BROCHURE, RATES and APPLICATION
 atriot America
Underwritten by
SIRIUS International Insurance Corporation
Travel medical insurance
for visitors to the USA
non- US citizens traveling outside their home country
Rates and Application are at the bottom of this
page.
Click here for Instant Quotes & Online Purchase
Patriot America
provides
coverage for non-US citizens traveling abroad for a minimum of 5 days up to
a maximum of
two years. Although the Patriot International Plan is not renewable, it can be rewritten
for succeeding or subsequent coverage periods. New Deductible, Coinsurance, Eligibility,
Conditions of Coverage and Pre-Existing Condition Exclusions apply to any succeeding or
subsequent Period of Coverage. A new application also must be completed. If you or other
family members applying for coverage are age 65 or older, please see the Eligibility
section of the Patriot brochure for additional information.
MEDICAL BENEFITS |
Usual reasonable and customary charges, subject to deductible and
coinsurance |
| Hospital Room and Board |
To Policy Maximum for average semi-private room rate |
| Intensive Care |
To Policy Maximum |
| Medical Expenses |
To Policy Maximum |
| Outpatient Medical |
To Policy Maximum |
| Local Ambulance |
To Policy Maximum |
| Emergency Room |
As described below |
|
Charges incurred for the use of the Emergency Room due to an accident are
covered up to the Policy Maximum.
Charges incurred for the use of the Emergency Room for treatment of an illness are subject
to an additional (extra) US$250 deductible if treatment does not require admittance to the
hospital. |
| Dental |
As described below |
Injury due to an accident:
Each Patriot plan covers the
cost of emergency dental treatment and dental procedures necessary to restore sound
natural teeth lost or damaged in an accident up to the Policy Maximum.
Sudden dental pain:
Each plan will pay up to US$100 for the necessary
treatment of sudden, unexpected pain to sound natural teeth. |
| INTERNATIONAL EMERGENCY CARE: |
| Emergency Evacuation |
To Policy Maximum when coordinated through the Plan Administrator |
|
Each Patriot Travel Medical Insurance® plan includes coverage for
Emergency Medical Evacuations to the nearest qualified medical facility; expenses for
reasonable travel and accommodations resulting from the evacuation; and the cost of
returning to either the home country or the country where the evacuation occurred, up to
the policy limit. |
|
Political Evacuation |
Up to US$10,000 when
coordinated through the Plan Administrator
If the United
States Department of State, Bureau of Consular Affairs issues a
travel advisory that becomes effective on or after the Insured
Person’s date of arrival in the Host Country, the Company will pay
up to US$10,000 for transportation to the nearest place of safety or
for repatriation to the Insured Person’s home country or country of
residence provided that:
- The Insured Person
contacts the Company within 10 days of the United States
Department of State, Bureau of Consular affairs issues the
travel advisory;
- Political
Evacuation and Repatriation is approved and coordinated by the
Company.
|
| Emergency Reunion |
To US$15,000 when coordinated through the Plan Administrator |
|
Each Patriot plan also provides emergency reunion coverage, up to
US$15,000 for a maximum of 15 days, for the reasonable travel and lodging expenses of a
relative or friend during an Emergency Medical
Evacuation: either the cost of accompanying the insured during the evacuation or traveling
from the home country to be reunited with the insured. |
| Return of Mortal Remains |
To US$25,000 when coordinated through the Plan Administrator |
|
If a covered illness/injury results in death, expenses for Repatriation of
bodily remains or ashes to the home country will be covered up to a maximum of US$25,000. |
| Returning Minor Children |
To US$5,000 when coordinated through the Plan Administrator |
|
If an insured person is hospitalized due to a covered illness/injury and
is traveling alone with child(ren) 19 or under that otherwise would be left unattended,
the Patriot plans will pay up to US$5,000 for one way economy fare to their home country,
including a chaperone, if necessary, for the safety of the child(ren). |
| PLAN INFORMATION |
| Deductible |
Your choice of US$0, $100, $250, $500, $1,000 or $2,5000 |
|
On the Application Form, you will be asked to circle your choice of a
deductible. Your premium rate is dependent on the deductible you choose. Please see the
Application Form for more information. |
| Coinsurance |
As described below |
For treatment received
outside the U.S. & Canada: No coinsurance
For treatment received within the U.S. & Canada:
In the PPO Network: The plan pays 90% of eligible expenses up to
US$5,000, then 100% up to the Policy Maximum
Outside the PPO Network:The plan pays 80% of eligible expenses up
to US$5,000, then 100% up to the Policy Maximum |
| Benefit Period |
Six months |
|
If a covered injury or illness requires continuing treatment after the
Period of Coverage expires, the six-month Benefit Period may provide continued coverage.
When the certificate expires, the Company will review the date of initial treatment for
the covered injury or illness. If treatment began less than six months before the Period
of Coverage expired, benefits for the covered injury or illness will continue subject to
the Policy Limits and the other terms of the plan until there have been six months of
continuous coverage for the covered injury or illness. |
SPECIAL COVERAGES |
| Home Country Coverage |
As described below |
Incidental Home Country Coverage -
During the Period of
Coverage an insured person may return to their home country for incidental visits up to a
cumulative two weeks total, subject to: a. The insured person must have
left their home country, b. The total Period of Coverage must be for a
minimum of 30 days, and c. The return to the home country may not be
taken to receive treatment for an illness or injury incurred while traveling.
End of Trip Home Country Coverage -
For every five months of continuous
coverage you purchase, you can purchase one additional month of home country coverage as
an accommodation and supplemental travel benefit, up to a maximum of two months. To
purchase this special home country extension coverage, please check the appropriate box on
the Application Form, and calculate your premium to include the additional month(s). |
| Trip Interruption |
To US$5,000 |
|
If, during a covered trip, there is a death of an immediate family member
(spouse, child, parent or sibling) or the substantial destruction of the insured’s
principal residence, each Patriot plan will pay to return the insured to the area of
principal residence. The plan will pay for a one way air or ground transportation ticket
of the same class as the unused travel ticket, less the value of the unused return ticket.
|
| Lost Luggage |
To US$50 per item or personal property; maximum of US$250 per Period of
Coverage |
|
This benefit will be paid in the event that the Common Carrier permanently
loses an insured person’s checked luggage. This coverage is secondary to any other
available coverage, including the Carrier’s. |
| Common Carrier Accidental Death |
US$50,000 to Beneficiary; maximum of US$250,000 per family |
|
If accidental death should occur while traveling on a commercial Common
Carrier, US$50,000 will be paid to the designated beneficiary, to a maximum of US$250,000
per family. |
| Sports & Activities Coverage |
To Policy Maximum for basic sports Coverage as described below |
Each Patriot plan covers injuries incurred during amateur athletic
activities which are non-contact and engaged in by the insured person solely for leisure,
recreation, entertainment or fitness purposes. However, activities not covered include
amateur or professional sports or other athletic activity which is organized and/or
sanctioned, or which involves regular or scheduled practices, games or competition.
The following hazardous activities are excluded: racing of any kind, aviation (except when
traveling as a passenger in a commercial aircraft), BMX, BASE jumping, bobsleigh, bungee
jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning,
inline skating, jet skiing, kayaking, luge, motocross (moto-x), mountain biking,
mountaineering, parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping,
sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling, surfing,
wakeboarding, water skiing, windsurfing and whitewater rafting.
Optional Leisure or Extreme
Sports Riders: Please
contact us at 877-211-3654 or
info@internationalriskmanagement.com for more
information. |
| Accidental Death & Dismemberment |
US$25,000 principal sum |
|
Each Patriot plan includes US$25,000 principal sum benefit for Accidental
Death and Dismemberment occurring during the Period of Coverage: • Accidental Loss of
life - principal sum; • Accidental Loss of two Members - principal sum; •
Accidental Loss of one Member - 50% of principal sum. “Member” means hand, foot
or eye. For more information, see the Conditions of Coverage section in the Patriot Travel
Medical Insurance brochure. |
| Terrorism Coverage |
Up to US$50,000 lifetime maximum |
Each Patriot Plan provides coverage for injuries and illness incurred as a
result of an act of Terrorism, limited in amount and by circumstances. If an insured
person is injured as a result of an act of Terrorism, and the insured person has no direct
or indirect participation in the act, the plan will reimburse eligible medical claims
subject to a US$50,000 lifetime maximum. However, claims incurred as a result of
radiological, nuclear, chemical or biological weapons or events are not covered.
Terrorism is defined as the systematic or planned use of
violence, fear, or threat of violence in order to intimidate a population or government,
especially as a means of coercion or to obtain a granting of any demand. However, this
benefit does not cover an act of Terrorism in any country or location where the United
States government has issued a travel advisory that has been in effect within the 6 months
prior to the insured person's date of arrival.
This benefit also does not cover an act of Terrorism
in the event that an advisory to leave a certain country or location is issued by the
United States government after the insured person's arrival date, and the insured person
unreasonably fails or refuses to depart the country or location. |
| Identity
Theft Assistance |
Up to
US$500 per Period of Coverage |
|
If an imposter obtains key personal information such as a Social Security
or Driver's License number, or other method of identifying an insured person in order to
impersonate or obtain credit, merchandise or services in the insured person’s name,
the Patriot plans will provide coverage for the reasonable, customary and necessary costs
incurred by the insured for: re-filing a loan or other credit application that is rejected
solely as a result of the stolen identity event; notarization of legal documents,
long-distance telephone calls, and postage that has resulted solely as a result of
reporting, amending and/or rectifying records as a result of the stolen identity event; up
to three credit reports obtained within one year of the insured person’s knowledge of
the stolen identity event; and stop payment orders placed on missing or unauthorized
checks as a result of the stolen identity event.
The identity theft event must occur during the Period of Coverage and must
be reported within 6 months of the termination of coverage date. |
|
This web page contains only a consolidated and summary description of all
current Patriot Travel Medical Insurance benefits, conditions, limitations and exclusions.
A certificate containing the complete Policy Wording with all terms, conditions and
exclusions will be included with the fulfillment kit. The Plan Administrator reserves the
right to issue the most current Policy Wording for this insurance plan in the event this
application and/or brochure has expired, is modified, or is replaced with a newer version.
Current Policy Wordings are available upon request. |
Exclusions:
Charges for the following services,
treatments and/or conditions are excluded from coverage under the Patriot plans.
Pre-existing Conditions. A
pre-existing condition is defined as any injury, illness, sickness, disease, or other
physical, medical, mental or nervous condition, disorder or ailment that existed at the
time of application or at any time during the three years prior to the effective date of
the insurance, whether or not previously manifested or symptomatic, diagnosed, treated, or
disclosed prior to the effective date, including any subsequent, chronic or recurring
complications or consequences related thereto or arising therefrom.
Treatment or surgeries which are
elective, investigational, experimental or for research purposes.
War, military action, terrorism,
political insurrection, protest, or any act thereof.
Immunizations and routine physical
exams.
Treatment of Temporomandibular Joint
or dental treatment, except as expressly provided for in the certificate of insurance.
Venereal disease, AIDS virus,
AIDS related illness, ARC Syndrome, or AIDS, and the cost of testing for these conditions, and charges for treatment or surgeries which are incurred by
any Insured who was HIV+ at time of enrollment into this insurance.
Pregnancy, childbirth, birth control,
artificial insemination, treatment for infertility or impotency, sterilization or reversal
thereof, or abortion.
Injury sustained while participating
in amateur or professional sports or other athletic activity which is organized and/or
sanctioned, or which involves regular or scheduled practices, games or competition. The
following hazardous activities are excluded: racing of any kind, aviation (except when
traveling as a passenger in a commercial aircraft), BMX, BASE jumping, bob sleigh, bungee
jumping, canyoning, caving, high diving, hang gliding, heli-skiing, hot air ballooning,
inline skating, jet skiing, kayaking, luge, motocross (moto-x), mountain biking,
mountaineering, parachuting, rappelling, rock climbing, rodeo, scuba diving, ski jumping,
sky diving, snow skiing, snowboarding, snowmobiling, spelunking, snorkeling, surfing,
wakeboarding, water skiing, windsurfing and whitewater rafting.
Vision or ear tests and the provision
of visual or hearing aids.
Vocational, recreational, speech or
music therapy.
Treatment while confined primarily to
receive custodial care, educational or rehabilitative care, or nursing services.
Charges, injuries and/or illnesses
resulting or arising from or occurring during the commission or continuing perpetration of
a violation of law by the insured, including without limitation, the engaging in an
illegal occupation or act, but excluding minor traffic violations.
Treatment for, and injuries and/or
illnesses resulting or arising from, substance abuse or drug addiction.
Injury and/or illness resulting or
arising from or sustained while under the influence of or disablement of drugs or alcohol.
Willfull self-inflicted injury or
illness.
Treatment required as a result of or
arising from complications from a treatment or condition not covered under the
certificate.
Any services or supplies performed
or provided by a relative of the Insured or provided at no cost to Insured.
Treatment for mental and nervous
disorders.
Organ or tissue transplants or
related services.
Illness or injury where the trip to
the host country is undertaken for treatment or advice for such Illness or injury, except
as expressly provided for in the certificate of insurance.
Treatment incurred as a result of
or arising from exposure to nuclear radiation, and/or radioactive material(s).
This information is only a
consolidated and summary description of all current Patriot Travel Medical InsuranceSM benefits, conditions, limitations and exclusions. A
certificate containing the complete Policy Wording with all terms, conditions and
exclusions will be included with the fulfillment kit.
PATRIOT AMERICA
RATES
for Non-U.S. Citizens
Displayed Rates are for $250 Deductible
Option (in USD)
Effective through 3/31/2008
|
| ANNUAL DEDUCTIBLE |
|
| POLICY LIMIT |
$50,000
|
$100,000
|
$500,000
|
$1,000,000
|
| AGE |
Monthly Rates |
| 18-29 |
$43.00 |
$50.00 |
$64.00 |
$76.00 |
| 30-39 |
$56.00 |
$67.00 |
$84.00 |
$97.00 |
| 40-49 |
$84.00 |
$96.00 |
$126.00 |
$142.00 |
| 50-59 |
$120.00 |
$147.00 |
$178.00 |
$206.00 |
| 60-64 |
$142.00 |
$174.00 |
$207.00 |
$248.00 |
| 65-69 |
$162.00 |
$208.00 |
$226.00 |
$270.00 |
| 70-79 |
$219.00 |
N/A |
N/A |
N/A |
| 80+* |
$381.00 |
N/A |
N/A |
N/A |
| DEP. CHILD |
$26.00 |
$28.00 |
$36.00 |
$39.00 |
| CHILD ALONE |
$39.00 |
$46.00 |
$59.00 |
$66.00 |
|
AGE |
Daily
Rates
(Minimum length of coverage is 5 days) |
| 18-29 |
$1.45 |
$1.75 |
$2.20 |
$2.55 |
| 30-39 |
$1.90 |
$2.25 |
$2.85 |
$3.25 |
| 40-49 |
$2.85 |
$3.25 |
$4.25 |
$4.80 |
| 50-59 |
$4.05 |
$4.95 |
$6.00 |
$6.90 |
| 60-64
|
$4.80 |
$5.85 |
$6.95 |
$8.35 |
| 65-69
|
$5.45 |
$7.00 |
$7.60 |
$9.05 |
| 70-79
|
$7.35 |
N/A |
N/A |
N/A |
| 80+*
|
$12.75 |
N/A |
N/A |
N/A |
| DEP.
CHILD |
$0.90 |
$1.00 |
$1.25 |
$1.35 |
| CHILD
ALONE |
$1.35 |
$1.60 |
$2.00 |
$2.25 |
Optional Leisure or Extreme
Sports Riders: Please contact
us at 877-211-3654 or
info@internationalriskmanagement.com for more
information.
*
US$10,000 Maximum
Rates include 2.5% surplus lines
tax. A dependent child is your child shown on the Enrollment Form
over 14 days and under 18 years of age, traveling with you, and for whom premium has been
paid. *See specific policy for age limit.
Benefit Period The Benefit Period is the period of time specified in the Policy Limits. It
begins once an eligible incident occurs to the insured. While coverage is in effect under
this policy, the Benefit Period does not apply. When coverage under this policy
terminates, as defined, Patriot Travel Medical InsuranceSM
will pay eligible expenses for covered Injuries or Illnesses which
commenced during the period of coverage for up to, but not exceeding the Benefit Period,
subject to the Policy Limits.
Refund
of Premium
Only if a written request is received prior to the policy's effective date. The premium is
non-refundable after that date.
This web page contains only a consolidated and
summary description of all current Patriot Travel Medical Insurance benefits, conditions,
limitations and exclusions. A certificate containing the complete Policy Wording with all
terms, conditions and exclusions will be included with the fulfillment kit. We reserve the
right to issue the most current Policy Wording for this insurance plan in the event this
application and/or brochure has expired, is modified, or is replaced with a newer version.
Current Policy Wordings are available upon request.
Click here to Apply Online
Back
to Brochure of Patriot Travel Medical Insurance
If you have any questions or concerns, please contact us
today.
info@internationalriskmanagement.com
877-211-3654 or
559-294-0316
|
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