONAL BENEFITS

Benefit Period	Six months
Incidental Home Country Coverage	Up to a cumulative two weeks
End of Trip Home Country Coverage	One month for every five months of travel coverage purchased, up to a maximum of two months
Common Carrier Accidental Death	US$50,000 to beneficiary; maximum of US$250,000 per family
Sports & Activities Coverage	Up to Policy Maximum for basic sports
Accidental Death & Dismemberment	US$25,000 principal sum
Terrorism Coverage	Up to US$50,000 lifetime maximum
Identity Theft Assistance	Up to US$500 per Period of Coverage
Trip Interruption	Up to US$5,000
Lost Luggage	Up to US$50 per item of personal property; maximum of US$250 per Period of Coverage

ADDITIONAL BENEFITS FOR U.S. CITIZENS ONLY

Indemnity	Up to US$100 per night
Sudden Recurrence of a Pre-existing Condition Medical	Up to US$15,000 of eligible expenses
Emergency Medical Evacuation	Up to US$25,000 of eligible costs and expenses

DESCRIPTION OF BENEFITS

DEDUCTIBLE:

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.

EMERGENCY ROOM:

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:

Injury due to an accident- Each Patriot Travel Medical Insurance 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.

BENEFIT PERIOD:

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.

EMERGENCY MEDICAL EVACUATION, EMERGENCY REUNION AND REPATRIATION COVERAGE:

All Conditions and Exclusions apply to these coverages.
All Emergency Medical Evacuation, Emergency Reunion, and Return of Mortal Remains expenses, including all costs arising from trips outside the country where the incident which gave rise to the claim occurred, must be approved and coordinated in advance by IMG to be eligible for coverage.

EMERGENCY EVACUATION:

Each Patriot 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 home country or the country where the evacuation occurred, up to the Policy Limit.

EMERGENCY REUNION:

Each Patriot plan 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 home country to be reunited with the insured.

RETURN OF MORTAL REMAINS:

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 US$25,000.

RETURN OF MINOR CHILDREN:

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 Patriot 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).

POLITICAL EVACUATION:

If the United States Department of State, Bureau of Consular Affairs issues a travel advisory that becomes effective on or after the Insured Person's date of arrival in the Host Country, the Company will pay up to US$10,000 for transportation to the nearest place of safety or for repatriation to the Insured Person's home country or country of residence provided that:

The Insured Person contacts the Company within 10 days of the United States Department of State, Bureau of Consular affairs issues the travel advisory;
Political Evacuation and Repatriation is approved and coordinated by the Company.

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:

The insured person must have left their home country,
The total Period of Coverage must be for a minimum of 30 days, and
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 check the appropriate box on the Application Form, and calculate your premium to include the additional month(s).

COMMON CARRIER ACCIDENTAL DEATH:

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 AND ACTIVITIES COVERAGE:

Each Patriot 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.

ACCIDENTAL DEATH AND DISMEMBERMENT:

Each Patriot 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.

TERRORISM COVERAGE:

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 will reimburse eligible medical claims subject to a US$50,000 lifetime maximum. However, claims incurred as a result of radiological, nuclear, chemical or biological weapons or events are not covered.

Terrorism is defined as the systematic or planned use of violence, fear, or threat of violence in order to intimidate a population or government, especially as a means of coercion or to obtain a granting of any demand. 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 6 months prior to the insured person's date of arrival.

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 depart the country or location.

IDENTITY THEFT ASSISTANCE:

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 will provide coverage for the reasonable, customary and necessary costs incurred by the insured for:

re-filing 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 and must be reported within 6 months of the termination of coverage date.

TRIP INTERRUPTION:

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 Patriot 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:

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.

INDEMNITY:

(U.S. citizens only) Patriot 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.

SUDDEN RECURRENCE OF A PRE-EXISTING CONDITION:

(U.S. citizens only) 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 U.S. 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.

DESCRIPTION OF OPTIONAL RIDERS

LEISURE SPORTS:

The Leisure Sports Rider is available on both Patriot plans and adds coverage for

jet skiing,
scuba diving,
snow skiing,
snowboarding,
snowmobiling,
snorkeling,
surfing,
wakeboarding,
water skiing and
windsurfing.

For premium information, please see the back of the Application Form.

EXTREME SPORTS:

The Extreme Sports Rider is available on both Patriot plans and adds up to 12 months of coverage for those under the age of 50. This rider provides up to US$50,000 lifetime maximum for the following activities:

abseiling,
BMX,
bungee jumping,
canyoning,
caving,
flying (private plane),
hang gliding,
heli-skiing,
high diving,
hot air ballooning,
kayaking,
inline skating,
mountain biking,
mountaineering (ropes and guides to 4500m from ground level),
paragliding,
parascending,
rappelling,
rock climbing (ropes and guides to 4500m from ground level),
skydiving,
spelunking,
whitewater rafting (to Class V).

These extreme activities must be engaged in solely for leisure, recreation, or entertainment purposes.

ENHANCED AD&D:

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 plans. Coverage must be purchased for a minimum of three months.

PATRIOT RETURN RIDER:

(Non-U.S. citizens only) When purchased at the time of application, Patriot Return provides temporary medical coverage for non-U.S. citizens returning to their home country. The insured person must be outside his/her home country at time of application. For premium information, please see the back of the Application Form.

EXCLUSIONS

Charges for the following services, treatments and/or conditions, among others, are excluded from coverage under the Patriot plans.

Pre-existing Conditions. A pre-existing condition is defined as 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, whether or not previously manifested or symptomatic, diagnosed, treated, or disclosed prior to the effective date, including any subsequent, chronic or recurring complications or consequences related thereto or arising therefrom.
Treatment or surgeries which are elective, investigational, experimental or for research purposes.
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.
Immunizations and routine physical exams.
Treatment of Temporomandibular Joint or dental treatment, except as expressly provided for in the certificate of insurance.
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
Pregnancy, childbirth, birth control, artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
Injury sustained while participating in 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,
- wind-surfing and
- whitewater rafting.
Vision or ear tests and the provision of visual or hearing aids.
Vocational, recreational, speech or music therapy.
Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services.
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.
Treatment for, and injuries and/or illnesses resulting or arising from,substance abuse or drug addiction.
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.
Willful self-inflicted injury or illness.
Treatment required as a result of or arising from complications from a treatment or condition not covered under the certificate.
Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured.
Treatment for mental and nervous disorders.
Organ or tissue transplants or related services.
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.
Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).

This brochure contains only a consolidated and summary description of all current Patriot Travel Medical Insurance 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.