Schedule of Benefits

Eligibility

This program is designed for foreign nationals visiting the United States. The program covers the visitor for a period under six months while in the U.S. or Canada. Persons under age 18, over69 years and citizens of the U.S. are not eligible. Eligible dependents include your spouse and unmarried children more than 14days old and under 18 years. Eligible visitors may enroll prior to departure from their home country or within 30 days of their ar-rival in the U.S.

Period of Coverage

Once we receive your enrollment form and the correct payment,the effective date of your coverage is whichever is later: (a) your requested effective date or (b) two days after the date the completed enrollment form and premium have been received by the administrator. Coverage terminates when the first of the following occurs: (a) expiration of period of requested coverage, (b) the date that follows the date coverage has been in effect for six months, (c) the date of departure for a location outside the U.S.or Canada or (d) termination of the master policy. Coverage be-gins and terminates at 12:01 a.m. on the dates specified.

Premium Refunds

Premium of refund, minus an administrative fee, is made if a written request is received prior to the effective date of the coverage. After the effective date of coverage, premium is refunded, minus an administrative fee, for remaining months of coverage.

Accident and Sickness Medical Expenses

The Company will pay Covered Expenses due to Accident or Sickness only, as per the limits stated in the Schedule of Benefits. Coverage is limited to Covered Expenses incurred subject to Exclusions. All bodily Injuries sustained in any one Accident shall be considered one Disablement, all bodily disorders existing simultaneously which are due to the same or related causes shall be considered one Disablement. If a Disablement is due to causes which are the same or related to the cause of a prior Disablement(including complications arising there from), the Disablement shall be considered a continuation of the prior Disablement and not a separate Disablement.

Treatment of an Injury or Illness must occur within 30 days of the Accident or onset of the Illness.

When a covered Injury or illness is incurred by the Insured Person the Company will pay Reasonable and Customary medical expenses excess of the Deductible and Coinsurance as stated in the Schedule of Benefits. In no event shall the Company’s maximum liability exceed the maximum stated in the Schedule of Benefits as to Covered Expenses during any one period of individual coverage.

Covered Accident and Sickness Medical Expenses

Covered Accident and Sickness Medical Expenses Only such expenses, incurred as the result of a Disablement, which are specifically enumerated in the following list of charges, and which are not excluded in the Exclusions section, shall be considered as Covered Expenses:

• Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the Hospital's average charge for semi-private room and board accommodation or $500 per day, whichever is less.
• Charges made for Intensive Care or Coronary Care charges and nursing services. Intensive care facility charges will be payable up to $1,000 per day.
• Charges made for diagnosis, treatment and Surgery by a Physician.
• Charges made for an operating room.
• Charges made for Outpatient treatment, same as any other treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physicians’ Outpatient visits/examinations,clinic care, and Surgical opinion consultations.
• Charges made for the cost and administration of anesthetics.
• Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood, transfusions, iron lungs, and medical treatment.
• Charges for inpatient physiotherapy, if recommended by a Physician for the treatment of a specific Disablement and administered by a licensed physiotherapist.
• Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or Surgeon.
• Charges made for artificial limbs, eyes, larynx, and orthotic appliances, but not for replacement of such items.
• Local transportation to or from the nearest Hospital or to and from the nearest Hospital with facilities for required treatment.Such transportation shall be by licensed ground ambulance only,within the metropolitan area in which the Insured Person is located at that time the service is used. If the Insured Person is ina rural area, then licensed ground ambulance transportation to the nearest metropolitan area shall be considered a Covered Expense.
• Medical expenses incurred for treatment of injuries sustained as a result of a covered motor vehicle Accident are payable up to $5,000.
• Medical expenses incurred for treatment of sports related Accidents are payable up to $2,500.

Accidental Death and Dismemberment

Accidental Death and Dismemberment Insurance is afforded to an Insured Person which shall apply only to Injury, as defined in Definitions, sustained by such Insured Person during the course of coverage. Such Insurance includes such Injury which occurs during the course of time the Insured Person is covered under the Policy. The full benefit amount will be paid for the loss of life and loss of two or more members (hand, foot, or eye). One half the benefit amount will be paid for the loss of one member. One quarter the benefit amount will be paid for the loss of thumb and index finger(actual severance through or above the joint that meets the finger at the palm). Loss must occur within 365 days of the date of the Accident.

Emergency Medical Evacuation/Repatriation

The Company shall pay benefits for Covered Expenses incurred up to the maximum stated in the Schedule of Benefits, if any Injury or covered Illness commencing during the Period of Coverage results in the Medically Necessary Emergency Medical Evacuation or Repatriation of the Insured Person. The decision for an Emergency Medical Evacuation or Repatriation must be ordered by the Company’s appointed Assistance Company in consultation with the Insured Person’s local attending Physician.

Emergency Medical Evacuation or Repatriation means: a) the Insured Person’s medical condition warrants immediate transportation from the place where the Insured Person is located (due to inadequate medical facilities) to the nearest adequate medical facility where medical treatment can be obtained; or b) after being treated at a local medical facility, the Insured Person’s medical condition warrants transportation with a qualified medical attendant to his/her Home Country to obtain further medical treatment or to recover; or c) both a) and b) above.

Return of Mortal Remains or Cremation

The Company will pay the reasonable Covered Expenses incurred up to the maximum as stated in the Schedule of Benefits, Return of Mortal Remains, to return the Insured Person’s remains to his/her then current Home Country, if he or she dies.

Covered Expenses include, but are not limited to, expenses for embalming, cremation, a minimally necessary container appropriate for transportation, shipping costs, and the necessary government authorizations. All Covered Expenses in connection with a Return of Mortal Remains must be pre-approved and arranged by an Assistance Company representative appointed by the Company. \

Team Assist Plan

The Team Assist Plan is designed by CISI in conjunction with the Assistance Company to provide travelers with a worldwide, 24-hour emergency telephone assistance service. Multilingual help and advice may be furnished for the insured in the event of any emergency during the term of coverage. The Team Assist Plan supplements the insurance benefits provided by Virginia Surety Company, Inc.

Exclusions

For benefits listed in the Schedule of Benefits, this Insurance does not cover:
• Pre-Existing conditions, defined as any Injury or Illness which meets the following criteria:
1) a condition that would have caused a person to seek medical advice, diagnosis, care or treatment anytime prior to the Effective Date of coverage under this Policy;
2) a condition for which medical advice, diagnosis, care or treatment was recommended or received anytime prior to the Effective Date of coverage under this Policy
• Charges for treatment which is not Medically Necessary
• Charges for treatment which exceed Reasonable and Customary charges
• Charges incurred for Surgery or treatments which are, Experimental/Investigational, 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 thereof, while sane or self destruction or any attempt thereof, while sane
• Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war; b) mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power
• Injury sustained while participating in professional athletics, unless otherwise covered under this Policy
• Injury sustained while participating in Amateur or Interscholastic Athletics, unless otherwise covered under this Policy
• Routine physicals, immunizations, or other examinations where there are no objective indications or impairment in normal health, including routine care of a newborn infant, and laboratory diagnostic or x-ray examinations, except in the course of a Disablement established by a prior call or attendance of a Physician
• 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
• The refusal of a Physician or Hospital to make all medical reports and records available to the Company will cause an otherwise valid claim to be denied
• Cosmetic or plastic Surgery, except as the result of a covered Accident; for the purposes of this Policy, treatment of a deviated nasal septum shall be considered a cosmetic condition
• Outpatient treatment for specified therapies including physiotherapy and acupuncture
• Elective Surgery or Elective Treatment which can be postponed until the Insured Person returns to his/her Home County, where the objective of the trip is to seek medical advice, treatment or Surgery
• 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
• Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent
• 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
• Any Mental and Nervous disorders or rest cures, unless otherwise covered under this Policy
• 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
• 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 selfinflicted 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 vehicle or motorcycle; parasailing; motorcycle/motor scooter riding
• 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, unless otherwise covered under this Policy
• Dental care, except as the result of Injury to natural teeth caused by Accident (limited to $250 per tooth per Injury), unless otherwise covered under this Policy
• Routine Dental Treatment
• 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
• Treatment for human organ tissue transplants and their related treatment
• Expenses incurred within the Insured Person’s home country or country of residence
• Weak, strained or flat feet, corns, calluses, or toenails
• Diagnosis and treatment of acne
• Injury sustained while the Insured Person is riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting from, any type of aircraft.

Definitions

Accident or Accidental means an event, independent of Illness or self inflicted means, which is the direct cause of bodily Injury to an Insured Person.

Amateur or Interscholastic Athletics means a sponsored and/or organized league.

Company is Virginia Surety Company, Inc.

Dependent means the spouse who is legally married to the Primary Insured Person; the Primary Insured Person’s unmarried Child from birth until his/her 19th birthday.

Elective Surgery or Elective Treatment means surgery or medical treatment, which is not necessitated by a pathological or traumatic change in the function or structure in any part of the body first occurring after the Insured's effective date of coverage. Elective Surgery includes, but is not limited to, circumcision, tubal ligation, vasectomy, breast reduction, sexual reassignment surgery, and submucous resection and/or other surgical correction for deviated nasal septum, other than for necessary treatment of covered acute purulent sinusitis. Elective Surgery does not apply to cosmetic surgery required to correct a covered Accident. Elective Treatment includes, but is not limited to, treatment for acne, nonmalignant warts and moles, weight reduction, infertility, learning disabilities.

Hospital means except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision.

Illness means sickness or disease of any kind contracted and commencing after the Effective Date of this Policy and Disablement covered by this Policy.

Injury means bodily Injury caused solely and directly by violent, Accidental, external, and visible means occurring while this Policy is in force and resulting directly and independently of all other causes in Disablement covered by this Policy.

Insured Person(s) means a person eligible for coverage under the Policy as defined in “Eligible Persons” who has applied for coverage and is named on the application and for whom the company has accepted premium. This may be the Primary Insured Person or Dependent(s).

Physician as used in this Policy shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed, however, such definition will exclude chiropractors and physiotherapists.

Reasonable and Customary means the maximum amount that the Company determines is Reasonable and Customary for Covered Expenses the Insured Person receives, up to but not to exceed charges actually billed. The Company’s determination considers: 1) amounts charged by other Service Providers for the same or similar service in the locality were received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; 2) any usual medical circumstances requiring additional time, skill or experience; and 3) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale.

For a Service Provider who has a reimbursement agreement, the Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company.

Policy terms and conditions are briefly outlined in this document. A complete description is contained in the Summary of Coverage which is mailed to your U.S. address after enrollment in the Plan.

Enrollment form

You may view and print the enrollment form by first downloading a pdf file reader (if you don't already have it) and then select the enrollment form file.

To find out more about the World Class Coverage Plan for international students and scholars offered by CISI, click here.