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Inbound Immigrant Health Insurance

January 1, 2010

 

 

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 are traveling to the United States 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 the plan administrator; or
     -The date your Application and premium are accepted by the plan administrator; or
    - The date you request on the Application.

EXPIRATION DATE - Your coverage will end on the earlier of the following:

1.      The date shown on the Insurance Confirmation Card, for which premium has been paid; or

2.      The date you return to your Home Country; or

3.      60 months after your original Effective Date; or

4.      The day an insured becomes a U.S. citizen; or

5.      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 insured 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

$50,000 Max per injury/sickness

$100,000 Max per injury/sickness

 

$50,000 Max per injury/sickness

Hospital Room & Board including miscellaneous

$1450/day, 30 day max

$2000 per day, 30 day max

 

$1050/day, 30 day max

Hospital Intensive Care Unit

Additional $600/day, 8 day max

Additional $850/day, 8 day max

 

Additional $450/day, 8 day max

Surgical Treatment

$3,500

$5,750

 

$2,850

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

$60/visit, 1/day, 30 visits

$85/visit, 1/day, 30 visits

 

$55/visit, 1/day, 30 visits

Consultant Physician, when requested by attending Physician

$450

$500

 

$400

Pre-Admission Tests w/in 7 days before Hospital admission

$1150

$1150

 

$800

Private Duty Nurse

$575

$575

 

$575

 

 

 

 

Surgical Treatment

$3,500

$5,750

 

$2,800

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

$60/visit, 1/day, 10 visits

$85/visit, 1/day, 10 visits

 

$55/visit, 1/day, 10 visits

Diagnostic X-rays & Lab Services

$450

$500

 

$400

 

Additional $280 - One Cat scan, PET scan or MRI

Additional $850 - One Cat scan, PET scan or MRI

 

Additional $285 - One Cat scan, PET scan or MRI

Hospital Emergency Room

75% of U&C to $345 max

75% of U&C to $575 max

 

75% of U&C to $280 max

Prescription Drugs

$115

$175

 

$90

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. 

$1000

$1150

 

$900

 

 

 

 

Ambulance Services

$450

$450

 

$450

Initial Orthopedic Prosthesis/brace

$1150

$1400

 

$900

Chemotherapy  and/or radiation therapy

$1150

$1425

 

$900

Dental Treatment for Injury to Sound, Natural Teeth

$575

$575

 

$575

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)

$2,500 max

$2,500 max

 

N/A

Physiotherapy

$40/visit, 1/day, 12 visits

$40/visit, 1/day, 12 visits

 

$40/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:

1.                Pre-existing Conditions;

2.                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;

3.                Expense incurred within the Insured Person's Home Country or country of regular domicile;

4.                Routine physical or other examinations where there are no objective indications of impairment of normal health, or well baby care;

5.                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;

6.                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:

7.                Dental treatment, except as the result of injury to sound, natural teeth as stated in the Schedule of Benefits:

8.                Professional services rendered by a Member of the Insured Person's immediate family, or anyone who lives with the Insured Person;

9.                Services or supplies not necessary for the medical care of the patient's injury or sickness;

10.             Weak, strained or flat feet, corns, calluses, or toenails;

11.             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;

12.             Elective Surgery and Elective Treatment;

13.             Diagnostic or surgical procedures in connection with infertility unless infertility is a result of a covered Injury or covered Sickness;

14.             Birth control, including surgical procedures and devices;

15.             Routine new-born baby care, well-baby nursery and related Physician charges;

16.             Participation in professional or intercollegiate athletics;

17.             Injury or Sickness for which benefits are paid or payable under any Worker's Compensation or Occupational Disease Law or Act, or similar legislation;

18.             Organ transplants;

19.             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);

20.             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;

21.             Suicide or attempted suicide (including drug overdose), while sane or insane (while sane in Missouri), or intentionally self-inflected Injury;

22.             Charges of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;

23.             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;

24.             Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;

25.             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);

26.             Duplicate services actually provided by both a certified nurse-midwife and Physician;

27.             Expenses payable under any prior policy which was in force for the person making the claim;

28.             Expenses incurred during a hospital emergency room visit which is not of an emergency nature;

29.             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;

30.             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;

31.             Voluntary or elective abortion;

32.             Expense covered by any other valid and collectible medical, health or accident insurance;

33.             Expense incurred after the date insurance terminates for an Insured Person except as may be specifically provided;

34.             Expenses incurred for injuries resulting from the use of alcohol or intoxicants, or any drugs unless prescribed by a Physician;

35.             Sexually transmitted diseases, including AIDS.

 

 ENROLLING IN INBOUND IMMIGRANT INSURANCE

1. Complete entire application

2. Select method of payment.

3. If paying by check or money order, make payable to:   "SRI" and enclose it together with completed Application.

4. If paying by credit card, complete Application and mail or fax to SRI.  Be sure to sign Method of Payment section.

 

Complete and return the Application with your payment for the total premium to:
SRI

303 Congressional Boulevard

Carmel, IN 46032 USA

Fax:  317-575-2659

(You may fax if paying by credit card only.  Originals are not required if applications is faxed to SRI with credit card payment)

 

 

Monthly Rates (Effective April 1, 2006)

 

$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.


 

 

InboundSM Immigrant Application - 2006

OFFICIAL USE ONLY:  Cert#:              Processed:                  Eff. Date:                    Agent: Health Insurance    MedSave.com
Rates April 1, 2006

All sections must be completed. Incomplete applications will be returned to the applicant without coverage.

 

Applicant Information

Mr.   Mrs.   Miss   Ms.   Last Name: __________________________________First Name: _______________________

 

U.S. Correspondence Address:  Name : ________________________________________________________________

 

Address: ____________________________________________  City: _________________  State: ___  Zip: _________

                                                            (Address must be in the United States)

 

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? ___ / ___ / ____ Date you would like coverage to begin: ___ / ___ / ____

 

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 or more months 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?   ___No   ___Yes        If Yes, ID Number: _____________________

Selected Medical Policy Maximum:  ¨ Plan A: $50,000    ¨ Plan B: $100,000

Selected Per Injury/Sickness Deductible:  ¨ $75    ¨ $150 (or 70 and over at $250)

If there are one or more applicants below age 70 and one ore more applicants age 70 and above, separate applications must be submitted.

 

Name of Persons to be Insured           Date of Birth    Monthly Premium

Applicant: ______________________     __ / __ / ____    _____________

Spouse: _______________________     __ / __ / ____    _____________

Child: _________________________     __ / __ / ____    _____________

Child: _________________________     __ / __ / ____    _____________

Child: _________________________     __ / __ / ____    _____________

                                                           

Totals:             _____________

 

 

 A

x

 

=

 B

+

     $10

=

 C

Total from Above

 

Number of months

 

 

 

Administrative Fee (required)

 

Total Payment Enclosed

 

Method of Payment

¨ Check          ¨ Money Order            ¨ MasterCard              ¨ Visa             ¨ Discover

 

Card Number: ________________________________    Name on Card: _______________________________

Expiration Date: _______________________________   Daytime Phone: ______________________________

Billing Address: ____________________________________________________________________________

Signature (Required) ______________________________________________________________________

 

Make Check or Money Order Payable to:  "SRI".   Total Payment for the Full Term of coverage requested on this application 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 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


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