MEDICAL INSURANCE THAT COVERS YOU OUTSIDE YOUR HOME COUNTRY Brochure and Application for the year 2004 The rates for this program are listed at the bottom of the brochure along with the product application. We encourage you to print this entire document for complete review. Click Here to Print

7 DAYS TO 3 YEARS OF COVERAGE FOR:

• NON-CITIZENS VISITING THE UNITED STATES.
• UNITED STATES CITIZENS TRAVELING OVERSEAS.
• INTERNATIONAL TRAVELERS REQUIRING CONTINUING COVERAGE.

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Effective Date
Your coverage will begin on the latest of the following: 1) Moment of departure from Home Country; or 2) The date and time the Application and full plan cost is received and accepted by SRI; or 3) The date requested on the Application.

Expiration Date
Coverage will end on the earlier of the following: 1) The arrival of the Insured Person back in their Home Country *; or 2) The date shown on the ID Card, for which plan cost has been paid; *See Home Country Coverage Section. 

1. Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service (and with the exception of personal services of a non-medical nature); charges made for an operating room.
2. Charges made for Intensive Care or Coronary Care charges and nursing services.
3. Charges made for diagnosis, treatment and Surgery by a Physician; charges made for the cost and administration of anesthetics.
4. Charges made for Outpatient treatment, same as any other treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physicians' Outpatient visits/examinations, clinic care, and Surgical opinion consultations.
5. Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood transfusions, iron lungs, and medical treatment;  dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or Surgeon.
6. Charges for physiotherapy, if recommended by a Physician for the treatment of a specific Disablement and administered by a licensed physiotherapist.

Ground ambulance (within the metropolitan area) to and from the nearest Hospital with facilities for required treatment. If the Insured Person is in a rural area, then licensed ground ambulance transportation to the nearest metropolitan area shall be considered a Covered Expense.

Emergency Medical Evacuation / Repatriation
The Program will pay Covered Expenses incurred if any covered Injury or Illness commencing during the Period of Coverage results in the Medically Necessary Emergency Medical Evacuation or Repatriation of the Insured Person (the Insured Person's medical condition warrants immediate transportation from the medical facility where the Insured Person is located to the nearest adequate medical facility where medical treatment can be obtained). The benefit must be ordered by the Assistance Company in consultation with the Insured Person’s local attending Physician.*

Return of Mortal Remains
The Program will pay the reasonable Covered Expenses incurred up to a maximum of $20,000 to return the Insured Person's remains to his/her Home Country, if he or she dies.*

Emergency Medical Reunion
When Emergency Medical Evacuation or Repatriation is ordered and the attending Physician recommends that a family member travel with the Insured, the program will arrange and pay, up to $10,000, for round trip economy-class transportation for one individual selected by the Insured Person, from the Insured Person’s Home Country to the location where the Insured Person is hospitalized and return to the Home Country.*

Return of Minor Child(ren)
Should the Insured Person be traveling alone with a Minor Child(ren) and is hospitalized because of a covered Illness or Injury and the Minor Child(ren), under age 19, is left unattended, the program will arrange and pay up to $5,000 for one way economy fare to their Home Country (including the cost of an attendant/escort, if necessary to insure the safety and welfare of the Minor Child(ren).*

Hospital Indemnity
If you are hospitalized while traveling outside of the United States or Canada, and the hospitalization is considered a Covered Expense, the program will indemnify the Insured $100 for each night spent in the hospital (this benefit is in addition to any other covered expenses of the program).

Interruption of Trip
If the Insured is unable to continue the Trip due to the death of an Immediate Family member (parent, spouse, sibling or child) or due to serious damage to the Insured's principal residence from fire, flood or similar natural disaster (tornado, earthquake, hurricane, etc.). The program will reimburse the Insured (up to $5,000) for the cost of economy travel, less the value of applied credit from an unused return travel ticket, to return home to their area of principal residence.*

Loss of Checked Luggage
If the Insured's checked luggage is permanently lost by the airline, the program will reimburse the Insured for the replacement of clothing and personal hygiene items lost to a maximum per bag limit of $50 (up to $250). This benefit is secondary to any other (including airline) coverage available. The Insured must furnish proof to the Company that full reimbursement has been obtained from the airline.*

Home Country Coverage
This benefit covers you for incidental trips to your Home Country (60 days per 12 months of purchased coverage or pro rata thereof - example: approximately 5 days per month). Maximum benefit is reduced to $50,000 while in your Home Country. Coverage will be limited to $5,000 for conditions first diagnosed outside Your Home Country (Does not apply for Emergency Evacuation or Repatriation).

Assistance Services
Upon enrollment into Liaison International, you are eligible to use any of the assistance services provided by the Assistance Service Provider. Additional information is contained in the Program Summary.

• Open 24 hours/day, 365 days a year.
• Multilingual personnel.
• Physicians/Nurses on staff.
• Locate local facilities.

Help with emergency situations.

While a new period of coverage will be issued, your original effective date will be used with regards to calculating your deductible and coinsurance (for up to a total of 12 months, then both will begin again), as well as determining any pre-existing conditions. Since SRI's Benefit Period states that the program will pay up to a total of 6 months for any one eligible condition, you can be protected beyond your period of coverage.

The maximum period of time SRI will offer this feature is three years (one year for persons age 70 and over). It is important to note that rates and benefits may change for each subsequent period of coverage. A $5.00 Administrative Fee will be included on each notice. This option is not available if you allow coverage to expire prior to reapplying. If this happens, an entirely new program must be purchased (preexisting condition begins again).

Continuing Coverage is available on a monthly basis when purchased using SRI's online system.

Hazardous Sport Coverage
To cover motorcycle / motor scooter riding, mountaineering (4500 meter limit), hang gliding, parachuting, bungee jumping, water skiing, snow skiing, snowmobiling, and snow boarding.

Please be aware that this is not a general health insurance policy, but an interim, limited benefit period, travel medical program intended for use while away from your Home Country.  Liaison International does not guarantee payment to a facility or individual for medical expenses until SRI determines that it is an eligible expense.

1. Any Injury or Illness which meets the following criteria: a) condition(s) that would have caused a person to seek medical advise, diagnosis, care or treatment during the 36 months prior to the Effective Date of coverage under this Policy; 2) condition(s) for which manifestation, medical advise, diagnosis, care or treatment was recommended, received, or noticed during the 36 months prior to the Effective Date of coverage under this Policy. For Insured Persons traveling outside the United States and Canada, the period is 12 months instead of 36 months. If the Insured Person is a United States citizen, this exclusion is waived for the first $2500 in eligible medical expenses incurred outside the United States and Canada (for persons age 65 and over, the amount is $1500).
2. Charges for treatment which exceed Reasonable and Customary charges; or Charges incurred for Surgeries or treatments which are Investigational, Experimental, or for research purposes; expenses which are nonmedical in nature; expenses for Vocational, Speech, Recreational or Music Therapy.
3. Expenses which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician.
4. Suicide or any attempt there at, while sane or self destruction or any attempt there at, while insane; intentionally self-inflicted Injury or Illness; or expenses as a result or in connection with the commission of a felony offense.
5. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war.
6. Injury sustained while participating in professional, sponsored and/or organized Amateur or Interscholastic Athletics.
7. Routine physicals, inoculations, or other examinations where there are no objective indications or impairment in normal health.
8. Treatment of the Temporomandibular joint.
9. Services or supplies performed or provided by a Relative of the Insured Person, or anyone who lives with the Insured Person.
10. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids, cosmetic or plastic Surgery (including deviated nasal septum), routine dental expenses, eye care or eye related expenses, unless caused by Accidental bodily Injury incurred while insured hereunder.
11. Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent; any Mental and Nervous disorders or rest cures; Injury sustained while under the influence of or Disablement due to wholly or partly to the effects of intoxicating liquor or drugs.
12. Congenital abnormalities and conditions arising out of or resulting therefrom.
13. Expenses incurred during a hospital emergency room visit which is not of an emergency nature.
14. Injury sustained while taking part in mountaineering where ropes or guides are normally used, hang gliding, parachuting, bungee jumping, racing by horse or motor vehicle or motorcycle, snowmobiling, motorcycle / motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snow boarding.*
15. Treatment paid for or furnished under any other individual, government, or group policy or charges provided at no cost to the Insured Person.
16. Treatment of venereal or sexually transmitted disease.
17. Pregnancy expenses or Illness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from Accident.
18. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth.
19. Expenses incurred while the Insured Person is in their Home Country (except after approved Emergency Evacuation/Repatriation or if treatment is a follow-up to a covered disablement during coverage or if the expenses pertain to the Home Country Coverage benefit).
20. Expenses incurred for which travel was undertaken to seek medical treatment for a condition; or incurred after the Insured Person’s physician has limited or restricted travel.

Policy terms and conditions are briefly outlined in this brochure. 

Complete provisions pertaining to this insurance are contained in the Master Policy on file with the trustee, American Consumer Insurance Trust, and Liaison International. In the event of any conflict between this brochure and the Master Policy, the Policy will govern. A Program Summary, listing more detailed exclusions, will be mailed to you along with Your ID Card once coverage is purchased.

Notice to Florida residents: the benefits of this policy providing Your coverage are governed by the law of a state other than Florida. Your Homeowners policy, if any, may provide coverage for loss of personal effects provided by the Loss of Checked Luggage coverage. This insurance is not required in connection with the purchase of Your travel arrangements.
 
 

1. Complete the entire Liaison International Application. Payment for the entire period of coverage is due at the time of application.
2. If paying by check or money order, make payable to: "SRI" and enclose it together with completed Application.
3. If paying by credit card, complete Application and mail or fax to The Insurance Exchange. Be sure to sign Method of Payment section.
4. Read the brochure and sign the application.

Liaison International 2004 Application       Click Here to Print
Effective Until December 31, 2004
 

OFFICIAL USE ONLY:    Cert#:                 Processed:                 Eff Date:              Agent:  1659  Kim Michaels

APPLICANT INFORMATION

 ADDRESS OF CORRESPONDENCE - where ID card is to be sent:

COVERAGE SPECIFICS - please check your chosen item

CALCULATING YOUR PREMIUM - (Please complete entire sections.)

METHOD OF PAYMENT - please check your payment method

Liaison® is a registered Trademark of Specialty Risk International, Inc.
In Florida, Florida Resident - Agent No. A10702