Diplomat America®

Diplomat America

Diplomat America plan provides Accident and Sickness medical coverage, Accidental Death and Dismemberment benefits, Travel Assistance for Non-U.S. citizens and Non-U.S. residents traveling to the United States. This plan is great for international students, business and tourists, study abroad, international exchange students, church or missionary travelers, and more.

Coverage for this plan is based on a per day rate. Minimum period of coverage is 15 days and the maximum period of coverage is 365 days.

This plan is available for 2 adults, any unmarried dependent children ages 14 days until their 18th birthday, or children traveling alone.

Note: This plan is not available for Australia citizens, U.S citizens, U.S residents, and not designed for any travels outside the US.

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Co-Insurance:

After you pay the selected deductible, the plan pays 80% up to $5,000 of eligible costs, then 100% to the Medical Maximum. There will be an additional $250 deductible for each emergency room visit as a result of an Illness. The emergency room deductible will be waived if hospital admittance is within 12 hours of the incident.

Deductible Choices: $0, $50, $100, $250, $500, $1,000, $2,500, $5000 (per person per policy period).

Covered Expenses

Only expenses that are specifically enumerated in
the following list of charges that are incurred for medical
care and supplies which are: (a) necessary and
customary; (b) prescribed by a Physician for the
therapeutic treatment of a disablement; (c) are not
excluded under the policy; (d) are not more than the
Usual and Customary charges (as determined by the
Company); and (e) are incurred within 180 days from the
date of the Disablement will be considered.

  1. Expenses made by a Hospital for room and board,
    floor nursing and other services, including Expenses for
    professional services, except personal services of a nonmedical
    nature, provided, however, that Expenses do
    not exceed the Hospital’s average charge for semiprivate
    room and board accommodation.
  2. Charges
    made for Intensive Care or Coronary Care charges and
    nursing services;
  3. Expenses made for diagnosis,
    Treatment and surgery by a Physician.
  4. Charges made
    for an operating room.
  5. Charges made for Outpatient
    Treatment, same as any other Treatment covered on an
    Inpatient basis. This includes ambulatory surgical
    centers, Physician’s Outpatient visits/examinations,
    clinic care, and surgical opinion consultations.
  6. Expenses made for administration of anesthetics.
  7. Expenses for medication, x-ray services, laboratory tests
    and services, the use of radium and radio-active
    isotopes, oxygen, blood transfusions, iron lungs, and
    medical Treatment.
  8. Expenses for physiotherapy, if
    recommended by a Physician, for the Treatment of a
    specific Disablement and administered by a licensed
    physiotherapist; With regards to chiropractic care,
    eligible charges up to $50.00 per visit, with a maximum
    of 10 visits.
  9. Dressings, drugs, and medicines that can only be obtained upon written prescription of a Physician.
  10. Hotel room charge, when the insured, otherwise necessarily confined in a Hospital, shall be under the care of a duly qualified Physician in a hotel room owing to the unavailability of a Hospital room by reason of capacity or distance or to any other circumstances beyond the control of the insured; The charges enumerated above shall in no event include any amount in excess of the Usual and Customary charges (as determined by the Company). To determine if Expenses are Usual and Customary, the Company will consider the following: the medical care or supplies usually given and the fees usually accepted for like cases in the area. “Area” means a region large enough to get a cross section of providers or medical care or supplies. All Expenses are deemed to be incurred on the date such service is received.

Other Benefits

  • Pre-Existing Condition Exclusion: 24 Months prior to the start date of coverage
  • Emergency Medical Evacuation and Repatriation: $500,000
  • Return of Mortal Remains: $50,000
  • Emergency Medical Reunion: $50,000
  • Return of Minor Child: $50,000
  • Interruption of Trip: $5,000
  • Loss of Baggage: $50 per article; up to a maximum of $250
  • Emergency Dental Treatment: $100
  • Accidental Death and Dismemberment: $25,000 (Enhanced Benefit Amounts available) with paralysis and coma, seat belt and airbag, felonious assault and home alteration and vehicle modification benefits.
  • Athletic & Hazardous Activity Benefit Available Political and Natural Disaster Evacuation: $50,000

Accidental Death and Dismemberment Benefits:

Enhanced AD&D Benefit Rates (Per Person / Month) *Enhanced AD&D amount and additional rate only apply to age 18+

  • $100,000 Total Coverage ……………. $6.00
  • $250,000 Total Coverage ……………..$18.00
  • $500,000 Total Coverage ………………$38.00
  • $750,000 Total Coverage………………. $58.00
  • $1,000,000 Total Coverage…………….. $78.00

Claim Forms

The Company, upon receipt of a written notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this Plan by submitting, within the time fixed in this Plan for filing proofs of loss, written proof showing the occurrence, nature and extent of the loss for which claim is made.
Claim Forms:

CLAIMS ADMINISTRATOR:
Global Claims Administration
3195 Linwood Rd, Suite 201
Cincinnati OH 45208
Inside US and Canada: 800-513-2981
Outside US and Canada: 513-533-1330
Fax: 513-533-9416

Exclusions

The Plan Document does not cover any loss resulting from any
of the following unless otherwise covered under the Plan Document by
Additional Benefits:

  • Suicide, attempted suicide (including drug overdose) self-destruction,
    attempted self-destruction or intentional self-inflicted Injury while
    sane or insane;
  • War or any act of war, declared or undeclared; unless War Risk Benefit
    was purchased;
  • An Accident which occurs while the Plan Participant is on Active Duty
    Service in any Armed Forces, National Guard, military, naval or air
    service or organized reserve corps;
  • Injury sustained while in the service of the armed forces of any
    country. When the Plan Participant enters the armed forces of any
    country, We will refund the unearned pro rata premium upon request;
  • Voluntary, active participation in a riot or insurrection;
  • Medical expenses resulting from a motor vehicle accident in excess of
    that which is payable under any other valid and collectible insurance;
  • Organ transplants;
  • Treatment for an Injury or Sickness caused by, contributed to or
    resulting from the Plan Participant’s voluntary use of alcohol, illegal
    drugs or any drugs or medication that is intentionally not taken in the
    dosage recommended by the manufacturer or for the purpose prescribed by the Plan Participant’s Physician;
  • Violation or in violation or attempt to violate any duly-enacted law or
    regulation, or commission or attempt to commit an assault or felony,
    or that occurs while engaged in an illegal occupation;
  • Eligible Expenses for which the Plan Participant would not be responsible in the absence of the Plan Document;
  • Treatment of acne;
  • Charges which are in excess of Usual and Customary charges;
  • Charges that are not Medically Necessary;
  • Charges provided at no cost to the Plan Participant;
  • Treatment of HIV infection, HIV related illness and AIDS (acquired
    immune deficiency syndrome);
  • Expenses incurred for treatment while in Your Home Country; except
    as provided under the Home Country Coverage Benefit;
  • Expenses incurred for an Accident or Sickness after the Benefit Period
    shown in the Schedule of Benefits or incurred after the termination
    date of coverage;
  • Regular health checkups; routine physical, immunizations or other
    examination where there are no objective indications or impairment in
    normal health;
  • Services or treatment rendered by a Physician, Registered Nurse or any
    other person who is employed or retained by the Participation
    Organization; or an Immediate family member of the Plan Participant;
  • Injuries paid under Workers’ Compensation, Employer’s liability laws
    or similar occupational benefits or while engaging in an occupation for
    monetary gain from sources other than the Participation Organization;
  • Benefits for enrolling solely for the purpose of obtaining Medical
    Treatment, while on a waiting list for a specific treatment, or while
    traveling against the advice of a Physician;
  • Aggravation or re-injury of a prior Injury that the Plan Participant
    suffered prior to his or her coverage Effective Date, unless We receive
    a written medical release from the Plan Participant’s Physician;
  • Pre-existing conditions as defined in the definitions;
    24) Treatment of a hernia, including sports hernia, whether or not caused
    by a Covered Accident;
  • Pregnancy or childbirth, miscarriage; elective abortion; elective
    cesarean section; or any complications of any of these conditions;
  • 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;
  • Charges incurred for Surgery or treatments which are,
    Experimental/Investigational, or for research purposes;
  • Expense incurred for treatment of temporomandibular joint (TMJ)
    disorders or craniomandibular joint dysfunction and associated
    myofascial pain;
  • Dental care or treatment other than care of sound, natural teeth and
    gums required on account of Injury resulting from an Accident while
    the Plan Participant is covered under the Plan Document, and
    rendered within 6 months of the Accident; unless otherwise provided
    by the plan document;
  • Eyeglasses, contact lenses, hearing aids braces, appliances, or
    examinations or prescriptions therefore;
  • Private-duty nursing services;
  • The cost of the Covered Person’s unused airline ticket for the
    transportation back to the Plan Participant’s Home Country, where an
    Emergency Medical Evacuation or Repatriation and/or Return of
    Mortal Remains benefit is provided;
  • For the cost of a one way airplane ticket used in the transportation
    back to the Plan Participant’s country where an air ambulance benefit
    is provided and medically necessary;
  • Treatment paid for or furnished under any other individual or group
    Plan Document, or other service or medical prepayment plan arranged
    through the employer to the extent so furnished or paid, or under any
    mandatory government program or facility set up for the treatment
    without cost to any individual;
  • Ionizing radiation or contamination by radioactivity from any nuclear
    fuel or from any nuclear waste, from combustion of nuclear fuel, the
    radioactive, toxic, explosive or other hazardous properties of any
    nuclear assembly or nuclear component of such assembly.
    Exclusions Continued:
  • Plan Participant being exposed to the utilization of nuclear, chemical,
    or biological weapons of mass destruction.
  • Travel in or upon: (a) A snowmobile; (b) A water jet ski; (c) Any two or
    three wheeled motor vehicle, other than a motorcycle registered for
    on-road travel; (d) Any off-road motorized vehicle not requiring
    licensing as a motor vehicle; when used for recreation or
    competition. Unless Hazardous Activity Benefit is purchased.
  • Injury sustained while taking part in: mountaineering; hang gliding;
    parachuting; bungee jumping; racing by horse, motor vehicle or
    motorcycle; snowmobiling; motorcycle/motor scooter riding; scuba
    diving, involving underwater breathing apparatus; water skiing; snow
    skiing; spelunking; parasailing; white water rafting; surfing, unless part
    of a school credit course; and snowboarding. Unless Hazardous
    Activity Benefit is purchased.
  • Practice or play in any amateur, club, intramural, interscholastic,
    intercollegiate, sports contest or competition; Unless Athletic Sports
    Activity Benefit is purchased.
  • Practice or play in any professional or semiprofessional contest or
    competition;
  • Rest cures or custodial care;
  • Treatment of Mental and Nervous Disorders;
  • Weight reduction programs or surgical treatment of obesity or
    venereal disease;
  • Elective or Cosmetic surgery and Elective Treatment or treatment for
    congenital anomalies (except as specifically provided), except for
    reconstructive surgery on a diseased or injured part of the body
    (Correction of a deviated nasal septum is considered cosmetic surgery
    unless it results from a covered Injury or Sickness);
  • Travel or flight in or on any vehicle for aerial navigation, including
    boarding or alighting from:
    a) While riding as a passenger in any Aircraft not intended or
    licensed for the transportation of passengers; or
    b) While being used for any test or experimental purpose; or
    c) While piloting, operating, learning to operate or serving as a
    member of the crew thereof; or
    d) while traveling in any such Aircraft or device which is owned or
    leased by or on behalf of the Participation Organization of any
    subsidiary or affiliate of the Participation Organization, or by the
    Plan Participant or any member of his household.
    e) A space craft or any craft designed for navigation above or
    beyond the earth’s atmosphere; or
    f) An ultralight, hang-gliding, parachuting or bungee-cord jumping.
    Unless Hazardous Activity Benefit is purchased.
    Except as a fare paying passenger on a regularly scheduled
    commercial airline or as a passenger in a non-scheduled, private
    aircraft used for business or pleasure purposes.
    In addition to any of the exclusions listed above, for Eligible Expenses under
    Trip Interruption, this Insurance also does not cover the following:
    1) The Plan Participant or Traveling Companion or Traveling Companion’s
    family making changes to personal plans; having business or
    contractual obligations; being unable to obtain necessary travel
    documents (passports, visas, etc.); being detained or having property
    confiscated by customs authorities; carrier caused delays (including
    bad weather);
    2) Prohibition or regulatory by any government; default of yacht charter
    companies; default of the organization from which the Plan Participant
    purchased their trip arrangements;
    3) A Pre-Existing Condition existing prior to the Plan Participant’s
    departure from their Home Country.
    In addition to any of the exclusions listed above, for Eligible Expenses under
    Baggage Loss and Delay, this Insurance also does not cover the following:
    (1) Animals; (2) Artificial teeth or limbs, hearing aids; (3) Sunglasses,
    contact lenses or eyeglasses; (4) Documents of any kind, including but
    not limited to documents, bills, currency, deeds, evidences of debt,
    letters of credit, stamps, credit cards, money, notes, securities,
    transportation or other tickets.
    Jurisdiction Limitation: Coverage is not available for citizens of the
    United States or Australia or any travel outside the United States.

Premium Refund (policy cancellation)

Refund of premium, less a $25 processing fee, will be considered only if written request is received prior to the effective date of coverage. After that date, the premium is considered fully earned and non-refundable. Partial refunds are not available.