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 SCHEDULE
OF BENEFITS | Lifetime
Medical Maximum | $5,000,000
per Insured Person. | | Policy
Period Deductible Options | $500, $1000,
$2500, $5000 Maximum of 3 deductible payments for families enrolling on one application.
Any eligible charges incurred and applied to your policy period deductible
in the last 30 days prior to your renewal date will carry over and be applied
to the next policy period deductible. | | Outside
of the United States | After the
Deductible, the Policy pays 100% of eligible expenses to the Policy Maximum.
Hospital Admissions must be Pre-Notified using SRI's Utilization Management
(U.M.) Program. | | Inside
of the United States | After
the Deductible, the Policy pays 80% of the next $5,000 of eligible expenses,
then 100% up to the Policy Maximum. Outpatient surgery, any expenses above
$1,000, and Hospital Admissions must be Pre-Certified using Sri's U.M. Program.
| | Hospital
Expenses | Average
Semi-Private room and board, Usual, Reasonable, and Customary Physician
Charges, Prescription Medications, Durable Medical Equipment, Nursing Services
and X-Rays up to the Policy Maximum. | | Intensive
Care | Intensive
Care room and board, Usual, Reasonable, and Customary Physician Charges,
Prescription Medications, Durable Medical Equipment, Nursing Services and
X-rays up to the Policy Maximum. | | Surgery | Usual,
Reasonable, and Customary Charges for Surgery, Physician and Anesthetics
up to the Policy Maximum. | | Outpatient
Treatment | Usual,
Reasonable, and Customary Charges for Emergency Treatment, Surgery, Prescription
Medication up to the Policy Maximum. | | Physiotherapy | Usual,
Reasonable, and Customary Charges up to the Policy Maximum, when referred
by a Physician. | | Medical
Supplies | Usual,
Reasonable, and Customary Charges up to Policy Maximum. | | Ambulance | Usual,
Reasonable, and Customary Charges up to Policy Maximum. | | Well
Child Care | Usual,
Reasonable, and Customary Charges up to Policy Maximum are Covered, limited
to 3 visits per Policy Period. | | Maternity | Usual,
Reasonable, and Customary Charges up to $7500 per Pregnancy, must be Pre-Notified
within the first 90 days of Pregnancy. | | Mental
& Nervous | Usual,
Reasonable, and Customary Charges up to a Maximum of $10,000 per Policy
Period. | | Dental | Usual,
Reasonable, and Customary Charges for repair and replacement of sound, natural
teeth damaged as a result of an accident, limited to $500 per Policy Period. | | Chiropractic | Usual,
Reasonable, and Customary Charges up to a $5,000 Lifetime Max. when referred
by a Physician. | | Emergency
Medical Evacuation | $50,000
Limit - when adequate medical facilities and/or treatment is not available.
(pre-approval required). | | Repatriation
of Remains | $20,000
Limit - when traveling outside your current Country of Residence. (Pre-approval
required). | | Emergency
Reunion | $10,000
Limit - when traveling outside your current Country of Residence. (Pre-approval
required). | | Preventive
Benefits | $50 Policy
Period Maximum for checkups and routine visits after 6 month waiting period. | | Accidental
Death & Dismemberment (AD&D) | Principal
Sum: $10,000 Insured and Spouse, $2,000 Dependent Children. For Common Carrier, Principal Sum: $40,000 Insured and Spouse, $8,000 Dependent
Children. | WHO NEEDS
THIS PLAN? US Citizens For US citizens relocating or spending an extended amount of time overseas,
security and flexibility are two essential ingredients of their medical program.
There are thousands of medical insurance programs offered throughout the world,
but there are just as many differences in the quality of both the programs and
the insurance companies offering them. As US citizens, we are accustomed to
a certain degree of stability. When choosing worldwide medical insurance, the
first and most important question to ask is "where is my insurance company
located?" The RESIDE Prime Worldwide Medical Plan is an approved program
underwritten by a US insurance company. Great care was taken to offer a program
that gives insured's the same level of security abroad that they experience
at home. Foreign Nationals A comprehensive plan providing protection in your home country as well as the
freedom to travel abroad is hard to find. Finding a program with these qualities
offered by a US insurance company is next to impossible. The RESIDE Prime Worldwide
Medical Plan combines the stability and financial strength of a US based insurance
company with the flexibility of a universal policy. In the United States, insurance
companies are strictly regulated and required to maintain a specified level
of financial strength. This supervision gives US insurance companies an added
level of security and a greater feeling of confidence with the general public,
which enhances the reputation of US insurance companies throughout the world. ELIGIBILITY All international
citizens are welcome to apply for RESIDE Prime as long as you have not yet reached
the age of 75 and meet the Eligibility Requirements listed on the application.
Dependents such as a spouse and children are also eligible for coverage. Dependent
children are considered natural or legally adopted unmarried children over 14
days old and under 19 years of age (or under 24 years of age if attending a
university full time and must rely on parents for support). APPLYING
FOR COVERAGE To apply, all
you need to do is complete the application in full and pay the appropriate premium,
given your age category and desired deductible amount. Be sure to answer all
sections and questions as completely, accurately, and as legible as possible.
The application you complete becomes part of your certificate of coverage should
you be accepted. Once the underwriters have had an opportunity to review the
application, SRI may request additional information from the applicant. If you
are accepted, you will receive and ID Card confirming your effective date and
conditions of acceptance, as well as a claim form and a certificate of coverage,
which describes the program in complete detail and describes how the insurance
can be utilized. If you are ultimately not accepted, SRI will return your premium
without delay. WORLDWIDE
COVERAGE RESIDE Prime
is designed to cover Insured Persons 24 hours a day, seven days a week, regardless
of where in the world they may be located. As an international citizen, you
will no longer need to purchase multiple insurance programs in order to have
seamless protection. Coverage in the United States is limited to 6 months during
any 12 month Policy Period. RENEWABILITY This coverage
is issued for twelve months, subject to receipt of premium payment when due.
The program is guaranteed renewable (at the then current renewal premium rate
for the age of the Insured Persons) and may not be terminated by the Company
unless the Company terminates an entire class of Insured Persons (persons of
the same age, location, etc.). MATERNITY RESIDE Prime
provides maternity and newborn child benefits to eligible Insured Persons, who
are the Primary Insured or Spouse, up to $7500 per pregnancy. A pregnancy must
be Pre-Notified during the first 90 days of the pregnancy. Failure to Pre-Notify
a pregnancy will result in a 100% reduction in eligible benefits. The plan does
not pay expenses related to a pregnancy within the first 12 months of coverage. INTERNATIONAL
TRAVELER'S COVERAGE When the Insured
Person travels outside of their home country, in addition to the standard benefit,
they will be covered for Repatriation of Mortal Remains and Emergency Reunion
coverage. PRE-EXISTING
CONDITIONS Some applicants
may have existing medical conditions (see Exclusion number 1). If the applicant
discloses a preexisting medical condition on the application and it is accepted
by the underwriters at SRI without an exclusionary rider or other restriction,
that condition will be covered as any other condition beginning on your effective
date. EXCLUSIONS The RESIDE
Prime Worldwide Medical Plan does not cover: - Any Injury or Illness
which meets the following criteria: 1.) A condition that would have caused
a person to seek medical advise, diagnosis, care or treatment prior to the
Effective Date of coverage under this Certificate; 2.) A condition for which
medical advise, diagnosis, care or treatment was recommended or received prior
to the Effective Date of coverage under this Certificate; 3.) Expenses for
Pregnancy within twelve (12) months of the Effective Date of coverage under
this Certificate. Preexisting Conditions that are disclosed on the application
and accepted by the Company shall be considered covered. Exclusionary Riders
may be issued by the Company for certain Preexisting Conditions.
- Injury or Illness which
is not presented to the Company for payment within ninety (90) days immediately
following the Incident.
- Charges for treatment
which is not Medically Necessary.
- Charges provided at no
cost to the Insured Person.
- Charges for treatment
which exceed Reasonable and Customary charges.
- Charges incurred for
Surgeries or treatments which are Investigational, Experimental, or for research
purposes.
- Services, supplies or
treatment, including any period of Hospital confinement, which were not recommended,
approved and certified as Medically Necessary and reasonable by a Physician.
- Suicide or any attempt
there at, while sane or self destruction or any attempt there at, while insane;
- 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.
- Injury sustained while
participating in professional, amateur, or interscholastic athletics;
- Routine physicals or
other examinations where there are no objective indications or impairment
in normal health, and laboratory diagnostic or x-ray examinations, except
in the course of a Disablement established by a prior call or attendance of
a Physician; or unless otherwise covered under this Certificate;
- Treatment of the Temporomandibular
joint.
- Vocational, Speech, Recreational
or Music Therapy.
- Services or supplies
performed or provided by a Relative of the Insured Person, or anyone who lives
with the Insured Person.
- Cosmetic or plastic Surgery,
except as the result of a covered Accident; for the purposes of this Insurance,
treatment of a deviated nasal septum shall be considered a cosmetic condition.
- Treatment and the provision
of false teeth or dentures, normal ear tests and the provision of hearing
aids;
- Eye refractions or eye
examinations for the purpose of prescribing corrective lenses for eye glasses
or for the fitting thereof, unless caused by Accidental bodily Injury incurred
while insured hereunder;
- Injury sustained while
under the influence of or Disablement due to 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 for a condition which is
covered hereunder, but not for the treatment of drug addiction.
- Telephone consultations
or failure to keep a scheduled appointment.
- Treatment while confined
primarily to receive Custodial Care, educational or rehabilitative care, or
nursing services.
- Congenital abnormalities
and conditions arising out of or resulting therefrom, unless otherwise covered
under this Certificate.
- Expenses which are non-medical
in nature.
- The cost of the Insured
Person's unused airline ticket for the transportation back to the Insured
Person's Home Country, where an Emergency Medical Evacuation or Repatriation
and/or Return of Mortal Remains benefit is provided.
- Expenses as a result
or in connection with intentionally self-inflicted Injury or Illness;
- Expenses as a result
or in connection with the commission of a felony offense;
- Injury sustained while
taking part in mountaineering where ropes or guides are normally used, hang
gliding, parachuting, bungee jumping, racing by horse, motor or motorcycle,
scuba diving, involving underwater breathing apparatus - unless PADI certified;
- Treatment paid for or
furnished under any other individual or group policy or other service or medical
pre-payment plan arranged through the employer to the extent so furnished
or paid, or under any mandatory government program or facility set up for
treatment without cost to any individual;
- Injuries for which benefits
are payable under any no-fault automobile insurance policy;
- Treatment of Venereal
disease, sexually transmitted disease, or expenses for a sex change;
- Dental care, except as
the result of Injury to sound, natural teeth caused by Accident;
- Routine Dental Treatment;
- Pregnancy expenses incurred
by a Dependent Child;
- Drug, treatment or procedure
that either promotes or prevents conception, or prevents childbirth, including
but not limited to: artificial insemination, treatment for infertility or
impotency, sterilization or reversal thereof, or abortion.
Exclusions
Regarding the AD&D benefit are listed in the Certificate of Insurance. This brochure
is only a brief description of RESIDE Prime. A complete description of the Master
Policy Provisions and Benefits is contained in the Certificate of Insurance,
which will be mailed to you once your application and premium have been received
and approved by SRI. PRE-NOTIFICATION
AND SRI'S UTILIZATION MANAGEMENT PROGRAM (U.M. PROGRAM) So that you
receive the best care possible, RESIDE Prime requires that the Insured Person
(or someone on the Insured Person's behalf) contact SRI Assist for notification
prior to all hospital admissions worldwide and any medical expenses above $1,000
that will be incurred within the United States. The methods of contacting SRI
Assist will appear on the back of your ID Card. SRI Assist will also be able
to assist you in locating the approval SRI medical care providers in the United
States for care prior to, during, and subsequent to hospital confinements. If
the U.M. Program is not followed, there will be a 50% reduction in eligible
benefits. THE
ADMINISTRATOR Since 1993,
Specialty Risk International, Inc. (SRI) has provided international insurance
plans to private citizens, governments, missionaries, students, and corporations
of various nations around the globe. As a premier underwriter, SRI has had the
opportunity to provide innovative solutions to unique and challenging situations. Our claims
professionals are experienced in the complexity of processing international
medical expenses. As an insured of SRI, you can feel confident that there is
someone ready to assist you with a medical situation 24 hours a day, 365 days
a year. Other services
including proficient administration, responsive underwriting, and access to
secure and stable insurance carriers and medical care providers worldwide. THE
INSURANCE COMPANY RESIDE Prime
is underwritten by The Mega Life & Health Insurance Company, rated A- "Excellent"
by AM Best.
Annual Premiums Effective January 1,
2001 (formerly Signature Worldwide
Medical Plan)
| If
you choose a $500 Annual Deductible | If
you choose a $1000 Annual Deductible | If
you choose a $2500 Annual Deductible | If
you choose a $5000 Annual Deductible | | Age | Male | Female | Male | Female | Male | Female | Male | Female | | 14 days
through 18 | $510 | $510 | $420 | $420 | $391 | $391 | $368 | $368 | | 19 through
29 | $1,002 | $1,746 | $778 | $1,351 | $679 | $1,179 | $533 | $920 | | 30 through
39 | $1,164 | $2,086 | $902 | $1,612 | $789 | $1,407 | $618 | $1,098 | | 40 through
44 | $1,334 | $1,675 | $1,033 | $1,296 | $902 | $1,131 | $740 | $941 | | 45 through
49 | $1,470 | $1,838 | $1,138 | $1,421 | $993 | $1,240 | $810 | $978 | | 50 through
54 | $1,801 | $2,011 | $1,392 | $1,560 | $1,215 | $1,389 | $1,030 | $1,152 | | 55 through
59 | $2,210 | $2,210 | $1,710 | $1,708 | $1,490 | $1,490 | $1,255 | $1,267 | | 60 through
64 | $3,025 | $2,830 | $2,550 | $2,251 | $2,310 | $2,072 | $1,930 | $1,715 | | 65 through
69 | $6,521 | $5,653 | $6,100 | $5,149 | $4,690 | $3,827 | $4,100 | $3,672 | | 70 | $7,805 | $6,674 | $7,200 | $6,158 | $5,700 | $4,660 | $4,503 | $3,738 | | 71 | $8,150 | $6,988 | $7,604 | $6,473 | $6,007 | $4,869 | $4,805 | $3,895 | | 72 | $8,535 | $7,327 | $8,034 | $6,853 | $6,342 | $5,147 | $5,073 | $4,119 | | 73 | $8,972 | $7,681 | $8,432 | $7,186 | $6,667 | $5,438 | $5,330 | $4,365 | | 74 | $9,385 | $8,081 | $8,875 | $7,559 | $7,022 | $5,724 | $5,623 | $4,575 | | Dependent
Child* | $410 | $410 | $321 | $321 | $281 | $281 | $258 | $258 | | * The
Dependent Child Premium is only available when one parent (legal guardian),
of a natural or legally adopted unmarried child over 14 days old and under
19 years of age (or under 24 years of age if attending a university full-time
and must rely on parents for support), is also covered under the same program.
No premium is charged for the first two (2) Dependent Children between
the ages of 14 days and 9 years old if both parents are also covered under
the same program. | | If the
Applicant desires to pay premiums on a Semi-Annual, Quarterly or Monthly
basis, they must do so by Visa or Master Card payment only. SRI will automatically
debit the credit card on the due date of the premium installment. The Premium
Installment Factors to be applied to the Annual Premium are as follows:
Annual = 1.00 Semi-Annual = .55 Quarterly = .28 Monthly = .10 | | IMPORTANT NOTICE:
The premiums referenced above are applicable for the initial 12 month
coverage period, only after the Applicant has been accepted by SRI. SRI
reserves the right to increase the stated premiums based upon the Applicant's
medical condition at the time of application and underwriting. Applicants
with chronic and/or severe medical conditions may be declined. At each
renewal period, SRI will inform the Applicant of the renewal premium for
each subsequent coverage period based upon the Applicant's age and deductible
category. |
Copyright 2001 Specialty Risk International, Inc.
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