INDIVIDUAL TRAVEL MEDICAL EXPENSES POLICY

Transcription

1 INDIVIDUAL TRAVEL MEDICAL EXPENSES POLICY

2 TABLE OF CONTENT IMPORTANT NOTICE...3 ARTICLE 1 - INSURANCE CLAUSE...3 ARTICLE 2 - TABLE OF BENEFITS AND LIMITS...4 ARTICLE 3 - DEFINITIONS...6 ARTICLE 4 - ELIGIBILITY, EFFECTIVE DATE, TERMINATION DATE, BENEFIT PERIOD AND HOME COUNTRY COVERAGE...11 ARTICLE 5 - GENERAL PROVISIONS...12 ARTICLE 6 - CONDITIONS...16 ARTICLE 7 - PRE-APPROVAL REQUIREMENTS...23 ARTICLE 8 - PREFERRED MEDICAL PROVIDER (PPO) REQUIREMENTS...24 ARTICLE 9 - ELIGIBLE EXPENSES (AND PERSONAL ACCIDENT BENEFITS)...24 ARTICLE 10 - EXCLUSIONS...29 ARTICLE 11 - HOW TO FILE A CLAIM

3 IMPORTANT NOTICE THE COVERAGE PROVIDED BY THIS POLICY IS NOT PERMANENT HEALTH INSURANCE OR COMPREHENSIVE HEALTH INSURANCE, OR ANY OTHER KIND OF PRIMARY HEALTH INSURANCE OR HEALTH PLAN. IT SHALL ONLY RELATE TO ACCIDENTAL BODILY INJURY AND/OR ILLNESS AS PROVIDED FOR BELOW. COVERAGE FOR ACTS OF WAR AND/OR TERRORISM IS INCLUDED IN THIS POLICY, SUBJECT TO ALL RESTRICTIONS AND EXCLUSIONS CONTAINED HEREIN. ARTICLE 1 - INSURANCE CLAUSE Underwriters will provide the Benefits described in this Policy in consideration of the Insured Person s Application and payment of Premium. Underwriter s agreement is subject to all terms, conditions, provisions and exclusions of this Policy, including the Policy Schedule, any Exhibits, Schedules, and/or Endorsements attached hereto. 3

4 ARTICLE 2 - TABLE OF BENEFITS AND LIMITS The limits stated under Benefits B. to G inclusive, are in addition to the Maximum Benefit for A. Eligible Medical Expenses). Except in respect of Benefit G. Accidental Death and Accidental Dismemberment, all Benefits are subject to the Deductible stated in the Policy Schedule, and are per Policy Period. Benefits Limits A. Eligible Medical Expenses Hospital Room and Board and Nursing Services For charges made by a Physician for professional services, including Surgery. Charges for an assistant surgeon Drugs which require prescription by a Physician for treatment of a covered Injury or Illness, Emergency Local Ambulance Transport Physical Therapy All other Eligible Medical Expenses Maximum Benefit - As stated in the Policy Schedule, inclusive of the following: 100% Up to the average Semi-private room rate. Up to 100% Usual, Reasonable and Customary. Up to 20% of the Usual, Reasonable and Customary charge of the primary surgeon. Up to 100% Usual, Reasonable and Customary, for a maximum supply of thirty (30) days per prescription. Up to 100% Usual, Reasonable and Customary, but not exceeding USD 1,000 per policy period. Up to USD 50 per treatment, maximum 10 treatments. Up to 100% Usual, Reasonable and Customary B. Emergency Medical Evacuation Up to USD 50,000 when approved in advance and coordinated by the Claims Administrator. C. Repatriation of Remains Up to USD 15,000 when approved in advance and co-ordinated by the Claims Administrator. 4

5 D. Local Burial or Cremation Up to USD 5,000 when approved in advance and co-ordinated by the Claims Administrator. E. Emergency Reunion Up to USD 5,000 when approved in advance and coordinated by the Claims Administrator. F. Return (following a covered Emergency Medical Evacuation Up to USD 5,000 when approved in advance and coordinated by the Claims Administrator. G. Accidental Death and Accidental Dismemberment Benefit Amount 1. Accidental Death USD 15, Accidental Dismemberment a. Loss of two (2) or more Limbs or both eyes (or sight of eyes) b. Loss of one (1) Limb or eye (or sight of eye) USD 15,000 USD 7, Accidental Death and Accidental Dismemberment Benefits will be doubled if Accidental Death or Accidental Dismemberment results from Kidnapping, attempted Kidnapping, Hijacking or attempted Hijacking, subject to a maximum total Benefit amount in respect of all Family members covered under this Policy. USD 250,000 5

6 ARTICLE 3 - DEFINITIONS The words and phrases below will always have the following meanings wherever they appear in bold type and starting with a capital letter in this Policy Document and the Policy Schedule. Accident: A sudden, unintentional and unexpected occurrence caused by external, visible means and resulting in physical Injury to the Insured Person. The cause or one of the causes of such Accident must be external to the Insured Person s own body and occur beyond the Insured Person s control. Accidental Death: Death of the Insured Person resulting from an Accident. Death must occur within thirty (30) days of the Accident. Accidental Dismemberment: Loss of one or more Limbs or eyes resulting from an Accident. For purposes of the Accidental Death and Accidental Dismemberment benefit provided by this insurance, the term Limb shall mean: the arm when the severance is at or above (toward the elbow) the wrist, or the leg when the severance is at or above (toward the knee) the ankle. Loss of eye(s) shall include complete, permanent and irrevocable loss of sight. For the purposes of this definition, Loss of shall include total and irrecoverable loss of use of said Limb or Limbs. Act of Terrorism: An act, including but not limited to the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear. AIDS: Acquired Immune Deficiency Syndrome howsoever it may be known or referred to ARC: AIDS Related Complex Amateur Athletics: A sport or other athletic activity that is organised and/or sanctioned, involving regular or scheduled practices and/or regular or scheduled games. This definition does not include athletic activities that are non-contact and engaged in by an Insured Person solely for recreational, entertainment or fitness purposes and not for wage, reward or profit. Application: The fully answered application that is completed by or on behalf of the Insured Person, submitted to, and maintained on file with Underwriters. Benefits: The Eligible Expenses that will be paid under this Policy for covered costs incurred while coverage is in effect. Benefit Period: Up to one hundred and eighty (180) consecutive days beginning on the first day of diagnosis or treatment (whichever occurs first) of a covered Injury or Illness that occurs during the Policy Period. Claims Administrator: Tangiers International Ltd 54, Melita Street, Valletta, VLT 1122, Malta. Contact Sports: A sport or other athletic activity that necessarily involves physical contact with opposing players as part of normal play, including but not limited to, American football, boxing, ice hockey, rugby, soccer, and wrestling. 6

7 Custodial Care: That type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist an insured Person in performing the activities of normal daily living, including but not limited to eating, drinking and washing. This includes non-acute care for the comatose, semi-comatose, paralysed or mentally incompetent patients until they are fit to return to their Home Country. Deductible: The USD amount of eligible expenses, specified in the Policy Schedule that the Insured Person must pay per Policy Period, before Benefits are paid hereunder. Delivery: Procedures concerning pregnancy or childbirth. Durable Medical Equipment: A standard basic hospital bed and/or a standard basic wheelchair. Educational or Rehabilitative Care: Care for restoration (by education or training) of the Insured Person s ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy. Effective Date: The Effective Date stated in the Policy Schedule at: a. 12:01am GMT; or b. The moment Underwriters receive the Application and correct premium; or c. The moment the Insured Person departs from his or her Home Country; whichever occurs last. Eligible Expenses: means the expenses covered by this insurance, as detailed in Article 9. Emergency: A medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person s life or limb in danger if medical attention is not provided within twenty four (24) hours. Emergency Dental Treatment: The emergency dental treatment and dental surgery necessary to restore or replace sound natural teeth lost or damaged in an Accident which was covered under this insurance, provided that this shall not include any form of routine dental examination, care or treatment. Emergency Room: That part of a Hospital designated for the immediate care of Emergency medical conditions. Extended Care Facility: An institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation facility by the jurisdiction in which it operates; and is regularly engaged in providing twenty four (24) hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a Physician; and provides each patient with active treatment of an Illness or Injury. This does not include a facility primarily for rest, the aged, Substance Abuse treatment, Custodial Care, nursing care or for care of Mental Health Disorders or the mentally incompetent. Family member: the Insured Person s fiancé(e) spouse or civil partner (or someone of either sex with whom the Insured Person has been living as though they were their spouse or civil partner), or the grandchild, child, brother, sister, parent, grandparent, grandchild, step-brother, step-sister, step-parent, parent-in-law, son-inlaw, daughter in-law, sister-in-law, brother-in-law, aunt, uncle, nephew, niece, of the Insured Person. GMT: Greenwich Mean Time. 7

8 Hijacking: Seizing control of a conveyance in transit by use of force. HIV+: Laboratory evidence confirming the Insured Person as positive for Human Immunodeficiency Virus infection Home Country: The country where the insured Person principally resides as declared on the Application and stated in the Policy Schedule or that country for which the Insured Person holds a passport. Home Health Care Agency: A public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse, and maintains a daily record on each patient, and provides each patient with a planned programme of observation and treatment by a Physician. Home Nursing Care: Services provided by a Home Health Care Agency and supervised by a Registered Nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of Medically Necessary Inpatient care in a Hospital. Hospital: An institution which operates as a hospital pursuant to law, and is licensed by the country or administrative unit in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as Inpatients; and provides twenty four (24) hour nursing service by Registered Nurses on duty or call; and has a staff of one or more Physicians available at all times; and provides organised facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, long-term care facility, Extended Care Facility, nursing, rest, Custodial Care or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment. Host Country: The country(ies) stated in the Policy Schedule under Destination(s), being visited by the Insured Person or where the Insured Person resides temporarily. This excludes the Insured Person s Home Country Illness: A sickness, disorder, pathology, abnormality, ailment, disease or any other medical, physical or health condition. This does not include learning disabilities, attitudinal disorders or disciplinary problems. Injury: Identifiable physical harm to the body caused by an Accident that requires medical treatment. Inpatient: A patient who occupies a Hospital bed for more than twenty four (24) hours for medical treatment and whose admission was recommended by a Physician. Insured Person: Each person for whom an Application has been completed and who has been accepted for coverage hereunder and is named in the Policy Schedule as an Insured Person. Intensive Care Unit: A Cardiac Care Unit or other unit or area of a Hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units or where appropriate, the relevant local government or local health authority standards. Investigational, Experimental or for Research Purposes: Terms used to describe procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current medical practice. Kidnapping: The taking away of a person by force, threat or deceit with intent to cause him or her to be detained against his or her will for ransom or political purposes. For purposes of this insurance Kidnapping does not include Kidnapping perpetrated by any Family member of the kidnapped person. 8

9 Medical Provider: A Hospital, Physician or other person or organisation which provides medical services and/or supplies. Medically Necessary: A service or supply which is necessary and appropriate for the diagnosis or treatment of an Illness or Injury based on generally accepted current medical practice as determined by Underwriters. A service or supply will not be considered Medically Necessary if it is provided only as a convenience to the Insured Person or Medical Provider, and/or is not appropriate for the Insured Person s diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment of an Illness or Injury. Mental Health Disorder: A mental or emotional disease or disorder which generally denotes a disease of the brain with predominant behavioral symptoms; or a disease of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. This includes but is not limited to: psychosis, psychiatric illnesses and other similar conditions as may be listed in recognised medical manuals or journals. Physician: A doctor of Medicine (MD), doctor of Dental Surgery (DDS), doctor of Dental Medicine (DDM) or a licensed Physical Therapist or Physiotherapist. Physician does not include a doctor of Chiropractic (DC), a doctor of Osteopathy (DO), a doctor of Psychology (Ph.D), a doctor of Psychiatry (Psy.D) or any other degree or designation. A Physician must be currently licensed by the jurisdiction in which the services are provided, and the services provided must be within the scope of that license. A Physician must be a person other than the Insured Person, the Insured Person s Relative or Family Member, or one who ordinarily resides with the Insured Person. Policy: This policy of insurance which comprises the policy schedule, any exhibits, declarations, schedules, endorsements attached hereto and the Application. Policy Period: The period of time not exceeding twelve (12) consecutive months beginning on the Effective Date and ending on the Termination Date specified in the Policy Schedule. Pre-existing Condition: Any: (1) condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the twelve (12) months immediately preceding the Policy Effective Date; (2) condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the twelve (12) months immediately preceding the Policy Effective Date; (3) Injury, Illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the twelve (12) months immediately preceding the Policy Effective Date. Preferred medical Provider: Medical Providers designated by the Claims Administrator as preferred. Principal residence: The location, indicated on the Insured Person s Application, where the Insured Person ordinarily resides, but not including locations in the Host Country. Professional Sports: A sporting activity undertaken for wage, reward or profit. 9

10 Proof of Claim: A completed and signed Claimant s Statement and Authorisation form, together with any/ all required attachments, original itemised bills from Physicians, Hospitals and other Medical Providers, original receipts for any expenses which have already been paid by or on behalf of the Insured Person, and any other documentation that is deemed necessary by the Underwriters and/or the Claims Administrator. Registered Nurse: (1) A graduate nurse who has been registered or licensed to practice by the local authority Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters RN after his or her name; or (2) Where (1) above is not appropriate it shall mean a nurse that has achieved the minimum training standards required to legally register to legally practice nursing in their Home Country. Relative: Biological or step parent; biological or step child; current spouse; biological or step-siblings; or sibling in law, fiancé(e) or betrothed individual. Sexually Transmitted Diseases: Include but are not limited to syphilis, gonorrhea, lymphogranuloma venereum, chancroid, granuloma inguinale, chlamydiosis, pelvic inflammatory disease, trichomoniasis, genital candidiasis, genital herpes, genital warts, amebiasis, viral hepatitis, scabies, crab lice, cervical dysplasia, and bacterial vaginitis howsoever they may be known or referred to. Substance Abuse: Alcohol, drug or chemical abuse, overuse or dependency. Surgery: An invasive diagnostic procedure, or the treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anaesthesia. Termination Date: The date when all cover under this Policy ends for an Insured Person, being the earlier of: a. midnight on the Termination Date stated in the Policy Schedule; or b. the moment of the Insured Person s arrival upon return to his or her Home Country (unless the Insured Person has started a Benefit Period). Underwriter(s): Certain underwriters at Lloyd s, London USD: United States Dollar Usual, Reasonable and Customary: The most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as Usual, Reasonable and Customary charges will be determined by Underwriters. In determining whether a charge is Usual, Reasonable and Customary, Underwriters may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the Illness or Injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the Medical Provider of providing the service, medicine or supply; and such other factors as Underwriters, in the reasonable exercise of discretion, determine are appropriate. 10

11 ARTICLE 4 - ELIGIBILITY, EFFECTIVE DATE, TERMINATION DATE, BENEFIT PERIOD AND HOME COUNTRY COVERAGE A. Eligibility Only individuals who meet all of the following requirements at the time of commencement of this insurance are eligible for coverage hereunder: 1. At the Effective Date the Insured Person must: a. be aged eighteen (18) years or over unless covered under the same policy as and travelling with their parent, guardian or a legally responsible adult who resides at the same address, in which case the minimum age is reduced to over one (1) month old, and not yet sixty five (65) years of age. b. have received all immunisations recommended by their Home Country prior to entry into the Host Country; and 2. At all times during the Policy Period the Insured Person a. must not carry any firearm or any instrument or device designed or intended to cause injury or death to another person; and b. must not be a member of any military or para military force actively participating in armed conflict of any nature whether war be declared or not unless declared to and accepted by Underwriters in advance of the Effective Date. B. Effective Date and Termination Date The cover provided under this Policy shall commence on the Effective Date and shall end on the Termination Date. C. Benefit Period Underwriters will pay Eligible Medical Expenses under ARTICLE 9. A of this Policy for the Benefit Period. The Benefit Period applies only to Eligible Medical Expenses covered under ARTICLE 9. A. of this Policy. D. Home Country Coverage In the event that an Insured Person begins a Benefit Period during the Policy Period, and insurance terminates as a result of the Insured Person returning to their Home Country, Underwriters will pay Eligible Medical Expenses under ARTICLE 9. A of this Policy, which are incurred in the Insured Person s Home Country during the Benefit Period and are not covered by any other insurance or government plan. Home Country coverage applies only to Eligible Medical Expenses related to the Injury or Illness that began during the Policy Period. 11

12 ARTICLE 5 - GENERAL PROVISIONS A. Entire Agreement This Policy, including the Policy Schedule, the Application and any Exhibits, Declarations, Schedules and Endorsements attached hereto, constitutes the entire agreement between Underwriters and the Insured Person. B. Currency The monetary limits and Premiums stated in this Policy are in USD. Benefits may be paid in local currency equivalents. C. Notice Any notice to an Insured Person shall be sent by registered mail and addressed to the Insured Person s mailing address on file with Underwriters on the date the notice is mailed. The insured Person is required to notify Underwriters promptly of any change in mailing address. D. Complaints Procedure Any questions or concerns about this Policy or the handling of a claim should be addressed to: Tangiers International Limited 54 Melita Street Valletta VLT1155 Malta Tel: Fax: medical@tangiersinternational.com A written acknowledgement of complaints will be provided within seven (7) days and a response within fourteen (14) days. If the Insured Person is not satisfied with the response, it may be possible to refer the matter to any appropriate complaints handling body in the territory in which the Insured Person resides. Details will be provided with the response. Alternatively or additionally, depending on circumstances, the Insured Person may be able to refer the matter to: Lloyd s Fidentia House Walter Burke Way Chatham Maritime Chatham Kent ME4 4RN Telephone: +44 (0) Fax: +44 (0) complaints@lloyds.com 12

13 BATTLEFACE // INDIVIDUAL TRAVEL MEDICAL EXPENSES POLICY Details of Lloyd s complaints procedures are set out in a leaflet Your complaint How we can help available at and are also available from the above address. If the Insured Person remains dissatisfied after Lloyd s has considered their complaint, the Insured Person may have the right to refer their complaint to the United Kingdom complaints body: Financial Ombudsman Services (FOS), Exchange Tower, Harbour Exchange Square, London. E14 9SR. United Kingdom. Tel: +44 (0) complaint.info@financial-ombudsman.org.uk web: GOING INTO HARM S WAY? YOU RE GOING TO NEED MORE THAN JUST A FLAK JACKET. 13

14 E. Cancelling this Policy and Cooling-off period Cancellation by the Policyholder For all policies that have a Policy Period of less than one month: there is no cancellation or cooling-off period and no refund of premium will be payable at any time. For all policies that have a Policy Period of one month or more: 1. If this policy cover is not suitable and the Insured Person wants to cancel within fourteen (14 ) days of receiving the policy documentation, the Insured Person must or write to: Tangiers Insurance Services Suite 21, 30 Churchill Square Kings Hill, West Malling Kent ME19 4YU United Kingdom. You will be refunded any money paid to the Underwriter free of any charges and within 30 days of receipt of the request to cancel, provided no claim has been made under the policy. 2. If the Insured Person cancels after fourteen (14) days of receiving the policy documentation the premium will be refunded on a pro rata basis from the date the Insured Person s instructions are received by the Underwriters or any later date specified by the Insured Person, provided no claim has been made under the policy. Cancellation by the Underwriter The Underwriter may cancel this Policy by giving you thirty (30) days notice in writing, which will be sent by post to the last address we hold for you. The Underwriter will only do this for a valid reason such as nonpayment of premium. The Underwriter may also cancel the Policy if the Insured Person commits a fraud which includes doing any of the following: Making any untrue statements to the Underwriter Failing to disclose any material facts relevant to the Policy or a claim. Acting fraudulently in any other way. If the Underwriter cancels the Policy because of fraud, the Policy will become void. If this happens, the Underwriter will return all the Policy premiums paid. 14

15 F. Data Protection Notice Information provided to Underwriters will be processed by them and their agents in compliance with the provisions of the Data Protection Act 1998 of England and Wales, for the purpose of administering this insurance and handling claims, if any. The information may also be sent for processing to other entities, including those located outside the European Economic Area and others where there is a legal obligation to provide it. Under the Act some information, such as that relating to health, is classed as sensitive personal data and requires explicit consent for processing. Underwriters may require the provision of such consent so that they can deal with claims. The person effecting this insurance should ensure that all persons covered are aware of this. G. Financial Services Compensation Scheme In the unlikely event of Underwriters being unable to meet their liabilities, the Insured Person may be entitled to compensation under the Financial Services Compensation Scheme. The contact details are: Financial Services Compensation Scheme 10th Floor, Beaufort House, 15 St Botolph Street, London. EC3A 7QU. United Kingdom. Tel: or +44 (0) Fax: +44 (0) Web: 15

16 ARTICLE 6 - CONDITIONS The following conditions apply to this insurance: A. Premium 1. The Premium for this insurance shall be as stated in the Policy Schedule. 2. Payment: Payment of the required Premium shall be remitted to the Underwriters on or before the Insured Person s Effective Date. B. Misrepresentation and Fraud 1. Application: Underwriters rely on the statements made by the Insured Person on the Application in determining whether or not the Insured Person meets the Eligibility requirements for insurance hereunder. The Application must be completed with all reasonable care, honestly and to the best of the knowledge of the person completing it. If Underwriters establish that the Insured Person deliberately or recklessly provided Underwriters with false or misleading information, Underwriters shall be entitled to declare this insurance null and void, retain the premium and decline all claims. If Underwriters establish that the Insured Person was careless, Underwriters shall be entitled to declare this insurance null and void and return the premium, vary the terms or reduce proportionately the amount paid for claims. If this Policy is wholly or mainly for purposes unrelated to the Insured Person s trade, business or profession then the effect of any misrepresentation will depend on its nature. If this Policy is wholly or mainly for purposes related to the Insured Person s trade, business or profession then any misstatement, concealment or fraud in the Application, or in relation to any statement or warranty made by the Insured Person or their authorised representative, whether in writing or otherwise, to Underwriters or their representatives, on or in connection with the Application shall render this insurance null and void and all claims hereunder shall be forfeited, in addition to any and all other remedies available to Underwriters. 2. Claims: Underwriters rely on the statements made by the Insured Person on the Claimant s Statement and in connection with the submission of any claim hereunder in determining whether or not and to what extent Benefits under this insurance may be payable. If this Policy is wholly or mainly for purposes unrelated to the Insured Person s trade, business or profession then the effect of any misrepresentation in connection with a claim will depend on the nature of the misrepresentation. If the representation was deliberate or reckless Underwriters shall be entitled to declare this insurance null and void and decline the claim and any subsequent claims. If the representation was careless, depending on the circumstances, Underwriters shall be entitled to declare this insurance null and void, return the premium and decline the claim or amend the terms or reduce proportionately the amount paid for claims. If this Policy is wholly or mainly for purposes related to the Insured Person s trade, business or profession then any misstatement, concealment or fraud in the making of any claim hereunder shall render this insurance null and void and all claims hereunder shall be forfeited, in addition to any and all other remedies available to Underwriters. 16

17 C. Proof of Claim When Underwriters receive notice of claim, they will provide the Insured Person with forms for filing Proof of Claim. The Insured Person shall have sixty (60) days beginning on the last day of the Policy Period or, if applicable, the last day of the Benefit Period, to submit Proof of Claim to Underwriters. Subsequent to receipt of Proof of Claim, Underwriters may, at their sole discretion, request and require additional information, including but not limited to medical records, necessary to confirm the validity of any claim prior to payment thereof. D. Payment of Claims If the Insured Person is 1. aged eighteen (18) years old or over a. Accidental Death - Underwriters will pay the Benefit Amount to the Insured Person s estate. b. Accidental Dismemberment - Underwriters will pay the Benefit Amount to the Insured Person. c. All Other Claims where the Claims Administrator has agreed in writing that payment or partial payment of Benefits is due to the Insured Person - Underwriters will make such payment to the Insured Person. whose receipt shall be a full discharge of all liability by Underwriters in respect of the claim. 2. aged under eighteen (18) years a. Accidental Death and Accidental Dismemberment - Underwriters will pay the Benefit Amount to the Insured Person s spouse (if any) or otherwise to the Insured Person s parent or legal guardian. b. All other claims where the Claims Administrator has agreed in writing that payment or partial payment of Benefits is due to the Insured Person - Underwriters will make such payment to the Insured Person s spouse (if any) or otherwise to the Insured Person s parent or legal guardian whose receipt shall be a full discharge of all liability by Underwriters in respect of the claim. E. Legal Actions No action of law or equity may be brought to recover Benefits under this insurance until sixty (60) days after written Proof of Claim has been provided to Underwriters. No such action may be brought after the end of two (2) years after the time that written Proof of Claim is required to be furnished. F. Waiver of Rights In the event that Underwriters do not enforce or require compliance with any provision herein, this will not invalidate, modify or render such provision unenforceable at any other time, whether or not the circumstances are the same. G. The Insured Person and their Physician(s), Hospital(s) and other Medical Provider(s) shall cooperate fully with Underwriters including granting full right of access to all related medical documentation, reports and evidence. Underwriters may deny coverage for any claim where there has been a refusal or material failure to so cooperate. 17

18 H. Patient Advocacy Underwriters may determine that a particular claim or diagnosis occurring under this insurance may be placed under the Patient Advocacy program to ensure that Medically Necessary services and supplies are provided in the most cost effective manner. In the event Underwriters determine that a claim or diagnosis meets the Patient Advocacy program requirements, they will notify the Insured Person, and a Patient Advocate will be assigned to the Insured Person. Thereafter, the Patient Advocate may make recommendations of alternative treatment settings and/or procedures and/ or supplies, which may be more cost effective for the Underwriters and/or the Insured Person. Such recommendations will be made with input from the Insured Person and the Insured Person s Physician(s) and will be made only when it can be reasonably demonstrated that the Medically Necessary services and supplies can be provided in a more cost-effective manner to Underwriters and/or the Insured Person. Underwriters will use best efforts to evaluate and recommend alternative treatment settings and/or procedures and/or supplies, which can reasonably be expected to result in the same or better care of the Insured Person. The Insured Person, in accepting the recommendations, agrees to hold Underwriters harmless and Underwriters shall not be held liable or otherwise responsible for any treatment, service, supply, procedure or care provided to the Insured Person except for the payment of Benefits under this insurance. After the Insured Person has been notified that the claim or diagnosis meets the Patient Advocacy program requirements, Underwriters reserve the right to: 1. make payment for treatments, services and/or supplies which are not covered under this insurance which would be beneficial to the Insured Person and cost effective to Underwriters; and 2. deny payment for expenses which would otherwise be covered under this insurance which are over the amount Underwriters would have paid had the Insured Person followed the recommendations of the Patient Advocacy program. I. Subrogation The Insured Person undertakes to cooperate with Underwriters in the prosecution of any and all valid claims they may have against third parties arising out of any occurrence which results or may result in a loss payment by Underwriters and to account for any amounts recovered on the basis that Underwriters shall be entitled to recover first in full any sums paid by them before the Insured Person shares in any amount so recovered. Should the Insured Person fail to prosecute any valid claims against third parties and Underwriters thereupon become liable to make payment under this insurance, then Underwriters shall be subrogated to all rights of the Insured Person. Any amount recovered by Underwriters shall be used to pay the expenses of collection and reimbursement of Underwriters for any amount that they may have paid or become liable to pay under this insurance. Any remaining amounts shall be paid to the Insured Person. J. Other Insurance Underwriters shall not pay any claim if there is other insurance that would, or would but for the existence of this insurance, pay such claim. Except, where benefit amounts insured elsewhere are less than the applicable benefit amount insured by this Policy, this Policy insures the difference between the benefit amounts insured elsewhere and the applicable benefit amount of this Policy, subject always to the applicable Deductible stated in the Policy Schedule. Underwriters shall not pay any claim in respect of care, treatment, services or supplies furnished by any program or agency funded by any government. 18

19 K. Assignment The Insured Person may assign Benefits under this insurance to a Hospital, Physician or other Medical Provider. Any assignment shall not confer upon such Hospital, Physician or other Medical Provider, any right or privilege granted to the Insured Person under this insurance except for the right to receive Benefits, if any, which are determined to be due and payable hereunder. No Hospital, Physician or other Medical Provider shall have any direct or indirect claim or right of action against Underwriters. L. Right of Recovery In the event of overpayment of any claim hereunder because: 1. All or some of the expenses were not paid for by or on behalf of the Insured Person or were subsequently recovered by or on behalf of the Insured Person; or 2. Any Relative of the Insured Person or Family Member, whether or not that person is or was an Insured Person, is repaid for all or some of those expenses by a source other than Underwriters; or 3. All or some of the expenses were not Eligible Expenses; or 4. All or some of the expenses were paid or reimbursed based on incorrect benefit application, Underwriters have the right to recover the amount of overpayment from the Insured Person and/ or the Hospital, Physician or other Medical Provider of services or supplies. The amount of the recovery is the difference between: a. The amount of expenses actually paid by Underwriters; and b. The amount of Benefits which should have been paid by Underwriters.If the Insured Person or the Hospital, Physician or other Medical Provider of services or supplies does not promptly make any such refund to Underwriters, Underwriters may, in addition to any other remedies available to them, either: i. reduce the amount of any future claim that is otherwise eligible for payment hereunder, to the full extent of the refund due Underwriters; or ii. cancel the Policy issued to the Insured Person by giving thirty (30) days advance written notice by mail to the Insured Person s last known address. M. Claims Assistance Every attempt will be made to help Insured Persons understand the Benefits provided by this insurance, however, any statement made by an employee of Underwriters will be deemed a representation and not a warranty. Actual Benefit payment can only be determined at the time a claim is submitted and all facts are presented in writing. If a definite answer to a specific question is required, the Insured Person can submit a written request, including all pertinent information and a statement from the attending Physician (if applicable), and a written reply will be sent to the Insured Person and kept on file. N. Several Liability Notice The subscribing Underwriters obligations under contracts of insurance to which they subscribe are several and not joint and are limited solely to the extent of their individual subscriptions. The subscribing Underwriters are not responsible for the subscription of any co- subscribing underwriter who for any reason does not satisfy all or part of its obligations. O. Sanction Limitation and Exclusion Clause (LMA3100) No Underwriter shall be deemed to provide cover and no Underwriter shall be liable to pay any claim or provide any benefit hereunder to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose that Underwriter to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America. The law and jurisdiction governing the insurance purchased and the agent for service of suit depends on 19

20 the territory in which the Insured Person resides. These are detailed below for certain territories. For other territories, the Insured Person and the Underwriters are free to choose the law that applies; however, unless the Underwriters agree otherwise: a. this insurance shall be governed exclusively by the law and practice of England and Wales; and b. any litigation arising under, out of or in connection with this insurance shall be subject to the exclusive jurisdiction of any competent court in England; and c. the agent for service of suit shall be: Clyde & Co The St. Botolph Building 138 Houndsditch London EC3A 7AG England Tel: +44 (0) Fax: +44 (0) Underwriters hereon agree that all summonses, notices or processes requiring to be served upon them for the purpose of instituting any legal proceedings against them in connection with this insurance shall be properly served if addressed to them and delivered to them care of the party(ies) indicated. Underwriters, by giving the above authority do not renounce their right to any special delays or periods of time to which they may be entitled for the service of any such summonses, notices or processes by reason of their residence or domicile in England. Any service which is carried out in accordance with the above manner shall be without prejudice to any other alternative method of service provided by law. TERRITORY LAW JURISDICTION AGENT FOR SERVICE OF SUIT Anguilla English Anguilla Denise Stott-Brown International Company Services (Anguilla) Limited Gilwell Offices P.O. Box 2 The Valley Anguilla,, B.W.I. Tel: (264) Fax: (264) Antigua English Antigua Johnson Gardiner 51A St. Mary s Street St. John s Antigua Tel: (268) Fax: (268)

21 TERRITORY LAW JURISDICTION AGENT FOR SERVICE OF SUIT Bahamas English Bahamas Higgs & Johnson Ocean Centre Montagu Foreshore East Bay Street P.O. Box N-3247 Nassau, Bahamas Barbados English Barbados Juris Chambers Wildey Business Park Wildey Road St Michael, Barbados Tel: Fax: Bermuda English Bermuda Appleby Global Canon s Court 22 Victoria Street PO Box HM 1179 Hamilton HM EX Bermuda Dominica English Dominica HHV Whitchurch & Co Ltd. P.O. Box 771 Old Street, Roseau Commonwealth of Dominica West Indies Tel: 1 (767) Fax: 1 (767) Grenada English Grenada Jonas Browne and Hubbard (Grenada) Carenage St George s, Grenada Tel: Fax: Malawi Malawi Malawi Knight & Knight 1st Floor St Martins House P. Bag B 324 Lilongwe 3 Lilongwe Malawi Tel: Fax: Malta English Malta Mark Gollcher Lloyds Malta Ltd 19 Zachary Street Valletta VLT 1133 Malta Tel: (+356) Fax: (+356)

22 TERRITORY LAW JURISDICTION AGENT FOR SERVICE OF SUIT South Africa South Africa South Africa Lloyd s South Africa 15th Floor The Forum 2 Maude Street Sandton 2196 South Africa Tel: +27 (11) Fax: +27 (11) Trinidad and Tobago English Trinidad and Tobago Huggins Services Ltd. P.O. Bag 26 B 26 Kitchener Street Wodbrook Trinidad West Indies Mikhail K. Ali Tel: operations.hsl@ gmail.com Zimbabwe Zimbabwe Zimbabwe Mr. David Birch Lloyd s Principal Officer in Zimbabwe THI House Mount Pleasant Office Park Harare Zimbabwe Tel: Fax: +263 (0) dbtobhail@yoafrica. com 22

23 ARTICLE 7 - PRE-APPROVAL REQUIREMENTS A. The following Medical expenses must always be Pre-certified: 1. Inpatient care; 2. Any Surgery 3. Care in an Extended Care Facility; 4. Home Nursing Care; 5. Durable Medical Equipment; 6. Artificial limbs; 7. Computerised Tomography (CT Scan); 8. Magnetic Resonance Imaging (MRI). B. To comply with the Pre-approval requirements, the Insured Person must: 1. Contact the Claims Administrator on the telephone number contained in the Insured Person s Policy as soon as possible before the expense is to be incurred; and 2. Comply with the instructions of the Claims Administrator and submit any information or documents they require; and 3. Notify all Physicians, Hospitals and other Medical Providers that this insurance contains Preapproval requirements and ask them to fully cooperate with the Claims Administrator. C. If the Insured Person complies with the Pre-approval requirements, and the expenses are Pre-approved, Underwriters will pay Eligible Medical Expenses subject to all terms, conditions, provisions and exclusions herein. If the Insured Person does not comply with the Pre-approval requirements or if the expenses are not Pre-approved: 1. Eligible Medical Expenses will be reduced by 50%; and 2. The Deductible will be subtracted from the remaining amount. D. Emergency Pre-approval: In the event of an Emergency Hospital admission, Pre-approval must be made within forty eight (48) hours after the admission, or as soon as is reasonably possible but no later than one week thereafter. E. Pre-approval Does Not Guarantee Benefits - The fact that expenses are Pre-approved does not guarantee either payment of Benefits or the amount of Benefits. Eligibility for and payment of Benefits are subject to all the terms, conditions, provisions and exclusions herein. F. Concurrent Review - For Inpatient stays of any kind, the Claims Administrator will pre-approve a limited number of days of confinement. Additional days of Inpatient confinement may later be pre-approved if the Insured Person receives prior approval. 23

24 ARTICLE 8 - PREFERRED MEDICAL PROVIDER (PPO) REQUIREMENTS To comply with the Preferred Medical Provider requirements, the Insured Person must receive medical treatment from Preferred Medical Providers as directed by the Claims Administrator. If the Insured Person chooses to seek treatment from a Preferred Medical Provider, Underwriters will remit payment for Eligible Expenses directly to the Medical Provider. Nothing contained in this insurance restricts or interferes with the Insured Person s right to select the Hospital, Physician or other Medical Provider of the Insured Person s choice. Nothing contained in this insurance restricts or interferes with the relationship between the Insured Person and the Hospital, Physician or other Medical Providers with respect to treatment or care of any condition, or the right of any Insured Person to receive, at his or her own expense, services and/or supplies that are not covered under this insurance. ARTICLE 9 - ELIGIBLE EXPENSES (AND PERSONAL ACCIDENT BENEFITS) A. Eligible Expenses Eligible Medical Expenses Subject to the Deductible and the limits stated in ARTICLE 2, Underwriters will pay the following expenses incurred while this insurance is in effect: 1. Charges made by a Hospital for: a. daily room and board and nursing services not to exceed the average semi-private room rate b. daily room and board and nursing services in Intensive Care Unit; c. use of operating, treatment or recovery room; d. services and supplies which are routinely provided by the Hospital to persons for use while Inpatients; e. Emergency Room treatment of an Injury; f. Emergency Room treatment of an Illness resulting in admission to the Hospital as Inpatient for further treatment of that Illness; g. Emergency Room treatment of an Illness which does not result in admission to the Hospital as Inpatient, if non Emergency Room care was not available due to the time or location of the Insured Person at the onset of symptoms. No coverage is provided for non-emergency treatment of Illness in Emergency Room when or where alternative non-emergency care facilities are available. Emergency medical expenses cease upon the Insured Person s return to their Home Country. 2. For Surgery at an outpatient surgical facility, including services and supplies. 3. For charges made by a Physician for professional services, including Surgery. Charges for an assistant surgeon are covered up to 20% of the Usual, Reasonable and Customary charge of the primary surgeon, but standby availability will not be deemed to be a professional service and therefore is not covered hereunder. 24

25 4. For dressings, sutures, casts or other supplies which are Medically Necessary and administered by or under the supervision of a Physician, but excluding nebulisers, oxygen tanks, diabetic supplies, other supplies for use or application at home, and all devices or supplies for repeat use at home, except Durable Medical Equipment as herein defined. 5. For diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included). 6. For artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof. 7. For reconstructive Surgery when the reconstructive Surgery is directly related to Surgery which is covered hereunder. 8. For hemodialysis and the charges by the Hospital for processing and administration of blood or blood components but not the cost of the actual blood or blood components. 9. For oxygen and other gasses and their administration by or under the supervision of a Physician. 10. For anaesthetics and their administration by a Physician or anaesthetist. 11. For drugs which require prescription by a Physician for treatment of a covered Injury or Illness, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of thirty (30) days per prescription. 12. For care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital. 13. Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from an acute care Hospital and only in lieu of Medically Necessary Inpatient hospitalisation. 14. Emergency Local Ambulance transport necessarily incurred in connection with Injury or Illness resulting in Inpatient hospitalisation. 15. Emergency Dental Treatment and dental Surgery necessary to restore or replace sound natural teeth lost or damaged in an Accident which was covered under this insurance. 16. Medically Necessary rental of Durable Medical Equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase price. 17. Physical therapy by an authorised physiotherapist necessarily incurred to continue recovery from a covered Injury or Illness, and subject to the maximum amounts specified in the ARTICLE 2. Such physical therapy must be prescribed by a Physician who is not affiliated with the authorised physiotherapy practice performing the physical therapy. B. Eligible Expenses - Emergency Medical Evacuation Subject to the Deductible and the Limits stated in ARTICLE 2, and subject to the Conditions and Restrictions contained in this provision, Underwriters will pay the following expenses arising out of Emergency Medical Evacuation: 1. Emergency air transportation to a suitable airport nearest to the Hospital where the Insured Person will receive treatment; and 2. Emergency ground transportation necessarily preceding Emergency air transportation; and from the destination airport to the Hospital where the Insured Person will receive treatment. 25

26 Conditions and Restrictions: a. The Insured Person must comply with all conditions and provisions of the insurance. b. Underwriters will provide Emergency Medical Evacuation Benefits only when the Illness or Injury giving rise to the Emergency Medical Evacuation is covered under this Insurance. c. Underwriters will provide Emergency Medical Evacuation Benefits only when all of the following conditions are met: i. Medically Necessary treatment, services and supplies cannot be provided locally; and ii. transportation by any other method would result in loss of Insured Person s life or limb; and iii. it is recommended by the attending Physician who certifies to the above; and iv. agreed upon by the Insured Person or a Relative of the Insured Person; andd v. approved in advance and coordinated by the Claims Administrator; and vi. the condition giving rise to the Emergency Medical Evacuation occurred spontaneously and without advance warning, either in the form of recommendations received from a Physician or symptoms which would have caused a prudent person to seek medical attention prior to the on set of the Emergency. d. Underwriters will provide Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary treatment, services and supplies to prevent the Insured Person s loss of life or limb. e. The Claims Administrator will use its best efforts to arrange any Emergency Medical Evacuation within the least amount of time possible. The Insured Person understands that the timeliness of Emergency Medical Evacuation can be affected by circumstances which are not within the control of the Claims Administrator such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems and weather. The Insured Person agrees to hold Underwriters and the Claims Administrator harmless and Underwriters and the Claims Administrator shall not be held liable for any delays that are not within their direct and immediate control. Notwithstanding the foregoing items c. i-iii and d, Underwriters will pay for expenses to return the Insured Person to their Home Country if the attending Physician and Underwriters or their duly appointed medical consultant agree that transfer to the Home Country is more appropriate than transfer to the nearest qualified Hospital. C. Eligible Expenses - Repatriation of Remains Subject to the Deductible and the Limits stated in ARTICLE 2, and subject to the Conditions and Restrictions contained in this provision, Underwriters will pay the following: Repatriation of Remains expenses arising from the death of an Insured Person: 1. air or ground transportation of bodily remains or ashes to the airport or ground transportation terminal nearest to the Principal Residence of the deceased Insured Person; and 2. reasonable costs of preparation of the remains necessary for transportation. Conditions and Restrictions: a. The Insured Person must be in compliance with all conditions and provisions of this insurance; and b. Repatriation of Remains must be approved in advance and coordinated by the Claims Administrator; and c. Underwriters will provide Repatriation of Remains Benefits only when the death of the Insured Person occurs: i. as a result of an Injury or Illness that is covered under this insurance; and ii. while this insurance is in effect. 26

27 d. The Claims Administrator will use its best efforts to arrange any Repatriation of Remains within the least amount of time possible. The Insured Person understands that the timeliness of Repatriation can be affected by circumstances which are not within the control of the Claims Administrator such as but not limited to: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems and weather. The Insured Person, and their heirs, agree to hold Underwriters and the Claims Administrator harmless and neither Underwriters nor the Claims Administrator shall be held liable for any delays which are not within their direct and immediate control. Further, Underwriters and the Claims Administrator are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the repatriation process or otherwise D. Eligible Expenses - Local Burial or Cremation Subject to the Deductible and the Limits stated in ARTICLE 2, and subject to the Conditions and Restrictions contained in this provision, Underwriters will pay the following Local Burial or Cremation expenses arising from the death of an Insured Person: Underwriters will pay for the Insured Person to be buried or cremated in the country of death in lieu of Repatriation of Remains Benefits herein provided. Conditions and Restrictions: a. The Insured Person must be in compliance with all conditions and provisions of this insurance. b. Local Burial or Cremation must be approved in advance and coordinated by the Claims Administrator. c. Underwriters will provide Local Burial or Cremation Benefits only when the death of the Insured Person occurs as a result of an Injury or Illness that is covered under this insurance. d. Underwriters will provide Local Burial or Cremation Benefits only when the death of the Insured Person occurs while this insurance is in effect. e. The Claims Administrator will use its best efforts to arrange any local burial or cremation within the least amount of time possible. The Insured Person understands that the timeliness of Burial or Cremation can be affected by circumstances that are not within the control of the Claims Administrator such as, but not limited to government officials, government rules, regulations or laws, telecommunications problems and weather. The Insured Person, and their heirs, agree to hold Underwriters and the Claims Administrator harmless and neither Underwriters nor the Claims Administrator shall be held liable for any delays which are not within their direct and immediate control. Further, Underwriters and the Claims Administrator are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the Local Burial or Cremation process or otherwise. f. Local Burial or Cremation Benefits cannot be used in conjunction with the Emergency Evacuation or Repatriation of Remains Benefit and excludes coverage for death in the Insured Person s Home Country. E. Eligible Expenses - Emergency Reunion Subject to the Deductible and the Limits stated in ARTICLE 2, and subject to the Conditions and Restrictions contained in this provision, Underwriters will pay the following Emergency Reunion expenses, following a covered Emergency Medical Evacuation under this insurance: 1. The cost of an economy round-trip air or ground transportation ticket for one Relative of the Insured Person for transportation to the terminal serving the area where the Insured Person is hospitalised or is to be hospitalised following Emergency Medical Evacuation; and 27

28 2. Reasonable expenses at Underwriter s discretion for lodging and meals for the Relative, which are incurred in the area where the Insured Person is hospitalised for a period not to exceed fifteen (15) days. Conditions and Restrictions: a. The Insured Person must be in compliance with all conditions and provisions of this insurance; and b. Emergency Reunion must be approved in advance and coordinated by the Claims Administrator; and c. Underwriters will provide Emergency Reunion Benefits only following an Emergency Medical Evacuation of an Insured Person that is covered hereunder. F. Eligible Expenses - Return (following a covered Emergency Medical Evacuation) Subject to the Deductible and the Limits stated in ARTICLE 2, and subject to the Conditions and Restrictions contained in this provision, Underwriters will pay the following return expenses: The cost of an economy one-way air and/or ground transportation ticket for the Insured Person from the area where the Insured Person was hospitalised following an Emergency Medical Evacuation to the area where the Insured Person was initially evacuated from, or to the terminal serving the area of the Insured Person s Principal Residence, subject to the following Conditions and Restrictions: Conditions and Restrictions: a. The Insured Person must be in compliance with all conditions and provisions of this insurance; and b. Return Benefits must be approved in advance and coordinated by the Claims Administrator; and c. Underwriters will provide Return Benefits only following a covered Emergency Medical Evacuation when the attending Physician states that it is Medically Necessary for the Insured Person to return to his or her Home Country or to the area from which he or she was initially evacuated for continued treatment, recuperation and recovery. G. Accidental Death and Accidental Dismemberment Subject to the Benefit Amounts stated in ARTICLE 2, and subject to the Conditions and Restrictions contained in this provision, Underwriters will pay Accidental Death and Accidental Dismemberment Benefits. The Benefit Amount will be doubled if Accidental Death or Accidental Dismemberment results from Kidnapping, attempted Kidnapping, Hijacking or attempted Hijacking, but subject to a maximum total Benefit amount in respect of all Family Members covered under this Policy as stated in the Policy Schedule. Conditions and Restrictions a. The Insured Person must comply with all conditions and provisions of this insurance; and b. The Accident giving rise to the Accidental Death or Accidental Dismemberment must be covered under this insurance and must not be an Accident occurring whilst the Insured Person is travelling within their Home Country. H. Underwriters will not pay more than one Benefit amount for Accidental Death and/or Accidental Dismemberment resulting from the same Accident. 28

29 ARTICLE 10 - EXCLUSIONS This insurance excludes any treatment in the Insured Person s Home Country, except as provided for in ARTICLE 4, Item D. Charges for the following treatments and/or services and/or supplies and/or conditions and/or items are excluded from coverage hereunder: 1. Any expense of any nature incurred in the Insured Person s Home Country. 2. All charges related to: a. pregnancy or childbirth unless a qualified medical practitioner confirms that the charges arise from complications of pregnancy or childbirth and that such complications could not reasonably have been foreseen by the Insured Person at the date this Policy was purchased; b. the care of children aged under one month old. 3. Treatment related to birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions. 4. Charges for treatment of Mental Health Disorders. 5. Charges which are not incurred by an Insured Person during the Policy Period, or during a Benefit Period, if applicable. 6. Charges for treatment of any condition(s) when the purpose of departing the Home Country was to obtain treatment in the Host Country(ies). 7. Charges for any Benefits hereunder which are not presented to Underwriters for payment within sixty (60) days beginning on the last day of the Policy Period, or Benefit Period if applicable. 8. Treatment, services or supplies that are not administered by or under the supervision of a Physician, and products that can be purchased without a Physician s prescription. 9. Treatment, services or supplies that are not Medically Necessary. 10. Treatment, services or supplies provided at no cost to the Insured Person. 11. Charges which exceed Usual, Reasonable and Customary charges. 12. Telephone consultations or failure to keep a scheduled appointment. 13. Surgery, treatments, services or supplies that are Investigational, Experimental or for Research Purposes. 14. Charges Incurred while confined primarily to receive Custodial Care, Educational or Rehabilitative Care, or any medical treatment in any establishment for the care of the aged. 15. Weight modification or surgical treatment of obesity, including but not limited to wiring of the teeth and all forms of intestinal bypass Surgery. 16. Modifications of the physical body intended to improve the psychological, mental or emotional well-being of the Insured Person, including but not limited to sex-change Surgery. 29

30 17. Surgery, treatments, services or supplies for cosmetic or aesthetic reasons, except for reconstructive Surgery when such reconstructive Surgery is directly related to and follows Surgery which was covered hereunder. 18. Treatment of Insured Persons who are HIV+, have AIDS or ARC, and all diseases caused by and/or related to HIV. 19. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility or impotency, sterilisation or reversal of sterilisation. 20. Any drug, treatment or procedure that either promotes, enhances or corrects impotency or sexual dysfunction. 21. Abortions, except to save the life of the mother. 22. Any dental treatment, including but not limited to routine dental examination, treatment, the care of teeth, gums or bones supporting the teeth, dentures and preparation of dentures, except for Emergency Dental Treatment necessary to replace sound natural teeth lost or damaged in an Accident covered hereunder. 23. Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations. 24. Eye Surgery, such as radial keratotomy, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism. 25. Treatment of the temporomandibular (jaw) joint. 26. Injury sustained while under the influence of or due wholly or partly to the effects of intoxicating liquor or drugs other than drugs taken in accordance with treatment prescribed and directed by a Physician but not for the treatment of Substance Abuse. 27. Costs resulting from self-inflicted Injury or Illness and/or suicide or any attempt thereat whether the Insured Person was sane or insane. 28. Diagnosis or treatment of venereal disease, including all Sexually Transmitted Diseases and conditions. 29. Routine medical examinations, including but not limited to vaccinations, immunisations, annual check-ups, the issue of medical certificates and attestations, and examinations as to the suitability of employment or travel. 30. Treatment by a chiropractor. 31. Charges resulting from or occurring during the commission of a violation of law by the Insured Person, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations. 32. Medical treatment for Substance Abuse or addiction or conditions that may be attributed to Substance Abuse or additions and direct consequences thereof. 33. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy. 34. Any services, supplies, or treatment performed or provided by a Relative of the Insured Person or any Family Member or any person who ordinarily resides with the Insured Person. 35. Orthoptics and visual eye training. 36. Services, supplies, or treatment that are not included as Eligible Expenses as described herein 30

31 37. The following care, treatment or supplies for the feet: orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails. 38. Services, supplies, or treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician. 39. Treatment related directly or indirectly to any Pre-existing Condition. 40. Exercise programmes, whether or not prescribed or recommended by a Physician. 41. Treatment required as a result of complications or consequences of a treatment or condition not covered hereunder. 42. Charges for travel or accommodation, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, Emergency Reunion, and Return sections of this insurance. 43. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s). 44. Organ or Tissue Transplants or related services. 45. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus. 46. All expenses of any cryogenic preservation and implantation or re-implantation of living cells. 47. Diagnosis or treatment of all forms of cancer / neoplasm. 48. All Emergency Medical Evacuation, Repatriation of Remains, or Local Burial or Cremation costs not approved or arranged in advance by the Claims Administrator. 49. Coverage for Local Burial or Cremation is excluded from coverage if death occurs in the insured Person s Home Country. 50. Claims payable under any government system, including the Australian Medicare system, are excluded from coverage. 51. The Accidental Death and Accidental Dismemberment and Eligible Medical Expense Benefits shall be excluded with respect to Accidents occurring while the Insured Person is participating in any of the following: a. Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, and club sports or athletic activities and Professional Sports. Non-contact and non-organised/non-sanctioned amateur sports or athletic activities engaged in by the Insured Person solely for leisure, recreational, entertainment or fitness purposes are not excluded unless they are excluded by (b) through (j) of this provision; b. mountaineering where a reasonably prudent person would use ropes or guides or at elevations of 4,500 meters or higher; c. aviation; d. hang gliding, sky diving, parachuting or bungee jumping; e. racing by any animal or motorised vehicle; f. caving / potholing; g. sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, accompanied by a certified instructor, and at depths of less than ten (10) meters; 31

32 BATTLEFACE // INDIVIDUAL TRAVEL MEDICAL EXPENSES POLICY h. jet skiing; and i. any other sport or activity which is undertaken for thrill seeking and exposes the Insured Person to abnormal risk of Injury. 52. Any Injury or Illness resulting directly or indirectly from the use of any biological, chemical, radioactive or nuclear agent, material, device or weapon. 53. Any Injury or Illness resulting from the Insured Person s direct or indirect involvement in any war, Act of Terrorism, strike, riot or civil commotion. Provided that nothing contained in this exclusion shall exclude any claim for Injury or Illness arising from the Insured Person s passive involvement in such situations; and 54. Any Injury or illness sustained when the Insured Person has unreasonably failed or refused to depart a country within forty eight (48) hours of the time an evacuation order has been issued by the Insured Person s Home Country. 55. Any expenses (medical travel or any other costs) relating directly or indirectly to the Ebola virus. ARTICLE 11 - HOW TO FILE A CLAIM Notice of claim, claimant s statement, and Proof of Claim must be mailed to the Claims Administrator: Tangiers International, Ltd 54 Melita Street Valletta VLT 1122, Malta Tel: Fax: medical@tangiersinternational.com GOING INTO HARM S WAY? YOU RE GOING TO NEED MORE THAN JUST A BAND AID. 32

33 Tangiers International, Ltd 54 Melita Street Valletta VLT 1122, Malta Tel: Fax: