- WHY
YOU NEED THIS PROGRAM
- While the United
States offers the most comprehensive medical care available, it is often
complicated as well as very expensive. For the visitor to the United
States or the recent immigrant, finding a program that is easy to
understand and reasonably priced is often difficult.
As a solution,
Inbound Immigrant was developed to provide a simple program to visitors
and immigrants that will provide up to 5 years of protection.
This is a brief
description of the Inbound Immigrant program. Detailed wording is
outlined in the Program Summary, which will be mailed to you once you
have enrolled into Inbound Immigrant.
- ELIGIBILITY
- This program is
available to non-United States citizens who come to the U.S. for
business, pleasure, to study, or to immigrate. The program must become
effective within 24 months of arrival in the United States.
-
- PERIOD
OF COVERAGE
- You may initially
enroll into Inbound Immigrant for between 1 and 12 months. If you
initially purchase at least 3 months, you may continue to renew coverage
for a minimum 3 months at a time, at the premium rate in force at the
time of renewal. Total period of coverage for Inbound Immigrant cannot
exceed 60 months and the product cannot be rewritten.
Effective Date
- Your coverage will begin on the latest of the following:
- Your departure
from your Home Country; or
- The date your
Application and premium are received by SRI; or
- The date your
Application and premium are accepted by SRI; or
- The date you
request on the Application.
Expiration Date
- Your coverage will end on the earlier of the following:
- The date shown
on the Insurance Confirmation Card, for which premium has been paid;
or
- The date you
return to your Home Country; or
- 60 months after
your original Effective Date; or
- The day an
insured becomes a U.S. citizen; or
- The date of
entry into active military service.
Upon each renewal,
rates, benefits, and program in general are subject to change.
- RENEWAL
- If Inbound
Immigrant is initially purchased for at least three months, one month
before the expiration date, SRI will send a renewal notice to the
Address of Correspondence listed on the application. Coverage may then
be renewed for a period of time, depending upon your specific need. If
you renew the coverage for 3 or more months (up to 12 months at a time),
SRI will continue to send renewal notices to you. If you renew the
coverage for only 1 or 2 months, SRI will assume that you no longer
require the coverage and will not send another renewal notice. Again,
total period of coverage for Inbound Immigrant cannot exceed 60 months.
Additionally, the company may change aspects of the program, including
rates, at any renewal date.
-
- SCHEDULE
OF BENEFITS
- When your covered
Injury or Sickness requires treatment by a physician, this program will
provide benefits for the Usual and Customary (U&C) charges scheduled
below which exceed the chosen Per Person Deductible (either $75 or $150,
or a $250 deductible for age 70 and over) for each Injury and each
Sickness and which are incurred within the 52 weeks following the Injury
or Sickness (within 32 weeks for those insureds age 70 and over).
Payment for any covered service will be no more than the Benefit Limit
shown for it. The total payable by all Benefits will be no more than
$50,000 or $100,000 for each Injury and each Sickness.
For persons age 70
and over, the maximum benefit limit is $50,000, the period in which
covered expenses must be incurred is 32 weeks following the Injury or
Sickness, and a separate schedule applies.
COVERED
SERVICES INJURY AND SICKNESS BENEFIT LIMITS
| |
Age
14 days to Age 69 |
Age
14 days to Age 69 |
|
Age
70 and over |
| Maximum
Limit |
$50,000
Max per Injury / Sickness |
$100,000
Max per Injury / Sickness |
|
$50,000
Max per Injury / Sickness |
INPATIENT
| INPATIENT |
Age
14 days to Age 69 |
Age
14 days to Age 69 |
|
Age
70 and over |
| Hospital
Room & Board including miscellaneous |
$1275/day,
30 day max |
$1750/day,
30 day max |
|
$950/day,
30 day max |
| Hospital
Intensive Care Unit |
Additional
$525/day, 8 day max |
Additional
$750/day, 8 day max |
|
Additional
$425/day, 8 day max |
| Surgical
Treatment |
$3000 |
$5000 |
|
$2500 |
| Anesthetist |
25%
of surgical benefit |
25%
of surgical benefit |
|
25%
of surgical benefit |
| Assistant
Surgeon |
25%
of surgical benefit |
25%
of surgical benefit |
|
25%
of surgical benefit |
| Physician's
Non-Surgical Visits |
$50/visit,
1/day, 30 visits |
$75/day,
1/day, 30 visits |
|
$50/visit,
1/day, 30 visits |
| Consultant
Physician, when requested by attending Physician |
$400 |
$450 |
|
$350 |
| Pre-Admission
Tests within 7 days before Hospital admission |
$1000 |
$1000 |
|
$700 |
| Private
Duty Nurse |
$500 |
$500 |
|
$500 |
OUTPATIENT
| OUTPATIENT |
Age
14 days to Age 69 |
Age
14 days to Age 69 |
|
Age
70 and over |
| Surgical
Treatment |
$3000 |
$5000 |
|
$2500 |
| Anesthetist |
25%
of surgical benefit |
25%
of surgical benefit |
|
25%
of surgical benefit |
| Assistant
Surgeon |
25%
of surgical benefit |
25%
of surgical benefit |
|
25%
of surgical benefit |
| Physician's
Non-Surgical Visits |
$50/visit,
1/day, 10 visits |
$75/visit,
1/day, 10 visits |
|
$50/visit,
1/day, 10 visits |
| Diagnostic
X-rays & Lab Services |
$400
Additional $250 - One Cat scan, PET scan or MRI |
$450
Additional $750 - One Cat scan, PET scan or MRI |
|
$350
Additional $250 - One Cat scan, PET scan or MRI |
| Hospital
Emergency Room |
75%
of U&C to $300 |
75%
of U&C to $500 |
|
75%
of U&C to $250 |
| Prescription
Drugs |
$100 |
$150 |
|
$80 |
| Day
surgery miscellaneous, related to outpatient scheduled surgery
performed at a Hospital or licensed outpatient surgery center;
including the cost of operating room, anesthesia, drugs and
medicines and medical supplies. |
$900 |
$1000 |
|
$800 |
OTHERS
| OTHERS |
Age
14 days to Age 69 |
Age
14 days to Age 69 |
|
Age
70 and over |
| Ambulance
Services |
$400 |
$400 |
|
$400 |
| Initial
Orthopedic Prosthesis / brace |
$1000 |
$1200 |
|
$800 |
| Chemotherapy
and / or radiation therapy |
$1000 |
$1250 |
|
$800 |
| Dental
Treatment for Injury to Sound, Natural Teeth |
$500 |
$500 |
|
$500 |
| Mental
& Nervous Disorder & Substance Abuse |
Same
as any Sickness |
Same
as any Sickness |
|
Same
as any Sickness |
| Maternity
(conception occurs at least 90 days after your effective date) |
$2500
Max |
$2500
Max |
|
N/A |
| Physiotherapy |
$35/visit,
1/day, 12 visits |
$35/visit,
1/day, 12 visits |
|
$35/visit,
1/day, 12 visits |
| Emergency
Evacuation |
$10,000 |
$10,000 |
|
$10,000 |
| Repatriation
of Remains |
$7,500 |
$7,500 |
|
$7,500 |
| AD&D
Principal Sum |
$25,000
Common Carrier |
$25,000
Common Carrier |
|
$25,000
Common Carrier |
Should an insured
person turn 70 during the purchased coverage period, the 70 and over
benefit schedule becomes effective upon the day the insured turns 70.
- Emergency
Medical Evacuation Expenses
- If you or any
covered dependents become sick or injured during the period of coverage
and it has been determined that an Emergency Medical Evacuation is
required to either the nearest medical facility, where appropriate
medical treatment can be obtained, or to your Country of Residence, all
eligible expenses incurred are covered up to $10,000. An Emergency
Medical Evacuation must be recommended by a legally licensed physician
who certifies that the severity of the Injury or Sickness necessitates
such Emergency Medical Evacuation, and agreed to by you or your
representative. All arrangements must be coordinated by the Assistance
Provider.
-
- Repatriation
of Mortal Remains Expenses
- If Injury or
Sickness commencing during the Period of Coverage results in death, all
reasonable expenses incurred for preparation and return of the remains
to the Country of Residence are covered up to a maximum of $7,500
provided that all arrangements are coordinated by the Assistance
Provider.
-
- Common
Carrier Accidental Death and Dismemberment (AD&D)
- Accidental Death
and Dismemberment shall apply to covered accidents sustained by an
insured person while riding as a passenger in or on any land, water or
air conveyance operated under a license for the transportation of
passengers for hire. A loss must occur within 365 days after the date of
accident causing the loss:
| For
Loss of: |
Indemnity |
| Life |
Principal
Sum |
| Both
Hands or Both Feet or Sight of Both Eyes |
Principal
Sum |
| One
Hand and One Foot |
Principal
Sum |
| Either
Hand or Foot and Sight of One Eye |
Principal
Sum |
| Either
Hand or Foot |
One-Half
the Principal Sum |
| Sight
of One Eye |
One-Half
the Principal Sum |
DEFINITIONS
"Injury"
means: bodily injury: (1) directly and independently caused by specific
accident which is unrelated to any pathological, functional, or
structural disorder of injury, (2) treated by a Physician within 30 days
after the date of accident; and (3) which causes loss during the term of
the policy.
"Sickness"
means: sickness or disease of the insured Person which causes loss and
originates while the Insured Person is covered under the policy. All
related conditions and recurrent symptoms of the same or a similar
condition will be considered one sickness.
"Pre-Existing
Condition" means: (1) the existence of symptoms within the 6 months
(or 12 months for persons 70 and older) immediately prior to the
Insured's Effective Date under the policy, or, (2) any condition which
originates, is diagnosed, treated or recommended for treatment within
the 6 months (or 12 months for persons 70 and older) immediately prior
to the Insured's Effective Date under the policy; or (3) congenital
conditions.
"Usual and
Customary Charges" means: a reasonable charge which is: (1) usual
and customary when compared with the charges made for similar services
and supplies; and (2) made to persons having similar medical conditions
in the locality of the Policyholder. No payment will be made under the
policy for any expenses incurred which in the judgment of the Company
are in excess of Usual and Customary Charges.
EXCLUSIONS
No benefits will
be paid for loss or expense caused by, contributed to, or resulting
from:
- Pre-existing Conditions;
- Any loss that occurs while traveling solely for the purpose of
obtaining medical treatment while on a waiting list for a specific
treatment, or while traveling against the advice of a physician;
- Expense incurred within the Insured Person's Home Country or
country of regular domicile;
- Routine physical or other examinations where there are no
objective indications of impairment of normal health, or well baby
care;
- Eye examinations; prescriptions or fitting of eyeglasses and
contact lenses; or other treatment for visual defects and problems.
"Visual defects: means any physical defect of the eye which
does or can impair normal vision;
- Hearing examinations or hearing aids; or other treatment for
hearing defects and problems. "Hearing defects: means any
physical defect of the ear which does or can impair normal hearing:
- Dental treatment, except as the result of injury to sound, natural
teeth as stated in the Schedule of Benefits:
- Professional services rendered by a Member of the Insured Person's
immediate family, or anyone who lives with the Insured Person;
- Services or supplies not necessary for the medical care of the
patient's injury or sickness;
- Weak, strained or flat feet, corns, calluses, or toenails;
- Cosmetic surgery, or treatment for congenital anomalies (except as
specifically provided), except reconstructive surgery as the result
of a covered Injury or Sickness. Correction of a deviated nasal
septum is considered cosmetic surgery unless it results from a
covered Injury or covered Sickness;
- Elective Surgery and Elective Treatment;
- Diagnostic or surgical procedures in connection with infertility
unless infertility is a result of a covered Injury or covered
Sickness;
- Birth control, including surgical procedures and devices;
- Routine new-born baby care, well-baby nursery and related
Physician charges;
- Participation in professional or intercollegiate athletics;
- Injury or Sickness for which benefits are paid or payable under
any Worker's Compensation or Occupational Disease Law or Act, or
similar legislation;
- Organ transplants;
- War or any act of war, declared or undeclared; or while in the
armed forces of any country (a pro-rata premium will be refunded
upon request for such period not covered);
- Participation in a riot or civil disorder, commission of or
attempt to commit a felony in the country in which it was attempted
or committed;
- Suicide or attempted suicide (including drug overdose), while sane
or insane (while sane in Missouri), or intentionally self-inflected
Injury;
- Charges of an institution, health service, or infirmary for whose
service payment is not required in the absence of insurance;
- Treatment of nervous or mental disorders, except as stated in the
Schedule of Benefits, or treatment of alcoholism or drug abuse,
except as provided for treatment of mental or nervous disorders,
according to the Schedule of Benefits;
- Loss incurred from riding in any aircraft, other than as a
passenger in an aircraft licensed for the transportation of
passengers;
- Treatment services, supplies or facilities in a hospital owned or
operated by: a) The Veteran's Administration; or b) A national
government or any of its agencies. (This exclusion does not apply to
treatment when a charge is made which the Insured is required by law
to pay);
- Duplicate services actually provided by both a certified
nurse-midwife and Physician;
- Expenses payable under any prior policy which was in force for the
person making the claim;
- Expenses incurred during a hospital emergency room visit which is
not of an emergency nature;
- Expenses incurred for outpatient treatment in connection with the
detection or correction by manual or mechanical means of structural
imbalance, distortion or sublimation in the human body for purposes
of removing nerve interference and the effects thereof, where such
interference is the result of or related to distortion, misalignment
or subluxation of or in the vertebral column;
- Injury sustained as the result of the Insured operating a motor
vehicle while not properly licensed to do so in the jurisdiction the
motor vehicle accident occurs;
- Voluntary or elective abortion;
- Expense covered by any other valid and collectible medical, health
or accident insurance;
- Expense incurred after the date insurance terminates for an
Insured Person except as may be specifically provided;
- Expenses incurred for injuries resulting from the use of alcohol
or intoxicants, or any drugs unless prescribed by a Physician;
- Sexually transmitted diseases, including AIDS.
ENROLLING
IN INBOUND IMMIGRANT INSURANCE
- Complete entire application.
- Select method of payment.
- If paying by check or money order, make payable to:
"SRI" and enclose it together with completed Application.
- If paying by credit card, complete Application and mail or fax to
SRI. Be sure to sign Method of Payment section.
Complete
and return the Application with your payment for the total
premium to:
SRI
9200 Keystone Crossing, Ste 300
Indianapolis, IN 46240
Fax: 317-575-2659(You may fax if paying by credit card only.
Originals are not required if applications is faxed to SRI with
credit card payment) |
INBOUND
IMMIGRANT MONTHLY RATES (Effective July 1, 2007)
$75 Per Injury
/ Sickness Deductible Per Person
| |
$50,000
Maximum |
$100,000
Maximum |
| Age
2 weeks - 49 |
$65 |
$95 |
| Age
50 - 69 |
$103 |
$145 |
| Dependent
Child (Age 2 weeks through age 18) |
$54 |
$81 |
$150 Per Injury
/ Sickness Deductible Per Person
| |
$50,000
Maximum |
$100,000
Maximum |
| Age
2 weeks - 49 |
$62 |
$91 |
| Age
50 - 69 |
$100 |
$142 |
| Dependent
Child (Age 2 weeks through age 18) |
$51 |
$76 |
$250 Per Injury
/ Sickness Deductible Per Person
| |
$50,000
Maximum |
$100,000
Maximum |
| Age
70 - 79 |
$111 |
N/A |
| Age
80 + |
$144 |
N/A |
Dependent Child
rate is applicable when at least one parent will also be covered under
Inbound Immigrant.
Please be aware
that this is not a general health insurance policy, but an interim
program intended for temporary use. Inbound Immigrant does not guarantee
payment to a facility or individual for medical expenses until the
Company determines that it is an eligible expense.
Refund
of Premium
Refund of premium
shall be considered only if written request is received by SRI prior to
the Effective Date of Coverage. After the Effective Date of Coverage,
the premium is considered fully earned and non-refundable.
What
You Will Receive
Upon successful
enrollment in Inbound Immigrant, you will receive an information packet
from SRI. This packet will include your ID Card and Program Summary. The
Program Summary describes all the benefits of Inbound Immigrant in
complete detail. In addition, the Program Summary tells you the
procedure for submitting claims.
The
Insurance Company
Inbound Immigrant
is underwritten by The Insurance Company of the State of Pennsylvania, a
member company of the American International Group of Companies (AIG)
and is rated A++ "Superior" by the A.M. Best Company.
| Inbound
Immigrant Application - 2007 |
| Official
Use Only: |
Cert# |
Processed: |
Eff.
Date: |
Agent: |
| Rates
Effective July 1, 2007 |
| All
sections must be completed. Incomplete applications will be
returned to the applicant without coverage. |
Applicant
Information
| Last
Name: |
| First
Name: |
| U.S.
Correspondence Address: |
| Name: |
| Address: |
| City: |
State: |
| Postal
Code: |
Country:
USA |
| Daytime
Phone Number: ( _____ ) |
Email: |
| AD&D
Beneficiary: |
Relationship: |
Passport
& Travel Information
| Passport
Number: |
| Country
Issuing Passport: |
| When
did or will you arrive in the United States? (MM/DD/YY) ____ /
____ / ____ |
| When
would you like coverage to begin? (MM/DD/YY) ____ / ____ / ____ |
| Note:
This program is not available to United States Citizens. Your
coverage must begin within twenty four (24) months of your
arrival in the United States. The minimum period of coverage is
1 month, maximum is 12. If 3 months or more of premium is sent,
an automatic renewal notice will be sent to the address above.
Total program length available is 60 months. Coverage cannot
begin until you depart from your Home Country and SRI both
receives and accepts your application and correct premium. |
Coverage
Requested
| Have
you purchased insurance through SRI before? [ ] Yes [ ] No |
If
Yes, ID Number: |
| Selected
Medical Policy Maximum: [ ] Plan A - $50,000 [ ] Plan B -
$100,000 |
| Selected
Per Injury / Sickness Deductible: [ ] $75 or [ ] $150 (70 and
over is $250) |
Inbound
Immigrant Premium Calculation
| Name
of Persons to be Insured: |
Date of
Birth
MM/DD/YY
|
Monthly
Premium
|
| Applicant: |
|
|
| Spouse: |
|
|
| Child: |
|
|
| Child: |
|
|
| Child: |
|
|
|
Total:
[A]
|
|
| Multiply
by number of months |
X
|
|
|
Total:
|
$ |
| Administrative
Fee (required) |
+
|
$10.00 |
|
Total
Payment Enclosed:
|
$ |
Method
of Payment - please check your payment method
| [
] Check |
[
] Money Order |
[
] MasterCard |
[
] Visa |
[
] Discover |
|
| Card
Number: |
| Expiration
Date: |
Daytime
Phone: |
| Name
on Card: |
Billing
Address
|
| Signature
(Required): |
|
Make Check or Money Order payable to "SRI". Total
payment for the Full Term of coverage requested must be paid
in U.S. dollars at the time application for coverage is made.
Coverage purchased by credit card is subject to validation and
acceptance by the credit card company.
I
declare that I agree and I agree to read and understand the
terms and conditions of this product as outlined in this
brochure and the program summary, including coverage is not
available to any U.S. citizen. I understand that pre-existing
conditions, as defined in this brochure, are not covered. I
understand that this is not a general health insurance
product, but a limited benefit program designed to provide
basic benefits under certain circumstances.
I hereby
subscribe to the AIG Life Trust and enroll in the group
coverage for which I am eligible under the group contract
issued by The Insurance Company of the State of Pennsylvania,
a member of the American International Group, Inc (AIG). As
signatory, I declare that I am affirming all statements for
all persons listed on the application (and declare that I have
the authority to do so).
____________________________________________________
Signature of Insured or Proxy (Required) ......... Date Signed
|
|
Your Agent:
Ron Hill - Long Term Consumer Care, Inc. Toll Free:
1-800-544-9505
|
Inbound Immigrant,
Copyright 2007, Specialty Risk International, Inc. (SRI)
"Inbound" is a service mark of SRI
|
