Patriot International provides coverage for U.S. citizens traveling outside the U.S. for
a minimum of 5 days up to a maximum of two years. If the plan is purchased for a minimum of three months, coverage may be
renewed (without break in coverage) for a total of up to two years.
In addition to the benefits listed on pages 3 through 6, Patriot International for U.S. citizens also provides the two
benefits outlined below, subject to all Conditions of Coverage.
Sudden Recurrence of a Pre-existing Condition - Up to US$15,000 will be paid for the eligible expenses
of a sudden and unexpected recurrence of a Pre-existing Condition while traveling outside of the U.S. In addition, up to
US$25,000 will be paid for the eligible costs and expenses of an Emergency Medical Evacuation arising or resulting from
a sudden and unexpected recurrence of a Pre-Existing Condition. For the definition of a Pre-Existing Condition, please
see Exclusion number 1 on page 12 of the brochure.
Indemnity - Patriot International will pay directly to the insured person US$100 for each night of a required
overnight stay in a hospital. However, the hospital stay must be covered under this plan in order to receive this benefit.
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PATRIOT INTERNATIONALSM MONTHLY POLICY
PREMIUMS
|
|
50,000
MAX |
100,000
MAX |
500,000
MAX |
1,000,000
MAX |
2,000,000
MAX |
|
option 5 |
option 6 |
option 7 |
option 8 |
option 9 |
|
AGE
|
One Month |
One Month |
One Month |
One Month |
One Month |
|
18-29
|
$32.00
|
$37.00
|
$43.00
|
$48.00
|
$54.00
|
|
30-39
|
$37.00
|
$43.00
|
$57.00
|
$63.00
|
$72.00
|
|
40-49
|
$59.00
|
$66.00
|
$73.00
|
$81.00
|
$99.00
|
|
50-59
|
$96.00
|
$109.00
|
$122.00
|
$136.00
|
$153.00
|
|
60-64
|
$109.00
|
$129.00
|
$153.00
|
$180.00
|
$201.00
|
|
65-69
|
$129.00
|
$138.00
|
$158.00
|
$189.00
|
$243.00
|
|
70-79
|
$189.00
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80 PLUS*
|
$378.00
|
N/A
|
N/A
|
N/A
|
N/A
|
|
DEP CHILD
|
$18.00
|
$23.00
|
$27.00
|
$28.00
|
$34.00
|
|
CHILD ALONE
|
$32.00
|
$36.00
|
$41.00
|
$46.00
|
$52.00
|
|
*US$10,000 POLICY MAXIMUM
|
|
|
|
|
|
|
PATRIOT INTERNATIONALSM DAILY RATES
(MINIMUM COVERAGE IS 10 DAYS)
|
|
50,000
MAX |
100,000
MAX |
500,000
MAX |
1,000,000
MAX |
2,000,000
MAX |
|
option 5 |
option 6 |
option7 |
option 8 |
option 9 |
|
AGE
|
|
Daily |
Daily |
Daily |
Daily |
|
18-29
|
$1.15
|
$1.25
|
$1.45
|
$1.65
|
$1.85
|
|
30-39
|
$1.25
|
$1.45
|
$1.95
|
$2.15
|
$2.45
|
|
40-49
|
$2.00
|
$2.25
|
$2.45
|
$2.75
|
$3.35
|
|
50-59
|
$3.25
|
$3.65
|
$4.15
|
$4.60
|
$5.15
|
|
60-64
|
$3.65
|
$4.35
|
$5.15
|
$6.05
|
$6.75
|
|
65-69
|
$4.35
|
$4.65
|
$5.35
|
$6.35
|
$8.15
|
|
70-79
|
$6.35
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80 PLUS*
|
$12.65
|
N/A
|
N/A
|
N/A
|
N/A
|
|
DEP CHILD
|
$.65
|
$.80
|
$.95
|
$1.00
|
$1.20
|
|
CHILD ALONE
|
$1.15
|
$1.25
|
$1.40
|
$1.55
|
$1.80
|
|
*US$10,000 POLICY MAXIMUM
|
|
|
|
|
|
All premium rates are in US dollars and are effective through 10/31/2008. 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.
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 Insurance� 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
Your satisfaction is very important to the plan underwriter, and to IMG as the plan administrator. If, for any reason, you are not pleased
with this product, you may submit a written request for cancellation and refund of your premium. In order to be considered for a full refund,
your request for cancellation must be received by IMG prior to your effective date. If you do not have any claims filed with IMG, you may
cancel your plan after your effective date, however, the following conditions will apply: 1)you will be required to pay a US$25 cancellation
fee and 2)only full month premiums will be considered for refunds (e.g., if you choose to cancel your coverage for two months and two weeks
prior to the date your coverage ends, IMG will only consider the two full months for a refund). If you have filed claims, your premium is
non-refundable.
For Precertification, Emergency Evacuation and Repatriation
Please call IMG
in the U.S. 1.800.628.4664
Outside the U.S. 01.317.655.4500
(collect if necessary).
IMG must be notified prior to treatment or within 48 hours of an emergency.
To Report Claims
Please mail to IMG
International Medical Group, Inc.
Claims Department
P.O. Box 88500
Indianapolis, IN 46208-0500 U.S.A.
Please include Identification Number in all correspondence.
This brochure contains 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. In support of Patriot Travel Medical Insurance SM,
IMG has established the Global Medical Services Group Insurance Trust, in Indiana. The trust owns a master group international
travelers insurance policy. Individual certificates of insurance are issued from the master policy.
Underwritten by: Sirius International Insurance Corporation
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