|CHUBB Premier Plan Enrollment||Premier Plan with Pre-Existing Benefits Brochure - PDF View||Periods Of Coverage & Premium Rates||Exclusions|
|Schedule Of Benefits: In-Patient, Out-Patient, Other, Pre-Existing||Claims Procedure|
|Program Eligibility||Assistance Services (Insured Members Only)|
|Insurance Enrollment||Other Policy Features|
|Coverage||Medical Evacuation And Repatriation|
|Continuous Coverage||Accidental Death Dismemberment|
When a covered Injury or Sickness requires treatment by a Doctor, this Policy will provide benefits while coverage is in force for the Usual and Customary charges incurred which exceed the deductible per person for each Injury or Sickness. Payment for any covered service will be no more than the Benefit Limit shown for it.
Standard and Premier Coverage Plans: Policy holders can choose ANY provider and there is no network linked to these policies.
SCHEDULE OF BENEFITS IN-PATIENT, OUT-PATIENT, AND OTHER
PRE-EXISTING CONDITIONS COVERAGE
This feature of the India Network Foundation’s Accident and Sickness Insurance Program provides coverage for Pre-Existing Conditions, defined as an illness, disease, or other condition of the Covered Person that in the 12 month period before the Covered Person’s coverage became effective under the Policy: (1) first manifested itself, worsened, became acute, or exhibited symptoms that would have caused a person to seek diagnosis, care, or treatment; or (2) required taking prescribed drugs or medicines, unless the condition for which the prescribed drug or medicine is taken remains controlled without any change in the required prescription; or (3) was treated by a Doctor or treatment had been recommended by a Doctor.
Pre-Existing Conditions coverage is subject to a Maximum Benefit as given below with a Deductible of $1,000/$5,000 (Age 69 & under). Coverage of Only $100,000 is available for Ages 70-99.
MEDICAL EXPENSE BENEFITS
The Plan will pay Medical Expense Benefits for Covered Expenses that result directly, and from no other cause, from a Covered Accident or Sickness. These benefits are subject to a Deductible of $75/$250 (69 and under age group) per person for each Injury and each Sickness. Medical Expense Benefits are only payable: (1) for Usual and Customary Charges incurred after the Deductible, if any, has been met; (2) for those Medically Necessary Covered Expenses that the Covered Person incurs; (3). for charges incurred for services rendered to the Covered Person while on a covered Trip; and (4) provided the first charge is incurred within 90 days of the Covered Accident or Sickness. Payment for Covered Expenses will not exceed the benefit limits shown below. The total amount payable under the policy for you and your Dependents (if you have elected Dependent coverage and paid the required premium) will not exceed the Policy Maximums shown below.
This is a Fixed benefit plan and it is put the providers to bill insurance directly. However, Insured can file a claim for reimbursement after they settle the bill with providers.
|COVERED SERVICES||$100,000 Policy Coverage||$150,000 Policy Coverage|
|Hospital Room (average semi-private) and Board and Miscellaneous||Up to $1,750 a day maximum, to 30 days||Up to $1,900 a day maximum, to 30 days|
|Hospital Intensive Care Unit||Up to $750 maximum additional a day, to 8 days||Up to $850 maximum additional a day, to 8 days|
|Surgeon||Up to $5,000 maximum||Up to $6,000 maximum|
|Anesthetist||Up to $1,250 maximum||Up to $1,500 maximum|
|Up to $1,250 maximum||Up to $1,500 maximum|
|Doctor’s Non-Surgical Visits||Up to $100 maximum a visit, 1 visit a day, to 30 visits||Up to $125 maximum a visit, 1 visit a day, to 30 visits|
|Consultant Doctor, when requested by attending Doctor||Up to $450 maximum||Up to $500 maximum|
|Pre-Admission Tests within 14 days before hospital admission||Up to $1,100 maximum||Up to $1,200 maximum|
|COVERED SERVICES||$100,000 Policy Coverage||$150,000 Policy Coverage|
|Surgical Room and Supply Expenses:||Up to $1,100 maximum||Up to $1,200 maximum|
|Surgeon:||Up to $5,000 maximum||Up to $6,000 maximum|
|Anesthetist:||Up to $1,250 maximum||Up to $1,500 maximum|
|Assistant Surgeon:||Up to $1,250 maximum||Up to $1,500 maximum|
|Doctor’s Non-Surgical Visits:||Up to $100 a visit maximum, 1 visit a day, to 10 visits||Up to $125 a visit maximum, 1 visit a day, to 10 visits|
|Diagnostic X-rays and Lab Services:||Up to $650 maximum||Up to $750 maximum|
|CAT Scan, PET Scan or MRI:||Up to $650 additional||Up to $1,000 additional|
|Hospital Emergency Room:||Up to $500||Up to $750|
|Prescription Drugs:||Up to $150 maximum||Up to $200 maximum|
|COVERED SERVICES||$100,000 Policy Coverage||$150,000 Policy Coverage|
|Ambulance Services:||Up to $450 maximum||Up to $500 maximum|
|Rehabilitative Braces or Appliances||Up to $1,100 maximum||Up to $1,200 maximum|
|Dental Treatment injury to sound, natural teeth- due to accident||Up to $500 maximum. There are no benefits for dental services for immediate relief of pain.||Up to $550. There are no benefits for dental services for immediate relief of pain.|
|Chemotherapy and/or Radiation Therapy:||Up to $1,150 maximum||Up to $1,250 maximum|
|Physical and Occupational Therapy:||Up to $45 a visit max, 1 visit a day to 12 visits||Up to $50 a visit max, 1 Visit a day to 12 visits|
|Private Duty Nurse||Up to $500 maximum||Up to $550 maximum|
|Pregnancy and Childbirth (conception must occur after the Trip begins)||Up to $5,000 maximum||Up to $5,500 maximum|
|Medical Evacuation*||$20,000 maximum||$25,000 maximum|
|Repatriation of Remains*||$15,000 maximum||$20,000 maximum|
|Intercollegiate Sports||No Benefits||No Benefits|
|Pre-existing Conditions Coverage||Options for Members Age 69 & Under:
$20,000 Benefit with $1,000 Deductible
$40,000 Benefit with $5,000 Deductible
Options for Members Age 70-99:
Options for Members Age 69 & Under*:
PERIODS OF COVERAGE & PREMIUM RATES
Premium Rates in all tables are per month (30 days coverage) and any single days premium is prorated based on 30 day monthly premium.
Enrollment is subject to the following rules:
- You must enroll and pay premium for at least 90 days of coverage
- You may enroll for up to 12 consecutive months and pay the required premium at the time of enrollment
- You must pay the full premium for the requested months at the time of enrollment
A $5 service fee will be charged for each enrollment and is non-refundable even if insurance is canceled. If you are on a Trip and wish to extend your coverage you may enroll for an additional period subject to a minimum period of one day and an overall maximum period of 12 months.
You are eligible to elect this insurance is you are an active member of the India Network Foundation visiting the USA, Canada or Mexico. You may elect coverage for your Eligible Dependents traveling with you.
Eligible Dependents are any of the following persons: the insured member's legal spouse, and their unmarried dependent children under 19 years of age (19 years and older if a child is incapable of self-sustaining employment due to physical or mental handicap).
If adoption, birth or marriage occurs while the insured member is covered under this insurance, the insured member will have 31 days within which to enroll a newly eligible dependent and pay the required premium for coverage to continue for the remainder of the period of coverage.
To enroll in the India Network Accident & Sickness Insurance Program, you may enroll online or download the forms and send the completed forms to India Network Services. You must be a Member to purchase insurance. Please enroll online.
India Network Services
7065 Westpointe Blvd, Suite 209
Orlando, FL 32835-8758
Processing of an insurance enrollment may take up to 2 working days; when processing is complete, if you enroll for a coverage term of 1 month or more, India Network Services will mail an insurance ID card and brochure to the USA address shown on the member’s enrollment.
NOTE: For coverage of less than one month, please print the brochure and keep the ID card generated after online submission form as proof of coverage.
Coverage for a member and any eligible dependents who enroll in this program will begin at 12:01 a.m. on the latest of the following dates, whichever is applicable:
Insured’s Effective Date: Insurance under this Policy shall become effective on the latest of the following dates:
Dependent's Effective Date:
Insurance under this Policy shall become effective on the latest of the following dates:
Insured’s Termination Date:
The coverage provided with respect to the insured member shall terminate on the latest of the following dates:
Dependent’s Termination Date:
The coverage provided with respect to the insured member’s covered Dependents shall terminate on the latest of the following dates:
Termination of Coverage will not affect a claim for a covered loss that occurred while the insured member’s coverage was in force under this policy.
This coverage will not duplicate benefits available from other valid and collectible insurance. If a covered person’s Injury or Sickness is due to an act or omission of another, benefits payable by this program are subject to recovery from amounts paid to, or on behalf of, the covered person.
Coverage for a Covered Person will be considered continuous during consecutive periods of coverage for up to 12 months if the required premium is received by India Network Services prior to any subsequent period of coverage purchased for a Covered Person.
The continuation of coverage will not establish a new benefit period, nor affect maximum benefits or benefit periods for a loss incurred during any preceding coverage period
“Country of Permanent Assignment” means a country, other than your Home Country, in which the Policyholder requires you to work for a period of time that exceeds 364 continuous days.
“Country of Permanent Residence” means a country or location in which you maintain a primary permanent residence.
“Covered Accident” means an accident that occurs while coverage is in force for a Covered Person and results directly of all other causes in a loss or Injury covered by the Policy for which benefits are payable.
“Covered Expenses” means expenses actually incurred by or on behalf of a Covered Person for treatment, services and supplies covered by the Policy. Coverage under the Policyholder’s Policy must remain continuously in force from the date of the Covered Accident or Sickness until the date treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date such treatment, service or supply, that gave rise to the expense or the charge, was rendered or obtained.
“Covered Person” means any eligible person for whom the required premium is paid.
“Deductible” means the dollar amount of Covered Expenses that must be incurred as an out-of-pocket expense by each Covered Person per Covered Accident or Sickness basis before Medical Expense Benefits and/or other Additional Benefits paid on an expense incurred basis are payable under the Policy.
“Dependent” means an Insured’s lawful spouse or an Insured’s unmarried child, from the moment of birth to age 19, 25 if a full-time student, who is chiefly dependent on the Insured for support. A child, for eligibility purposes, includes an Insured’s natural child; adopted child, beginning with any waiting period pending finalization of the child’s adoption; or a stepchild who resides with the Insured or depends on the Insured for financial support. A Dependent may also include any person related to the Insured by blood or marriage and for whom the Insured is allowed a deduction under the Internal Revenue Code.
Insurance will continue for any Dependent child who reaches the age limit and continues to meet the following conditions: 1) the child is handicapped, 2) is not capable of self-support and 3) depends mainly on the Insured for support and maintenance. The Insured must send Us satisfactory proof that the child meets these conditions, when requested. We will not ask for proof more than once a year.
“Doctor” means a licensed health care provider acting within the scope of his or her license and rendering care or treatment to a Covered Person that is appropriate for the conditions and locality. It will not include a Covered Person or a member of the Covered Person’s Immediate Family or household.
“Home Country” means a country from which you hold a passport. If you hold passports from more than one Country, your Home Country will be the country that you have declared to Us in writing as your Home Country. Home Country also includes your Country of Permanent Assignment or Country of Permanent Residence.
“Hospital” means an institution that: 1) operates as a Hospital pursuant to law for the care, treatment, and providing of inpatient services for sick or injured persons; 2) provides 24-hour nursing service by Registered Nurses on duty or call; 3) has a staff of one or more licensed Doctors available at all times; 4) provides organized facilities for diagnosis, treatment, and surgery, either: (i) on its premises; or (ii) in facilities available to it, on a prearranged basis; 5) is not primarily a nursing care facility, rest home, convalescent home, or similar establishment, or any separate ward, wing, or section of a Hospital used as such; and 6) is not a place for drug addicts, alcoholics, or the aged.
“Injury” means accidental bodily harm sustained by a Covered Person that results, directly and independently from all other causes, from a Covered Accident. All injuries sustained by one person in any one Covered Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury.
“Insured” means a person in a Class of Eligible Persons for whom the required premium is paid making insurance in effect for that person.
“Medical Emergency” means a condition caused by an Injury or Sickness that manifests itself by symptoms of sufficient severity that a prudent lay person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy.
“Medically Necessary” means a treatment, service, or supply that is: 1) required to treat an Injury or Sickness; 2) prescribed or ordered by a Doctor or furnished by a Hospital; 3) performed in the least costly setting required by the Covered Person’s condition; and 4) consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered. Purchasing or renting 1) air conditioners; 2) air purifiers; 3) motorized transportation equipment; 4) escalators or elevators in private homes; 5) eyeglass frames or lenses; 6) hearing aids; 7) swimming pools or supplies for them; and 8) general exercise equipment are not Medically Necessary. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may consider the cost of the alternative to be the Covered Expense.
“Preexisting Condition” means an illness, disease, or other condition of the Covered Person that in the 12 month period before the Covered Person’s coverage became effective under the Policy:
“Sickness” means an illness, disease or condition that causes a loss for which you incur medical expenses while covered under the Policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.
“Trip” means travel by air, land, or sea from your Home Country. It includes the period of time from the start of the trip until its end provided you are engaged in a Covered Activity or Personal Deviation if covered under the Policy.
“Usual and Customary Charge” means the average amount charged by most providers for treatment, service, or supplies in the geographic area where the treatment, service, or supply is provided.
“We, Our, Us” means the insurance company underwriting this insurance or its authorized agent.
We will not pay benefits for any loss or Injury that is caused by or results from:
In addition, We will not pay Medical Expense Benefits for any loss, treatment, or services resulting from:
Report at once to the nearest physician or hospital. Claims may be submitted to the Claims Administrator (Administrative Concepts Inc.) by the provider of service directly or by you, using the claim forms found under the “Print/Fax Forms” section of the Members Area. All claims must be submitted using the applicable claim form, which can be found online or requested from the Claims Administrator.
Completed claim forms must be furnished to Administrative Concepts, Inc. within 90 days after the date of such loss. Failure to furnish such proof within the time required will not invalidate or reduce any claim if it was not reasonably possible to furnish proof.
Administrative Concepts, Inc., 994 Old Eagle School Rd., S. 1005, Wayne, PA 19087-1706. Toll Free: 1-888-293-9229 (from inside the U.S.), Phone: 610-293-9229 (from outside the U.S.), Fax: 610-293-9299 for claims or inquiries or e-mail www.visit-aci.com
Should you to check upon the status of your filed claim, or claims related questions you may call the claims office at the above number during business hours 7 AM to 7 PM (CST).
Should you have questions regarding your brochure or insurance program, please contact India Network Services. They can be reached by phone at 408-540-3600, from 9:00 AM to 6:00 PM (EST) during week days, Monday through Friday.
AXA ASSISTANCE SERVICES (AVAILABLE FOR INSURED MEMBERS ONLY)
AXA Travel Assistance Services at 855-327-1414 for 24-hour access to the following services:
You will receive a Travel Assistance ID card that will provide you with emergency call numbers and information on how to access CHUBB’s Travel Assistance Web Portal.
This information provides you with a brief outline of the services available to you. These services are subject to the terms and conditions of the Policy under which you are insured. Travel assistance services are not available if your coverage under the Policy providing insurance benefits is not in effect.
OTHER POLICY FEATURES
Accidental Death and Dismemberment**
Type of Coverage
EMERGENCY MEDICAL EVACUATION AND REPATRIATION OF REMAINS BENEFITS*
Emergency Medical Evacuation Benefit - We will pay up to the maximum indicated above in the Schedule of Benefits for your medical evacuation if you: 1) suffer a Medical Emergency during the course of the Trip; 2) require Emergency Medical Evacuation; and 3) are traveling on a covered Trip.
Covered Expenses include;
Benefits for these Covered Expenses will not be payable unless: 1) the Doctor ordering the Emergency Medical Evacuation certifies the severity of your Medical Emergency requires an Emergency Medical Evacuation; 2) all transportation arrangements made for the Emergency Medical Evacuation are by the most direct and economical conveyance and route possible; 3) the charges incurred are Medically Necessary and do not exceed the Usual and Customary Charges for similar transportation, treatment, services or supplies in the locality where the expense is incurred; and 4) do not include charges that would not have been made if there were no insurance.
Benefits will not be payable unless We authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our assistance provider. In the event you refuse to be medically evacuated, we will not be liable for any medical expenses incurred after the date medical evacuation is recommended.
Repatriation of Remains Benefit - We will pay up to the maximum indicated above in the Schedule of Benefits for the preparation and return of your body to your home if you die as a result of a Medical Emergency while traveling on a covered Trip.
Covered expenses include: 1) expenses for embalming or cremation; 2) the least costly coffin or receptacle adequate for transporting the remains; 3) transporting the remains; and 4) Escort Services which include expenses for an Immediate Family Member or companion who is traveling with you to join your body during the repatriation to your place of residence.
All transportation arrangements must be made by the most direct and economical route and conveyance possible and may not exceed the Usual and Customary Charges for similar transportation in the locality where the expense is incurred. Benefits will not be payable unless We authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our assistance provider
ACCIDENTAL DEATH DISMEMBERMENT of $25,000**
ACCIDENTAL DEATH AND DISMEMBERMENT INDEMNITY
Definition of Injury and Scope of Coverage – 24 Hour Coverage
Principal sum for Covered Injury: $25,000
Accidental Death and Dismemberment Benefits - If your Injury results, within 365 days from the date of a Covered Accident, in any one of the losses shown below, We will pay the Benefit Amount shown below for that loss. Principal Sum for you and your Dependents (if you have elected Dependent coverage and the required premium has been paid) is $25,000. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Covered Accident.
Schedule of Covered Losses
Covered Loss Benefit Amount
Life......................................... 100% of the Principal Sum
Two or more Members...................................... 100% of the Principal Sum
One Member................................... 50% of the Principal Sum
“Member” means Loss of Hand or Foot, and Loss of Sight. “Loss of Hand or Foot” means complete Severance through or above the wrist or ankle joint. “Loss of Sight” means the total, permanent Loss of Sight of one eye. “Severance” means the complete separation and dismemberment of the part from the body.
Aggregate Limit - We will not pay more than $125,000 for all losses. If, in the absence of this provision, We would pay more than this amount for all losses under the policy, then the benefits payable to each person with a valid claim will be reduced proportionately.
Refund of premium, less a $25 processing fee, will be considered only if Cancellation Form is received by the India Network Services prior to the effective date of coverage. After that date, the premium is considered fully earned and non-refundable. All cancellation requests should be submitted by completing the Cancellation Form found under 'Members Area' section of the web pages. The form can be faxed to 408-520-4967. Policy changes can not be made under any circumstances once the policy becomes effective.
INDIA NETWORK ACCIDENT AND SICKNESS MEDICAL INSURANCE PROGRAM
This Description of Coverage is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the Policy issued to the Policyholder on Form # AH-15090. The Policy is subject to the laws of the state in which it is issued. Coverage may not be available in all states or certain terms or conditions may be different if required by state law. Please keep this information as a reference.
Insurance policies providing certain health insurance coverage issued or renewed on or after September 23, 2010 are required to comply with all applicable requirements of the Patient Protection and Affordable Care Act ("PPAC"?). However, there are a number of insurance coverages that are specifically exempt from the requirements of PPACA (See §2791 of the Public Health Services Act). CHUBB maintains this insurance is short-term, limited duration insurance and is not subject to PPACA.