AXIS Plan with pre-existing conditions coverage | Accident and Sickness Visitor Insurance | India Network Health Insurance, USA

AXIS Plan with pre-existing conditions coverage $25K/$50K/$75K/$100K/$150K/$250K Program*

* Pre-existing limited to Acute Onset coverage.

Insurance Plan Enrollment Plan Brochure in PDF PDF View AXIS Insurance Plan Brochure

Insurance Eligibility Insurance Enrollment
Plan Benefits Teladoc Program
Definitions Exclusions
Assistance Services Claims Procedure
Medical Evacuation And Repatriation Accidental Death Dismemberment
Cancellation Policy First Health PPO

Important Notice: This information provides 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 in the state in which the policy was delivered under form number BACC-001-0909-PA. Complete details may be found in the policy on file with the Policyholder. The policy is subject to the laws of the state in which it was issued. Please keep this information as a reference.

INSURANCE ELIGIBILITY

All non-US citizens and their eligible dependents Child(ren) or Spouse (if coverage has been elected), while visiting the United States. Eligible dependents Child means the insured Member's unmarried child who meets the following requirements: 1) a child from birth to 17 years old; 2) a child who is 17 or more years old but less than 30 years old, enrolled in school as a full-time student and primarily supported by the Insured Person. Coverage will continue during and period between school terms or school years as long as the Company is provided satisfactory proof that he or she has enrolled for the next following school term or year; or 3) a child who is 17 or more years old, primarily supported by the Insured Person, and incapable of self-sustaining employment by reason of mental or physical handicap. For purposes of this definition, a Dependent Child includes: a natural child; an adopted child, beginning with any waiting period pending finalization of the child's adoption; a stepchild that resides with the Insured Person; and a child for whom the Insured Person is the legal guardian, as long as the child resides with the Insured Person and depends on him for financial support. Spouse means the Insured Person's lawful spouse.

Members may enroll for coverage, subject to the following rules: Minimum Period of Enrollment is 30 days. The maximum period is 300 days. The full premium for the entire stay in the US is payable at the time of enrollment.

Coverage for an Insured Person will be considered as continuous during consecutive periods of insurance under this Policy when premium payment is received by the administrator on or before the termination of the last coverage period. This continuation of coverage will not establish a new benefit period, nor affect any lifetime or specifically stipulated benefit limits or maximums under the Policy.

HOW TO ENROLL FOR COVERAGE

Enrollment into this program can be done as follows:
Visit Online Forms at http://www.kvrao.org/onlineEnroll.php and follow step-by-step instructions; or
Visit the Members Area to print out forms at http://www.kvrao.org  or http://health.indianetwork.org and select “Insurance Application for Print and Faxing Printable Forms”.


On successful completion of online application, ID cards will be produced on the web page for your record and as proof of insurance.

Membership and AXIS Plan with pre-existing conditions coverage Insurance forms can also be downloaded from our websites and faxed to (800)-490-9678 with proper credit card authorization for membership and premium. The India Network Services will mail the insurance card and Benefit Information to the member's temporary address in the U.S. for coverage of two months or more. For duration of less than 2 months, India Network Services will email the insurance card and Benefit Information to the member's email provided during the enrollment.

EFFECTIVE AND TERMINATION DATES OF INSURANCE

The India Network Foundation Group Policy Effective date is 12/1/2017.

Coverage of Insured Person and any eligible Dependent Child(ren) or Spouse enrolled in this plan will begin at 12:01 AM on the latest of the following dates: the Policy's Effective Date; the departure date from the Insured Person's Home Country; or the date that India Network Services receives the insurance enrollment form and the required premium.

The Company will pay benefits while an Insured Person is traveling:
1. Outside of his or her Home Country in the United States or during a Personal Deviation as listed in the Policy; and 2. up to 300 days.

This Coverage will start on the actual start of the Covered Trip and will end on the first of the following dates to occur: the date the Insured Person returns to his or her Home Country; the date the Insured Person makes a Personal Deviation for more than 2 days; the date the Insured Person is no longer eligible; or the last day of the period for which the required premium is paid. Coverage of an Insured Person's Dependent Child(ren) or Spouse will end when the Insured Person's coverage ends.

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DEFINITIONS
Accident or Accidental means a sudden, unexpected, specific and abrupt event that occurs by chance at an identifiable time and place while the Insured Person is covered under the Policy.

Covered Accident means an Accident that results in a Covered Loss during the Policy Term.

Covered Injury means Accidental bodily injury: (1) which is sustained by an Insured Person as a direct result of an unintended, unanticipated Covered Accident that is external to the body and that occurs while the injured person's coverage under the  Policy is in force, and (2) which results directly and independently from all other causes from a Covered Accident and (3) which occurs while such person is participating in a Covered Activity. The Covered Injury must be caused through Accidental means. All injuries sustained by an Insured Person in any one Covered Accident, including related conditions and recurrent symptoms of these injuries, are considered a single injury.

Covered Loss means a loss which meets the requisites of one or more benefits and results from a Covered Accident, Covered Injury or Covered Activity.

Covered Expenses means expenses actually incurred by or on behalf of an Insured Person for treatment, services and supplies covered by this Policy. Coverage under the Policyholders. Policy must remain continually in force from the date of the Covered Accident or Sickness until the date of treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date treatment, service or supply that gave rise to the expense or the charge, was rendered or obtained.

Covered Trip means travel by air, land or sea from the Insured Person's Home Country.

Deductible means the amount that must be paid for Covered Medical Services by the Insured Person before benefits will become payable. A separate deductible shall apply to each Covered Loss.

Eligible Person means an individual as defined in the Policy Schedule of Benefits.

Emergency Sickness means an illness or disease diagnosed by a Physician which: 1. causes a severe or acute symptom that, if not provided with immediate treatment, would reasonably be expected to result in serious deterioration of the Insured Person's health or place his or her life in jeopardy; and 2. first manifests itself suddenly and unexpectedly while the Insured Person is covered.

Home Country means a country from which the Insured Person holds a passport or where the Insured Person has primary residency. If the Insured Person holds passports from more than one Country, his or her Home Country will be the country that he or she has declared to the Company in writing as his or her Home Country.

Hospital means a facility that: 1. is operated according to law for the care and treatment of injured people; 2. has organized facilities for diagnosis and surgery on its premises or in facilities available to it on a prearranged basis; 3. has 24 hour nursing service; and 4. is supervised by one or more Physicians.
A Hospital does not include: a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care; a facility that is, other than incidentally, a rest home, nursing home, convalescent home or home for the aged; nor does it include any ward, room, wing, or other section of the hospital that is used for such purposes; or any military or veterans hospital or soldiers home or any hospital contracted for or operated by any national government or government agency for the treatment of members or ex-members of the armed forces.

Insured Person means an Eligible Person, as defined in the Policy Schedule of Benefits, for whom required premium has been paid when due and for whom coverage under the Policy remains in force.

Medically Necessary means medical services that: (1) are essential for diagnosis, treatment or care of the Covered Injury or Covered Accident or Emergency Sickness for which it is prescribed or performed; (2) meets generally accepted standards of medical practice; and (3) are ordered by a Physician and performed under His care, supervision or order.

Other Health Care Plan means any arrangement, whether individually purchased or incident to employment or membership in an association or other group, which provides benefits or services for health care, dental care disability benefits or repatriations of remains. An Other Health Care Plan includes group, blanket, franchise, family or individual: 1. insurance policies; 2. subscriber contracts; 3. uninsured agreements or arrangements; 4. coverage provided through Health Maintenance Organizations, Preferred Providers Organizations and other prepayment, group practices and individual practice plans; 5. medical benefits provided under automobile fault and no-fault type contracts; 6. medical benefits provided by any governmental plan or coverage or other benefit law, except: a. a state sponsored Medicaid plan; or b. a plan or law providing benefits only in excess of any private or nongovernmental plan.

Physician means a licensed health care provider practicing within the scope of his license and rendering care and treatment to the Insured Person that is appropriate for the condition and locality, and who is not: 1. the Insured Person; 2. an Immediate Family Member of either the Insured Person or the Insured Person's Spouse; 3. a person living in the Insured Person's household; or 4. a person providing homeopathic, aroma-therapeutic, or herbal therapeutic services.

Personal Deviation means 1. an activity that is not reasonably related to the Insured Persons Covered Activity; 2 such travel or activities coincide with the Insured Persons Covered Activity; and 3. Personal Deviation is limited to any consecutive 2 day period immediately prior to, during or following such Covered Activity.

Pre-Existing Condition means an illness, disease, injury or other condition of the Insured Person that in the 3 month period before the Insured Person's coverage became effective under the Policy: 1. was treated by a Physician or treatment had been recommended by a Physician; 2. required taking prescribed drugs or medicines, or 3. first manifested itself, worsened, became acute or exhibited symptoms that would have caused an ordinarily prudent person to seek diagnosis.

Sickness means disease or illness, including related conditions and recurrent symptoms, which begin after the effective date of an Insured Person's coverage and while coverage is in force.

Usual and Customary Charge (s) - 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.

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EXCLUSIONS AND LIMITATIONS

We will not pay benefits for any loss or Injury that is caused by or results from:

  • Intentionally self-inflicted injury, suicide, or any attempt while sane or insane.
  • Commission or attempt to commit a felony or an assault.
  • Commission of or active participation in a riot or insurrection.
  • Declared or undeclared war or act of war or any act of declared or undeclared war unless specifically provided by this Policy.
  • Flight in, boarding or alighting from, an Aircraft or any craft designed to fly above the Earths surface, except as a fare-paying passenger on a regularly scheduled commercial airline.
  • Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage.
  • The Insured Person's intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the Accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officers report, or similar items will be considered proof of the Insured Persons intoxication.
  • An Accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator's license, unless: (a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver's education instructor.
  • Injuries compensable under Workers Compensation law or any similar law.
  • Operating any type of vehicle or Conveyance while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Insured Person has been provided a written warning against operating a vehicle or Conveyance while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the motor vehicle laws of the state in which the Covered Loss occurred.
  • Medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice, unless it occurs during treatment of injuries sustained in a Covered Injury.

In addition, We will not pay Covered Medical Services for any loss, treatment, or services resulting from:

  • Expenses incurred during travel for the purposes of seeking medical care or treatment, or while on a waiting list for specific treatment or while traveling against the advice of a Physician.
  • Expenses incurred within the Insured Persons Home country or country of regular domicile.
  • Routine physical or other examinations where there is not objective indications of impairment for normal health or well-baby care.
  • Dental treatment, except as the result of Covered Injury to sound, natural teeth as stated in the Rider Schedule.
  • Cosmetic or plastic surgery or treatment for congenital abnormalities, except reconstructive surgery as a result of a Covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a Covered Injury or Sickness
  • Eye refractions or eye examinations for the purpose of prescribing corrective lenses or for the fitting thereof; eyeglasses, contact lenses.
  • Hearing examination or hearing aids or other treatment for Hearing Defects and problems. Hearing Defects means any physical defect of the ear which does or can impair normal hearing.
  • Treatment by any Immediate Family member or member of the Insured Person's household. Immediate family member means an Insured Person's spouse, child, brother, sister, grandparents or in laws.
  • Services, supplies, or treatment including any period of Hospital Confinement which is not recommended, approved, and certified as Medically Necessary and reasonable by a Physician, or expenses which are non-medical in nature;
  • In connection with alcoholism and drug addiction, or use of any drug or narcotic agent unless prescribed by a Physician;
  • The commission of a felony offense;
  • Charges for Covered Medical Expenses for which the Insured Person would not be responsible for in the absence of this coverage;
  • Any expense paid or payable by any Other Health Care Plan;
  • Any treatment provided under any mandatory government program or facility set up for treatment without cost to any individual
  • Treatment, services supplies or facilities in: a) a Hospital owned or operated by the Veterans Administration, or b) a national government or any of its agencies (this exclusion does not apply to treatment when a charge is made which the Insured Person is required by law to pay)
  • Elective treatment, exams or surgery; elective termination of pregnancy.
  • Expenses for services, treatment or surgery deemed to be experimental and which are not recognized and generally accepted medical practices in the United States.
  • Expenses payable by any automobile insurance policy without regard to fault.
  • Organ or tissue transplants and related services.
  • Expenses incurred for services related to the diagnostic treatment of infertility or other problems related to the inability to conceive a child, including but not limited to, fertility testing and in-vitro fertilization.
  • Birth control including surgical procedures and devices.
  • Expenses incurred in connection with weak, strained or flat feet, corns, calluses or toenails.
  • Birth defects and congenital anomalies, or complications which arise from such conditions.
  • Related Complex (ARC), or Human Immunodeficiency Virus (HIV) infection, or any illness or disease arising from these medical conditions.
    specific named hazards: piloting any aircraft;
  • Expenses incurred for any treatment if the Insured Person is traveling against the advice of a Physician.
  • Expenses incurred after the date insurance terminates for an Insured Person under this Policy
  • Any mental or nervous disorders or rest cures;
  • Duplicates services actually provided by both a certified nurse- midwife and Physician.
  • Expenses payable under any prior Policy which was in force for the person making the claim.
  • Expenses incurred in a Hospital emergency room visit which is not of an emergency nature.
  • Expenses incurred for chiropractic care-outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance distortion or sublimation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or sublimation of or in the vertical column.
  • Injury sustained while participating in club, intramural, intercollegiate, interscholastic, professional or semi-professional sports.

Benefits will not be paid for services or treatment rendered by any person who is: Employed or retained by the Policyholder; Living in the Insured Persons household; An Immediate Family Member of either the Insured Person or the Insured Persons Spouse; or The Insured Person.

If We determine the benefits paid under this Policy are eligible benefits under any other benefit plan, We may seek to recover any expenses covered by another plan to the extent that the Insured Person is eligible for reimbursement.

Payment of claims under any policy issued shall only be made in full compliance with all economic or trade and sanction laws or regulations, including but not limited to, laws and regulations administered and enforced by the US Treasury Departments Office of Foreign Assets Control.

This is a brief description of the coverage provided under the policy, and is subject to the terms, conditions, limitations and exclusions of the policy. Please see the policy for details.

This insurance includes limited benefits. Limited benefits plans are insurance products with reduced benefits and are not intended to be an alternative to or integrated with comprehensive coverage. Further, this insurance does not coordinate with any other insurance plan. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

General questions about the Insurance Plan should be addressed to India Network Services. Contact India Network Services between 9.00 a.m. and 6.00 p.m. (EST), Monday through Friday. Please provide your Primary ID (Passport Number) when you call India Network Services Office or WebTPA Claims Office.

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Europ TRAVEL ASSISTANCE SERVICES
Europ Assistance can help travelers with medical emergencies by:

  • Emergency Medical Evacuation & treatment en-route if necessary
  • Repatriation of remains in the event of Insured Persons death
  • Medical emergencies and many other services (see web)

The Europ Assistance communications network is available 24 hours a day, seven days a week to provide assistance to the Insured Person.
Inside the United States/Canada call (877) 243-4134
Outside United States/Canada call collect 240-330-1528
or email OPS@europassistance-usa.com

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TELADOC PROGRAM

The Teladoc program is available 24 hours a day, seven days a week and provides you with access to a physician in the United States for any medical consultation and short-term prescription refills. This program is not insurance. Please find more details at www.Teladoc.com.

CLAIMS

Claims process begins by submitting a duly completed online claim form found on the website under Members Area. The claim form has two sections. First section should be completed online by the Insured Person; and the second section should be completed by the provider (doctor office or hospital, etc.)
Providers or Insured Persons can submit the fully completed claim form to WebTPA Claims Office below.

MAIL CLAIM FORMS TO:
WebTPA
PO Box 99906
Grapevine, TX 76099-9706
fax (469) 417-1989

CLAIM QUESTIONS

All claims related questions should be addressed to WebTPA Claims Office after claims have been submitted; and more than six weeks elapsed. Contact claims office between 8:00 AM and 8:00 PM (EST) Monday through Friday at:

Services are provided by third-party agreements and are not insurance. These services include travel assistance services through Europ Assistance, USA and physician consultation services through Teladoc.

Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.

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SCHEDULE OF BENEFITS - SUMMARY

We will pay Medical Benefits for Covered Medical Services that result directly, and from no other cause, from a Covered Accident or Sickness. These benefits are subject to a Deductible of $75, $250, $500, $1,000, $5,000 or $10,000 per person for each Covered Injury and each Sickness. Medical Benefits are only payable: (1) for Usual and Customary Charges incurred after the Deductible, has been met; (2) for those Medically Necessary Covered Medical Services that the Insured Person incurs; (3) for charges incurred for services rendered to the Insured 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 Medical Services will not exceed the benefit limits shown below. The total amount payable under the policy will not exceed the Policy Maximums shown below.

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Policy Maximum Coverage
Pre-Existing Maximum Coverage for each deductible
$75
$250
$500
$1, 000
$5, 000
$10, 000
$25, 000
$1, 000
$1, 500
$1, 750
$50, 000
$1, 500
$2, 000
$2, 500
$75, 000
$2, 500
$3, 500
$4, 500
$100, 000
$3, 500
$4, 500
$5, 500
$6, 500
$150, 000
$4, 500
$5, 500
$6, 500
$7, 500
$250, 000
$7, 000
$9, 000
$13, 000
$15, 000

AXIS PLAN WITH PRE-EXISTING CONDITIONS COVERAGE BENEFITS*

Covered Medical Services

Option 1: $25K
Policy-Max

Option 2: $50K
Policy-Max

Option 3: $75K
Policy-Max

Option 4: $100K
Policy-Max

Option 5: $150K
Policy-Max

Option 6: $250K
Policy-Max

Inpatient Services

Hospital Room and Board
100% of Usual & Customary Charge incurred, Up to $900 a day, to a maximum of 30 days
100% of Usual & Customary Charge incurred, Up to $1,300 a day, to a maximum of 30 days
100% of Usual & Customary Charge incurred, Up to $1,525 a day, to a maximum of 30 days
100% of Usual & Customary Charges incurred, Up to $1,750 per day, to a maximum of 30 days
100% of Usual & Customary Charge incurred, Up to $1,900 per day, to a maximum of 30 days
100% of Usual & Customary Charge incurred, Up to $2,200 a day, to a maximum of 30 days
Hospital Intensive Care Unit Room and Board
100% of Usual & Customary Charge incurred, Up to $400 a day, to a maximum of 8 days
100% of Usual & Customary Charge incurred, Up to $525 a day, to a maximum of 8 days
100% of Usual & Customary Charge incurred, Up to $625 a day, to a maximum of 8 days
100% of Usual & Customary Charge incurred, Up to $750 a day, to a maximum of 8 days
100% of Usual & Customary Charge incurred, up to $850 per day, to a maximum of 8 days
100% of Usual & Customary Charge incurred, Up to $950 a day, to a maximum of 8 days
Surgeon Services
100% of Usual & Customary Charge incurred, Up to $2,000 max
100% of Usual & Customary Charge incurred, Up to $3,000 max
100% of Usual & Customary Charge incurred, Up to $4,000 max
100% of Usual & Customary Charges incurred, Up to $5,000 max
100% of Usual & Customary Charge incurred, Up to $6,000 max
100% of Usual & Customary Charge incurred, Up to $7,000 max
Anesthetics
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred, Up to $750 max
100% of Usual & Customary Charge incurred, Up to $1,000 max
100% Usual & Customary Charge incurred, Up to $1,250 max
100% of Usual & Customary Charge incurred, Up to $1,500 max
100% of Usual & Customary Charge incurred, Up to $1,750 max
Assistant Surgeon
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred, Up to $750 max
100% of Usual & Customary Charge incurred, Up to $1,000 max
100% of Usual & Customary Charge incurred, Up to $1,250 max
100% Usual & Customary Charge incurred, Up to $1,500 max
100% of Usual & Customary Charge incurred, Up to $1,750 max
Physician Non-Surgical Treatment/Examination Visits
100% of Usual & Customary Charge incurred, Up to $40 per visit, 1 visit per day, Up to 30 visits max
100% of Usual & Customary Charge incurred, Up to $60 max per visit, 1 visit per day, Up to 30 visits max
100% of Usual & Customary Charge incurred, Up to $80 max per visit, 1 visit per day, Up to 30 visits max
100% Usual & Customary Charge incurred, Up to $100 per visit, 1 visit per day, Up to 30 visits max
100% of Usual & Customary Charge incurred, Up to $125 per visit, 1 visit per day, Up to 30 visits max
100% of Usual & Customary Charge incurred, Up to $150 max per visit, 1 visit per day, Up to 30 visits max
Consultant visits, when requested by a Physician
100% of Usual & Customary Charge incurred, Up to $375 max
100% of Usual & Customary Charge incurred, Up to $400 max
100% of Usual & Customary Charge incurred, Up to $425 max
100% Usual & Customary Charge incurred, Up to $450 max
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred, Up to $550 max
Pre-admission Tests, when requested by Physician
100% of Usual & Customary Charge incurred, Up to $950 max, test must occur within 14 days prior to Hospital Admission
100% of Usual & Customary Charge incurred, Up to $1,000 max, test must occur within 14 days prior to Hospital Admission
100% of Usual & Customary Charge incurred, Up to $1,050 max, test must occur within 14 days prior to Hospital Admission
100% of Usual & Customary Charge incurred, Up to $1,100 max, test must occur within 14 days prior to Hospital Admission
100% of Usual & Customary Charge incurred, Up to $1,200 max, within 14 days prior to Hospital admission
100% of Usual & Customary Charge incurred, Up to $1,350 max, test must occur within 14 days prior to Hospital Admission

Outpatient Services

Day Surgery (including the cost of the operating room, anesthesia, drugs, medicines and medical supplies)
100% of Usual & Customary Charge incurred, Up to $375 max
100% of Usual & Customary Charge incurred, Up to $1,000 max
100% of Usual & Customary Charge incurred, Up to $1,050 max
100% of Usual & Customary Charge incurred , Up to $1,100 max
100% of Usual & Customary Charge incurred, Up to $1,200 max
100% of Usual & Customary Charge incurred, Up to $1,350 max
Surgeon Services
100% of Usual & Customary Charge incurred, Up to $2,000 max
100% of Usual & Customary Charge incurred, Up to $3,000 max
100% of Usual & Customary Charge incurred, Up to $4,000 max
100% of Usual & Customary Charge incurred, Up to $5,000 max
100% of Usual & Customary Charge incurred, Up to $6,000 max
100% of Usual & Customary Charge incurred, Up to $7,000 max
Anesthetics
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred, Up to $750 max
100% of Usual & Customary Charge incurred, Up to $1,000 max
100% of Usual & Customary Charge incurred, Up to $1,250
100% of Usual & Customary Charge incurred, Up to $1,500 max
100% of Usual & Customary Charge incurred, Up to $1,750 max
Assistant Surgeon
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred, Up to $750 max
100% of Usual & Customary Charge incurred, Up to $1,000 max
100% of Usual & Customary Charge incurred, Up to $1,250 max
100% of Usual & Customary Charge incurred , Up to $1,500 max
100% of Usual & Customary Charge incurred, Up to $1,750 max
Physician Non-Surgical Treatment/Exam Visits
100% of Usual & Customary Charge incurred, Up to $40 per visit, 1 visit per day, Up to 10 visits max
100% of Usual & Customary Charge incurred, Up to $60 max per visit, 1 visit per day, Up to 10 visits max
100% of Usual & Customary Charge incurred, Up to $80 max per visit, 1 visit per day, Up to 10 visits max
100% of Usual & Customary Charge incurred, Up to $100 per visit, 1 visit per day, Up to 30 visits max

100% of the Usual & Customary Charge incurred, Up to $125 per visit, 1 visit per day, Up to 10 visits max
100% of Usual & Customary Charge incurred, Up to $150 max per Day, 1 visit per day, Up to 10 visits max
Diagnostic X-Rays and Laboratory Procedures
100% of Usual & Customary Charge incurred, Up to $275 max
100% of Usual & Customary Charge incurred, Up to $400 max
100% of Usual & Customary Charge incurred, Up to $525 max
100% of Usual & Customary Charge incurred, Up to $650 max
100% of Usual & Customary Charge incurred, Up to $750 max
100% of Usual & Customary Charge incurred, Up to $900 max
CAT Scan, PET Scan or MRI
100% of Usual & Customary incurred, Up to an additional $275 of the Diagnostic X-Ray and Lab Services Benefits
100% of Usual & Customary Charge incurred, Up to an additional $400 of the Diagnostic X-Ray and Lab Services Benefits
100% of Usual & Customary Charge incurred, Up to an additional $525 of the Diagnostic X-Ray and Lab Services Benefits
100% of Usual & Customary Charge incurred, Up to $650 of the Diagnostic X-Ray and Lab Services Benefits
100% of Usual & Customary Charge incurred, Up to an additional $1,000 of the Diagnostic X-Ray and Lab Services Benefits
100% of Usual & Customary Charge incurred, Up to an additional $1,250 of the Diagnostic X-Ray and Lab Services Benefits
Hospital Emergency Room
100% of Usual & Customary Charge incurred, Up to $275 max
100% of Usual & Customary Charge incurred, Up to $350 max
100% of Usual & Customary Charge incurred, Up to $425 max
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred, Up to $750 max
100% of Usual & Customary Charge incurred, Up to $1,000 max
Prescription Drug
100% of Usual & Customary Charge incurred, Up to $75 max
100% of Usual & Customary Charge incurred, Up to $100 max
100% of Usual & Customary Charge incurred, Up to $125 max
100% of Usual & Customary Charge incurred, Up to $150 max
100% of Usual & Customary Charge incurred, Up to $200 max
100% of Usual & Customary Charge incurred, Up to $250 max
Ambulance Services
100% of Usual & Customary Charge incurred, Up to $375 max
100% of Usual & Customary Charge incurred, Up to to $400 max
100% of Usual & Customary Charge incurred, Up to $425 max
100% of Usual & Customary Charge incurred, Up to $450 max
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred, Up to $600 max
Rehabilitative Braces or Appliances
100% of Usual & Customary Charge incurred , Up to $950 max
100% of Usual & Customary Charge incurred, Up to $1,000 max
100% of Usual & Customary Charge incurred, Up to $1,050 max
100% of Usual & Customary Charge incurred, Up to $1,100 max
100% of Usual & Customary Charge incurred, Up to $1,200 max
100% of Usual & Customary Charge incurred, Up to $1,350 max
Dental Treatment Injury to Sound, Natural Teeth Due to Accident (does not include dental services for immediate relief of pain)
100% of Usual & Customary Charge incurred, Up to $425 max
100% of Usual & Customary Charge incurred, Up to $450 max
100% of Usual & Customary Charge incurred, Up to $475 max
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred, Up to $550 max
100% of Usual & Customary Charge incurred, Up to $650 max
Chemotherapy and/or Radiation Therapy
100% of Usual & Customary Charge incurred, Up to $925 max
100% of Usual & Customary Charge incurred, Up to $1,000 max
100% of Usual & Customary Charge incurred, Up to $1,075 max
100% of Usual & Customary Charge incurred, Up to $1,150 max
100% of Usual & Customary Charge incurred , Up to $1,250 max
100% of Usual & Customary Charge incurred, Up to $1,400 max
Physical and Occupational Therapy
100% of Usual & Customary Charge incurred, Up to $30 per visit, 1 visit per day, 12 visits max
100% of Usual & Customary Charge incurred, Up to $35 per visit, 1 visit per day, 12 visits max
100% of Usual & Customary Charge incurred, Up to $40 per visit, 1 visit per day, 12 visits max
100% of Usual & Customary Charge incurred, Up to $45 per visit, 1 visit per day, 12 visits max
100% of Usual & Customary Charge incurred, Up to $50 per visit, 1 visit per day, 12 visits max
100% of Usual & Customary Charge incurred, Up to $55 per visit, 1 visit per day, 12 visits max
Private Duty Nursing
100% of Usual & Customary Charge incurred, Up to $350 max
100% of Usual & Customary Charge incurred, Up to $400 max
100% of Usual & Customary Charge incurred, Up to $450 max
100% of Usual & Customary Charge incurred, Up to $500 max
100% of Usual & Customary Charge incurred , Up to $550 max
100% of Usual & Customary Charge incurred, Up to $600 max
Pregnancy and Childbirth
100% of Usual & Customary Charge incurred, Up to $4,250; conception must occur after the trip begins
100% of Usual & Customary Charge incurred, Up to $4,500 max; conception must occur after the trip begins
100% of Usual & Customary Charge incurred, Up to $4,750; conception must occur after the trip begins
100% of Usual & Customary Charge incurred, Up to $5,000; conception must occur after the trip begins
100% of Usual & Customary Charge incurred, Up to $5,500; conception must occur after the trip begins
100% of Usual & Customary Charge incurred, Up to $6,000; conception must occur after the trip begins
Emergency Medical Evacuation
100% of Usual & Customary Charges incurred, Up to a maximum of $10,000 max
100% of Usual & Customary Charge incurred, Up to $10,000 max
100% of Usual & Customary Charge incurred, Up to $10,000 max
100% of Usual & Customary Charge incurred, Up to $10,000 max
100% of Usual & Customary Charge incurred, Up to $10,000 max
100% of Usual & Customary Charge incurred, Up to $10,000 max
Repatriation of Remains
100% of Usual & Customary Charges incurred, Up to a maximum of $10,000
100% of Usual & Customary Charge incurred, Up to $10,000 max
100% of Usual & Customary Charge incurred, Up to $10,000 max
100% of Usual & Customary Charges incurred, Up to $10,000 max
100% of Usual & Customary Charge incurred, Up to $10,000 max
100% of Usual & Customary Charge incurred, Up to $10,000 max
Accidental Death and Dismemberment
$500,000 Principal Sum
$500,000 Principal Sum
$500,000 Principal Sum
$500,000 Principal Sum
$500,000 Principal Sum
$500,000 Principal Sum

* Pre-existing limited to Acute Onset coverage. If you experience an acute onset of a pre-existing condition, benefits are payable according to your policy benefits. Treatment for said condition must be obtained within 12 hours of the sudden and unexpected outbreak or reoccurrence.

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OTHER BENEFITS - MEDICAL EVACUATION AND REPATRIATION BENEFITS

EMERGENCY MEDICAL EVACUATION AND REPATRIATION: These Benefits will not be payable unless We (or Our authorized travel assistance provider) authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our a travel assistance provider. Contact Europ Assistance for these services at (877) 243-4134 or call collect from outside the United States at (240) 330-1528 (24 hours a day, 7 days a week). Email: OPS@europassistance-usa.com

EMERGENCY MEDICAL EVACUATION BENEFIT: We will pay Emergency Medical Evacuation Benefits as shown for Covered Expenses incurred for the Emergency Evacuation of a Insured Person. Benefits are payable up to the Benefit Maximum shown, if the Insured Person suffers a Covered Injury or Emergency Sickness during the course of the Covered Trip that requires Emergency Evacuation.

REPATRIATION OF REMAINS BENEFIT: We will pay Repatriation Benefits up to the Benefit Maximum shown for preparation and return of a Insured Persons body to his or her place of primary residence if he or she dies as a result of a Covered Injury or Emergency Sickness while traveling on a Covered Trip.

ACCIDENTAL DEATH AND DISMEMBERMENT: If Injury to the Insured Person results, within 365 days of 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. The Principal Sum is $500,000 as shown. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Covered Accident.

Covered Loss

Benefit Amount

Loss of Life

100% of the Principal Sum

Loss of Two or More Hands or Feet

100% of the Principal Sum

Loss of Sight of Both Eyes

100% of the Principal Sum

Loss of One Hand and Foot

100% of the Principal Sum

Loss of One Hand or Foot and Sight in One Eye

100% of the Principal Sum

Loss of One Hand or Foot

50% of the Principal Sum

Loss of Sight in One Eye

Exposure and Disappearance

50% of the Principal Sum

Included

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CANCELLATION POLICY

Refund of premium, less a $25 processing fee, will be considered only if the 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 800-490-9678. Policy changes cannot be made under any circumstances once the policy becomes effective.

ADMINISTERED BY:
INDIA NETWORK SERVICES, USA
407-243-8760 * 408-850-2154

CLAIMS OFFICE:
WebTPA
(877) 563-7492, fax (469) 417-1989

Rev. 1/18/18