Certain Underwriters at Lloyds, London ("Underwriters") promise to provide the benefits described in the Master Policy. Underwriters make this promise in consideration of the Member’s Application, and payment of Premium.

MultiNational Underwriters, Inc. is hereby recognized by Underwriters as the Plan Administrator. All communications, notices and payments required under this Certificate shall be transmitted through the Plan Administrator. Receipt by the Plan Administrator shall be considered receipt by Underwriters.

Underwriter’s agreement is subject to all terms, conditions, provisions and exclusions of the Master Policy, including any Exhibits, Schedules, Endorsements and/or Riders attached thereto.
 
 

1. ENTIRE AGREEMENT

 

 
 
 
 
 

The Master Policy, including any Exhibits, Schedules, Endorsements and/or Riders attached thereto, constitutes the entire agreement between Underwriters and the Assured. This Certificate issued to the Member, including the Member’s Application and any Exhibits, Schedules, Endorsements and/or Riders attached hereto, is an outline of the insurance provided by the Master Policy. The Certificate does not extend or change the insurance provided by the Master Policy. The insurance described in the Certificate is subject to all terms, conditions, provisions and exclusions of the Master Policy, including any Exhibits, Schedules, Endorsements and/or Riders attached thereto.

2. INSOLVENCY

 

 
 
 
 
 

The insolvency, bankruptcy, financial impairment, receivership, voluntary plan of arrangement with creditors or dissolution of the Assured or any Member shall not impose upon Underwriters any liability other than that specifically included in this insurance.

3. ARBITRATION

 

 
 
 
 
 
 

If any dispute shall arise as to the amount to be paid under this insurance (liability being otherwise admitted), such dispute shall be referred to arbitration in accordance with procedures of the American Arbitration Association. Where any dispute is by this provision referred to arbitration, the making of an award shall be a condition precedent to any right of action against Underwriters.

4. CURRENCY

The following are conditions precedent to Underwriter’s liability under this insurance:

1. PREMIUM

1. Payment: Payment of the required Premium shall be remitted to

Underwriters on or before the Due Dates(s) specified on the Declaration attached hereto.
2. A grace period of 15 days will be allowed to Members for the payment of

each Premium except the first.
3. If any Premium is unpaid at the end of a grace period, all insurance shall

1. MISREPRESENTATION AND FRAUD

 

 
 
 
 
 

Any misstatement, concealment or fraud in the Member’s Application, or in relation to any statement or warranty made by the Member or their authorized representative, whether in writing or otherwise, to Underwriters or their representatives, or in connection with 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. If any claim under this insurance shall be in any respect fraudulent or if any fraudulent means or devices are used by the Member or anyone acting on their behalf, this insurance shall be null and void and all claims hereunder shall be forfeited, in addition to any and all other remedies available to Underwriters.

2. PROOF OF CLAIM

1. A completed and signed Claim Form; and
2. Original itemized bills from Physicians, Hospitals and other medical providers; and
3. Original receipts for any expenses which have already been paid by or on behalf of the Member.

1. TIME LIMIT FOR APPEALING A CLAIM

 

 
 
 
 
 

In the event Underwriters deny all or part of a claim under this insurance, the Member shall have 90 days form the date the notice of denial was mailed to the Member’s last known address to file a written appeal with Underwriters.

2. CLAIMS COOPERATION

 

 
 
 
 

The Member and his/her Physician(s), Hosptial(s) and other providers shall cooperate fully with Underwriters including granting full right of access to all related medical documentation, reports and evidence.

3. PATIENT ADVOCACY

1. Make payment for treatments, services and/or supplies which are not covered under this insurance which would be beneficial to the Member and cost effective to Underwriters; and

Deny payment for expenses which would otherwise be covered under this insurance which are over the amount Underwriters would have paid had the Member followed the recommendations of the Patient Advocacy program.

1. SUBROGATION

 

 
 
 

The Member 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 Member shares in any amount so recovered. Should the Member 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 Member. Any amount recovered by Underwriters shall be used to pay the expenses of collection and reimbursement of Underwriters for any amount that it may have paid or become liable to pay under this insurance. Any remaining amounts shall be paid to the Member.

2. OTHER INSURANCE

 

 
 
 
 

Underwriters shall not pay any claim if there is other insurance which would, or would but for the existence of this insurance, pay such claim, except in respect of any excess beyond the amount payable under such other insurance had this insurance not been effected. Underwriters shall not pay any claim in respect to care, treatment, services or supplies furnished by any program or agency funded by any government.

3. RIGHT OF RECOVERY

1. all or some of the expenses were not paid for by or on behalf of the

Member or were subsequently recovered by or on behalf of the Member; or
2. any Relative of the Member or any person in the Member’s family, whether or not that person is or was a Member, 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

all or some of the expenses were paid or reimbursed based on incorrect benefit application,

1. the amount of expenses actually paid by Underwriters; and
2. the amount of expenses which should have been paid by Underwriters.

not promptly make any such refund to Underwriters, Underwriters may, in addition to any other remedies available to them, either

1. reduce the amount of any future claim that is otherwise eligible for payment

hereunder, to the full extent of the refund due Underwriters; or
2. cancel the Certificate issued to the Member by giving 30 days advance written notice by mail to the Member’s last known address.

1. CLAIMS ASSISTANCE

In order to be eligible for insurance hereunder, the person must:

1. Complete and sign an Application with all questions answered truthfully; and
2. Pay the required Premium on or before the Due Dates; and
3. Receive written acceptance of the Application or Renewal from Underwriters; and
4. Be at least 14 days old but not yet 75 years old; and
5. If a US citizen, must be located outside the US at time of Application or Renewal or plan to reside outside the US continuously for at least 6 months with departure from the US not more than 30 days after the initial Certificate Effective date or renewal Effective date; and
6. If not a US citizen, must be located outside the US at time of Application or Renewal or plan to reside outside the US continuously for at least 6 months with departure from the US not more than 30 days after the initial Certificate Effective date or renewal Effective date; and
7. If not a US citizen but located in the US at time of Application or Renewal, must not be eligible for any other medical insurance plan which is available to individuals similarly situated in the US from US insurers; and
8. Not be Pregnant, Hospitalized or Disabled on the initial Certificate Effective date; and
9. Not be HIV+ on the initial Certificate Effective date.

Coverage hereunder with respect to a Member shall become effective on the date specified by Underwriters and indicated in item #2 of the Declaration attached to the Certificate issued to the Member.
 
 

Coverage hereunder with respect to a Member shall terminate effective the earliest of the following dates:

1. The end of the period for which Premium has been paid; or
2. Twelve months following the Effective date indicated in item #2 of the Declaration attached to the Certificate issued to the Member; or
3. The date the Member no longer meets the Member Eligibility requirements set forth herein; or
4. The 30^th day after the Certificate Effective date if the Member is a citizen of the US and located in the US at time of Application for this insurance and has not departed the US; or
5. The 30^th day after the Certificate Effective date if the Member is not a citizen of the US but is located in the US at the time of Application for this insurance and has not departed the US, unless the Member is not eligible for any other medical insurance plan which is available to individuals similarly situated in the US from US insurers; or
6. The date Underwriters, at their sole option, elect to cancel all Members of the same sex, age, class or geographic location of the Member, provided Underwriters give no less than 30 days advance written notice by mail to the Member’s last known address; or
7. The Cancellation Date specified by Underwriters pursuant to Article 7 – CANCELLATION BY MEMBER.

The Member may request Cancellation of insurance hereunder by giving Underwriters not less than 60 days advance written request. Cancellation is at the option of Underwriters. If Underwriters grant Cancellation, coverage shall terminate with effect from the Cancellation Date specified by Underwriters. Underwriters shall calculate the Short Rate Earned Premium in accordance with the Short Rate Cancellation Table For Term of One Year, set forth in form SLC3(USA). If the Member has paid more than the Short Rate Earned Premium, Underwriters shall refund the difference between the amount actually paid and the Short Rate Earned Premium. If the Member has paid less than the Short Rate Earned Premium, the Member shall remit to Underwriters the difference between the Short Rate Earned Premium and the amount actually paid.
 
 

In the event insurance with respect to a Member is terminated in accordance with Article 6 or canceled in accordance with Article 7, the Member may apply to Underwriters for Reinstatement. Reinstatement is at the option of Underwriters. In order to be considered for Reinstatement, the Member must submit all of the following to Underwriters:

1. A written request for Reinstatement; and
2. A completed Application for Reinstatement; and
3. A written statement giving full details, as requested by Underwriters, of any claims incurred by the Member since the termination date; and
4. Payment of all Premiums due.

1. The following expenses must always be Pre-certified:

1. Inpatient care; and
2. any Surgery or Surgical Procedure; and
3. care in an Extended Care Facility; and
4. Home Nursing Care; and
5. Durable Medical Equipment; and
6. artificial limbs; and
7. Computerized Tomography (CAT Scan); and
8. Magnetic Resonance Imaging (MRI); and
9. Maternity (see special requirements); and
10. Newborn care; and
11. Human Organ/Tissue Transplants.

1. To comply with the Pre-certification requirements, the Member must:

1. Contact the Plan Administrator at the telephone number contained in the Member’s Certificate as soon as possible before the expense is to be incurred; and
2. If Pre-certification is for Maternity, contact the Plan Administrator at the telephone number contained in the Member’s Certificate as soon as possible but always during the first 90 days of Pregnancy; and
3. Comply with the instructions of the Plan Administrator and submit any information or documents they require; and
4. Notify all Physicians, Hospitals and other providers that this insurance

1. If the Member complies with the Pre-certification requirements, and the expenses

1. Eligible Medical Expenses will be reduced by 50%; and
2. The Deductible will be subtracted from the remaining amount; and
3. The Coinsurance will be applied.

1. Emergency Pre-certification: In the event of an Emergency Hospital admission, Pre-Certification must be made within 48 hours after the admission, or as soon as is reasonably possible.
2. Pre-certification Does Not Guarantee Benefits – The fact that expenses are Pre-certified 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.
3. Concurrent Review – For Inpatient stays of any kind, the Plan Administrator will Pre-certify a limited number of days of confinement. Additional days of Inpatient confinement may later be Pre-certified if a Member receives prior approval.

Subject to the Deductible, Coinsurance, Limits, geographical and coverage requirements set forth in the ARTICLE 9 – SCHEDULE OF BENEFITS AND LIMITS, Underwriters will pay the following expenses incurred while this insurance is in effect:

1. Charges made by a Hospital for:

1. Daily room and board and nursing services not to exceed the amount and duration specified in the Schedule of Benefits and Limits; and
2. Daily room and board and nursing services in Intensive Care Unit not to exceed the amount and duration specified in the Schedule of Benefits and Limits; and
3. Use of operating, treatment or recovery room; and
4. Services and supplies which are routinely provided by the Hospital to persons for use while Inpatients; and
5. Emergency treatment of an Injury, even if Hospital confinement is not required; and
6. Emergency treatment of an Illness; however, charges for use of the emergency room itself will not be covered unless the Member is directly admitted to the Hospital as Inpatient for further treatment of that Illness.

1. For Surgery at an Outpatient surgical facility, including services and supplies.
2. 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.
3. For dressings, sutures, casts or other supplies which are Medically Necessary.
4. For diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, behavioral and educational testing are not included).
5. For artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof.
6. For reconstructive Surgery when the Surgery is directly related to Surgery which is covered hereunder.
7. For radiation therapy or treatment and chemotherapy.
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.
10. For anesthetics and their administration by a Physician.
11. For drugs which require prescription by a Physician for treatment of Injury or Illness, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of 60 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.
14. Emergency Local Ambulance transport necessarily incurred in connection with Injury or Illness resulting in Hospitalization.
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. For routine and Medically Necessary care of Newborns during the first 31 days of life provided the Delivery of the Newborn is covered hereunder.
17. For pre-natal care, delivery of Newborn, and post-natal care.
18. For treatment of Mental and Nervous conditions.
19. For charges for physical therapy performed by a professional physical therapist prescribed by a Physician necessarily incurred to continue recovery from a covered Injury or Illness.
20. Medically Necessary rental of Durable Medical Equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.
21. The following Wellness expenses for Members age 35 and older (covered under the Platinum plan): One Routine Physical Exam per Certificate Period provided that at least 12 months has elapsed since the last Routine Physical Exam. For female Members, Routine Physical Exam includes expenses for mammography exams and pap smears.
22. The following Human Organ/TissueTransplant-related expenses:

1. Eligible Medical Expenses incurred by a live donor will be treated as if they were the expenses of the Member receiving the Transplant if the Member received an organ or tissue of the live donor; and
2. Organ procurement and harvesting costs, excluding acquisition or purchase of the actual organ or tissue, up to a Lifetime Maximum of $10,000; and
3. Reasonable travel and lodging expenses of the Member if travel of more than 100 miles is necessary to receive Transplant treatment and services, up to a Lifetime Maximum of $5,000.

1. Emergency Medical Evacuation:

1. Emergency air transportation to a suitable airport nearest to the Hospital where the Member will receive treatment; and
2. Emergency ground transportation necessarily preceding Emergency air

1. The Member must be in compliance with all conditions and provisions of the

insurance; and
2. Underwriters will provide Emergency Medical Evacuation benefits only when the

condition giving rise to the Emergency Medical Evacuation is covered under this
Insurance; and
3. Underwriters will provide Emergency Medical Evacuation Benefits only when all

1. Medically Necessary treatment, services and supplies cannot be provided locally; and
2. Transportation by any other method would result in loss of Member’s life; and
3. Recommended by the attending Physician who certifies to the above; and
4. Agreed upon by the Member or a Relative of the Member; and
5. Approved in advance and coordinated by Underwriters; and
6. The condition giving rise to the Emergency Medical Evacuation occurred

1. 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 Member’s loss of life.
2. Underwriters will use their best efforts to arrange any Emergency Medical

War: Underwriters shall not be liable for any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with:

1. war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war; or
2. mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power; and
3. any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence; or
4. martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the "Occurrences").

The following charges, treatments, care, services, supplies and/or conditions are excluded from coverage hereunder:

1. Pre-existing Conditions – Charges resulting directly or indirectly from any Pre-existing Condition that is not fully disclosed on the Member’s Application are excluded from this insurance; non-disclosure of any Pre-existing Condition may render this insurance null and void in accordance with ARTICLE 3 – CONDITIONS PRECEDENT, B. MISREPRESENTATION AND FRAUD.
2. Special Illnesses – Charges for treatment of the following Illnesses which manifest themselves and/or procedures which take place and/or are recommended during the first 180 days of coverage hereunder beginning on the initial Certificate Effective Date: any condition of the breast, any condition of the prostate, tonsillectomy, adenoidectomy, hemorrhoids or hemorrhoidectomy, disorders of the reproductive system, hysterectomy, hernia, gall stones or kidney stones.
3. Maternity: Charges related directly or indirectly to Pregnancy, including

pre-natal care, delivery and post-natal care are excluded from this insurance until the Member has maintained coverage hereunder continuously for 12 months.
4. Charges for routine and Medically Necessary care of Newborns are excluded

unless the Delivery of the Newborn is covered hereunder.
5. Charges for routine and Medically Necessary care of Newborns after the first 31 days of life.
6. Mental or Nervous Disorders: Charges for treatment of Mental or Nervous Disorders are excluded from this insurance until the Member has maintained coverage hereunder continuously for 12 months.
7. Wellness: Charges for Routine Physical Exams are excluded from this insurance until the Member has maintained coverage hereunder continuously for 24 months, and for all Members who have not yet reached the age of 35. In no event will Underwriters pay for more than one Routine Physical Exam during any 12 month period.
8. Charges which are not incurred by a Member during his/her Certificate Period.
9. Charges for any benefit hereunder which are not presented to Underwriters for payment within 60 days beginning on the last day of the Certificate Period.
10. Treatment, services or supplies which are not administered or ordered by a Physician.
11. Treatment, services or supplies which are not Medically Necessary.
12. Treatment, services or supplies provided at no cost to the Member.
13. Charges which exceed Usual, Reasonable and Customary.
14. Telephone consultations or failure to keep a scheduled appointment.
15. Surgeries, treatments, services or supplies which are Investigational, Experimental or for Research purposes.
16. While confined primarily to receive Custodial Care, Educational or Rehabilitative Care.
17. Weight modification or surgical treatment of obesity, including wiring of the teeth and all forms of intestinal bypass Surgery.
18. Modifications of the physical body in order to improve the psychological, mental or emotional well-being of the Member such as sex-change Surgery.
19. Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is directly related to and follows a Surgery which was covered hereunder.
20. Treatment of Members who were HIV+ at their initial Certificate Effective Date, whether or not the Member had knowledge of his/her HIV status.
21. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal of sterilization.
22. Any drug, treatment or procedure that either promotes, enhances or corrects impotency or sexual dysfunction.
23. Dental Treatment, except for Emergency Dental Treatment necessary to replace sound natural teeth lost or damaged in an Accident covered hereunder.
24. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, or for any examination or fitting related to these devices.
25. Eye surgery, such as radial keratotomy, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
26. Treatment of the temporomandibular joint.
27. Injury sustained while taking part in the following activities:

1. Amateur Athletics or professional sports or athletic activities, except this does not include Amateur sports or athletic activities which are non-contact and engaged in by the Member solely for leisure, recreational, entertainment or fitness purposes unless such sports or activities are otherwise excluded by this provision; and
2. mountaineering where ropes or guides are normally used; and
3. aviation (except when traveling solely as a passenger in a commercial aircraft); and
4. hang gliding, sky diving, parachuting or bungee jumping; and
5. snow skiing or snowboarding, except for recreational downhill and/or cross country snow skiing or snowboarding (no cover provided whilst skiing away from prepared and marked in-bound territories and/or against the advice of the local ski school or local authoritative body); and
6. racing by any animal or motorized vehicle; and
7. spelunking; and
8. subaqua pursuits involving underwater breathing apparatus; and
9. jet skiing; and
10. any other sport or athletic activity which is undertaken for thrill seeking and exposes the Member to abnormal or extraordinary risk of Injury.

1. 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.
2. Willfully self-inflicted Injury or Illness.
3. Venereal disease.
4. Immunizations and Routine Physical Exams except for Newborns under the age of 31 days and except for the Wellness expenses provided for herein.
5. Treatment by a chiropractor unless ordered in advance by a Physician.
6. Charges resulting from or occurring during the commission of a violation of law by the Member, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
7. Treatment of Substance Abuse.
8. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy.
9. Any services or supplies performed or provided by a Relative of the Member or any family member of the Member or any person who ordinarily resides with the Member.
10. Orthoptics and visual eye training.
11. Services or supplies which are not included as Eligible Expenses as described herein.
12. 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.
13. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician.
14. Treatment of sleep disorders.
15. Exercise programs, whether or not prescribed or recommended by a Physician.
16. Treatment required as a result of complications or consequences of a treatment or condition not covered hereunder.
17. Charges for travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, and Human Organ/TissueTransplant sections of this insurance.
18. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
19. Human Organ or Tissue Transplants or related services, except for Covered Transplants.
20. Artificial or mechanical devices designed to replace human organs temporarily or permanently.
21. Expenses to keep a donor alive for a transplant procedure, whether or not the transplant procedure is a Covered Transplant.
22. Transplant benefits for more than one Covered Transplant during any 12 month period, except re-transplantation if during initial transplant procedure.

Accident: A sudden and unexpected occurrence resulting in Injury of the Member.

AIDS: Acquired Immune Deficiency Syndrome as that term is defined by the United States Centers of Disease Control.

ARC: AIDS Related Complex as that term is defined by the United States Centers for Disease Control.

Amateur Athletics: A sport or other athletic activity that is organized 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 a Member solely for recreational, entertainment or fitness purposes.

Application: The fully answered and signed Application which is attached to the Certificate issued to the Member.

Assured: The Atlas/International Citizen Group Insurance Trust, Hamilton, Bermuda.

Certificate: The document issued to the Member which provides evidence of benefits payable under the Master Policy, and which includes the Member’s Application.

Certificate Period: The twelve month period of time beginning on the Certificate Effective date, both days at 12:01am at the location of the Member.

Coinsurance: The payment by the Member of Eligible Expenses at the percentage specified in the Schedule of Benefits and Limits.

Complicated Delivery: A Pregnancy that results in or is expected to result in delivery by Cesarean Section, provided such Cesarean Section is Medically Necessary.

Covered Transplant: Heart, Heart/Lung, Lung, Kidney, Kidney/Pancreas, Liver, and Allogenic and Autologous Bone Marrow.

Custodial Care: That type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist a Member.

Declaration: The Declaration is attached to and forms a part of this Certificate.

Deductible: The dollar amount of Eligible Expenses, specified in the Schedule of Benefits and Limits, that the Member must pay per Certificate Period.

Dental Treatment: The care of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.

Disabled: A person who has a congenital or acquired mental or physical defect that interferes with normal functioning of the body system or the ability to be self-sufficient.

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 one’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.

Emergency: A medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Member’s life or limb in danger if medical attention is not provided within 24 hours.

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 state in which it operates; and is regularly engaged in providing 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. Extended Care Facility does not include a facility primarily for rest, the aged, Substance Abuse treatment, Custodial Care, nursing care or for care of Mental or Nervous Disorders or the mentally incompetent.

HIV+: Laboratory evidence defined by the United States Centers for Disease Control as being positive for Human ImmunodeficiencyVirus infection.

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 program 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 State or Country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as Inpatients; and provides 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 organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a 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.

Illness: A sickness or disease. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.

Incurred: A charge is incurred on the date the service is provided or the supply is purchased.

Injury: Bodily Injury resulting from an Accident.

Inpatient: A person who is an overnight resident patient of a Hospital, using and being charged for room and board.

Intensive Care Unit: A Cardiac Care Unit of other unit or area of a Hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.

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 why which deviates from generally accepted standards of current medical practice.

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 is provided only as a convenience to the Member or provider, and/or is not appropriate for the Member’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.

Member: An individual who is covered under this insurance.

Mental or Nervous 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. Mental or Nervous Disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, and those psychiatric illnesses listed in the current edition of the diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.

Normal Delivery: A Pregnancy that results in or is expected to result in a vaginal delivery.

Outpatient: A Member who receives Medically Necessary treatment by a Physician for Injury or Illness that does not require overnight stay in a Hospital.

Physician: A duly licensed practitioner of the medical arts. A Physician must be currently licensed by the state in which the services are provided, and the services must be within the scope of that license.

Plan Administrator: MultiNational Underwriters, Inc., 107 South Pennsylvania Street, Suite #402, Indianapolis, Indiana 46204, Telephone (317)262-2132, Fax (317)262-2140.

Pre-existing Condition: Any Injury, Illness or Mental or Nervous Disorder which existed at the initial Certificate Effective Date and/or any chronic or recurring Illness and/or chronic or recurring Mental or Nervous Disorder which existed at or prior to the initial Certificate Effective Date. Pre-existing Condition also includes any complications or consequences associated with these conditions.

Pregnancy: The physical condition of being pregnant.

Registered Nurse: A graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters "R.N" after his or her name.

Relative: Biological, adopted or step parent(s), current spouse, biological, adopted or stepsibling(s), and biological, adopted or step child(ren).

Routine Physical Exam: Examination of the physical body by a Physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition.

Substance Abuse: Alcohol, drug or chemical abuse, overuse or dependency.

Surgery or Surgical Procedure: 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 anesthesia.

US: The United States of America including all states, districts, and possessions.

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 provider of providing the service, medicine or supply; such other factors as Underwriters, in the reasonable exercise of discretion, determine are appropriate.
 
 

Notice of Claim, Claim Forms and Proof of Claim must be mailed to:

MultiNational Underwriters, Inc.

107 South Pennsylvania Street, #402

Indianapolis, Indiana 46204