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Worldwide Trip Protector GoldT - 4010 (4/2008 - Rev. 1)Description of CoverageNotice to Residents of Vermont and the State of Washington:This is not Your Description of Coverage. To obtain Your state-specific insurance policy, call 1-800-243-3174. You are not eligible for insurance under the plan until You have enrolled for coverage and paid the appropriate plan cost and providing You have not already departed on Your Trip. Schedule of Coverage and ServicesWorldwide Assistance Services are included with the purchase of Your plan.24-Hour Emergency Assistance Telephone Numbers Continental USA . . . . . 800-494-9907 International . . . . . . . . 202-659-7775 Be sure to use the appropriate country and city codes when calling. -KEEP THESE NUMBERS WITH YOU WHEN YOU TRAVEL Optional CoverageOptional Coverage applies only when requested on the application and the appropriate additional plan cost has been paid.Medical Upgrade Excess Insurance Limitation does not apply and no deductible. Accidental Death & Dismemberment Common Carrier (Air Only) Coverage Up to the amount purchased. Select limits of $500,000, or $1,000,000 per person Cancel for Work Reasons Coverage for Trip Cancellation and Trip Interruption up to the limit purchased. Not available for residents of Oregon, New York, or Washington State. Cancel for Any Reason Trip Cancellation coverage up to 48 hours prior to departure; for up to 75% refund. Not available for residents of Oregon, New York, or Washington State. Sports Coverage Up to a combined maximum limit of $1,000 per person. Purchase within 14 days of Your initial Trip deposit for Pre-Existing Condition Waiver: The Pre-Existing Condition exclusion will be waived if the protection plan is purchased within 14 days of the initial Trip deposit, You purchase this policy for the full non-refundable cost of Your Trip, You are not disabled from travel at the time You pay the plan cost and this is the first and only booking for this same destination and dates of travel. How to contact us to file a claim: Report a claim online at www.travelinsured.com Travel Insured International, Inc.® P.O. Box 280568 East Hartford, CT 06128-0568 Toll free at: 800-243-2440 PART A - TRAVEL PROTECTIONTrip Cancellation/Trip Interruption: The Insurer will pay a benefit, up to the maximum shown on the Schedule of Coverage and Services, if You are prevented from taking or continuing Your Trip due to the following Unforeseen events:
Not available for residents of Oregon, New York, or Washington State If You have purchased the Cancel for Work Reasons Protection the Insurer will pay up to the maximum shown on the Schedule of Coverage and Services if You or Your Traveling Companion are prevented from taking Your Trip due to one of the following unforeseen events:
“Cancel For Any Reason” Protection: Not available for residents of Oregon, New York, or Washington State If You purchase the Cancel For Any Reason protection and You cancel Your Trip for any reason not otherwise covered by this plan, the Insurer will reimburse You for up to 75% of the prepaid, forfeited, non-refundable payments or deposits You paid for Your Trip provided You cancel Your Trip more than two (2) days prior to Your Scheduled Departure Date. Trip Cancellation (not applicable if $0 Trip cost displayed on Your Confirmation of Benefits): Non-refundable cancellation charges imposed by Your Travel Supplier and/or airfare cancellation charges for flights joining or departing Your Land/Sea Arrangements; or the additional costs You may incur as a result of a change in the per-person occupancy rate of prepaid travel arrangements if a person booked to share accommodations with You cancels his/her Trip for a covered reason and You do not cancel. If Your Travel Supplier cancels Your Trip, You are covered up to the cost of the ticket or the reissue fee charged by the airline for the tickets. You must have covered the entire cost of the Trip including the airfare. If You purchase Sports Coverage the Insurer will pay up to the combined maximum limit shown on the Schedule of Coverage and Services for prepaid non-refundable ski passes, greens fees and sporting equipment rental. All cancellations must be reported directly to the Travel Supplier within 72 hours of the event causing the need to cancel, unless the event prevents it, and then as soon as is reasonably possible. If the cancellation is not reported within the specified 72-hour period, the Insurer will not pay for additional charges which would not have been incurred had You notified the Travel Supplier in the specified period. If the event prevents You from reporting the cancellation, the 72-hour notice requirement does not apply; however, You must, if requested, provide proof that said event prevented You from reporting the cancellation within the specified period. Trip Interruption (Return Air Only up to $1,000 if $0 displayed for Trip Cancellation on Your Confirmation of Benefits): Unused, non-refundable travel arrangements prepaid to Your Travel Supplier and additional transportation expenses incurred by You to return home or rejoin the original Land/Sea Arrangements (airfare limited to the cost of one-way air fare, using the same class of fare as the original travel ticket, by scheduled carrier, from the point of destination to the point of origin shown on the original travel tickets) less the value of applied credit from an unused return travel ticket. In no event shall the amount reimbursed exceed the lesser of the amount You pre-paid for Your Trip, or the maximum benefit shown on the Schedule of Coverage and Services; or the additional costs You may incur as a result of a change in the per-person occupancy rate of prepaid travel arrangements if a person booked to share accommodations with You cancels his/her Trip for a covered reason and You do not cancel. The Insurer will also pay for reasonable additional meals, lodging and transportation expenses incurred by You, up to $200 per day, if a Traveling Companion must remain hospitalized or if You must extend the Trip with additional hotel nights due to a Physician certifying You cannot fly home due to an Accident or a Sickness but does not require hospitalization, or if Your Trip must be extended due to an Unforeseen event listed under Part A Travel Protection – Trip Cancellation/ Trip Interruption. If You purchase Sports Coverage the Insurer will pay up to the combined maximum limit shown on the Schedule of Coverage and Services for prepaid non-refundable ski passes, greens fees and sporting equipment rental. Trip Delay: The Insurer will reimburse You for covered expenses on a one time basis, up to the maximum shown on the Schedule of Coverage and Services, if You are delayed en route to or from the covered Trip for six (6) or more hours due to a covered reason. Covered expenses include Your additional transportation cost to join the Trip or return home and up to $200 per day for reasonable additional expenses incurred for meals and lodging or any prepaid, unused, non-refundable land and water accommodations. Covered reasons for Trip Delay are:
In the event a cruise/tour supplier makes a change in Your Trip itinerary which prevents You from participating in an event/activity prepaid prior to departure and scheduled on Your Trip itinerary, nonrefundable pre-paid event/activity expenses will be payable up to the Maximum Benefit Amount. Benefits will not be paid if the event/activity is rescheduled during the course of the Trip. Verification by the cruise/tour supplier of the change in the scheduled Trip itinerary will be necessary for claim payment. Pet Care: The Insurer will pay up to $50 per day up to the maximum benefit shown on the Schedule of Coverage and Services for additional boarding fees incurred after the first 24 hours of Your delayed return from Your Trip due to Hospital in-patient treatment abroad which results in Your pet exceeding a pre-booked period of accommodation within a recognized boarding kennel, cattery, or animal shelter. In addition to the General Exclusions the Insurer will not pay for the following:
Baggage/Personal Effects: The Insurer will reimburse You up to the maximum shown on the Schedule of Coverage and Services for loss, theft, or damage to Baggage and personal effects. The Insurer will pay the lesser of the following: Actual Cash Value at the time of the loss, less depreciation as determined by the Insurer, or the cost of repair or replacement. There is a limit of $250 per article. There will also be a combined maximum limit of $500 for the following:
The Insurer will reimburse You for fees associated with the replacement of Your passport during Your Trip. Receipts are required for reimbursement. Baggage Delay (Outward Journey Only): The Insurer will reimburse You for expenses for necessary personal effects, up to the maximum shown on the Schedule of Coverage and Services, if Your checked Baggage is delayed or misdirected by a Common Carrier for more than 12 hours from the time You arrive at the destination stated on the ticket, except travel to Your final destination or Your place of residence. You must be a ticketed passenger of a Common Carrier. If You purchase Sports Coverage the Insurer will reimburse You up to the combined maximum limit shown on the Schedule of Coverage and Services for expenses for rental equipment if Your sporting equipment is delayed or misdirected by Common Carrier. PART C - MEDICAL PROTECTIONEmergency Accident and Sickness Medical Expense: The Insurer will pay benefits up to the maximum shown on the Schedule of Coverage and Services, for Covered Medical Expenses You incur during Your Trip for Emergency Treatment as a result of an Accidental Injury which occurs on the Trip or a Sickness which first manifests itself during the Trip. A $50 deductible applies to each occurrence. (The deductible is waived if You purchase the Medical Upgrade.) “Emergency Treatment” means necessary medical treatment, including services and supplies, which must be performed during the Trip due to the serious and acute nature of the Accidental Injury or Sickness.”Covered Medical Expenses” are necessary services and supplies which are recommended by the attending Physician. They include, but are not limited to: the services of a Physician; charges for Hospital confinement and use of operating rooms; charges for anesthetics (including administration); x-ray examinations or treatments, and laboratory tests ambulance service; and drugs, medicines, prosthetic and therapeutic services and supplies. The Insurer will not pay benefits in excess of the Reasonable and Customary Charges. “Reasonable and Customary Charges” means charges commonly used by providers of medical care in the locality in which care is furnished. The Insurer will not cover any expenses provided by another party at no cost to You or already included within the cost of the Trip. The Insurer will pay benefits, up to $750.00, for emergency dental treatment for Accidental Injury to sound natural teeth. The Insurer will advance payment to a Hospital, up to the maximum shown on the Schedule of Coverage and Services, if needed to secure Your admission to a Hospital because of Accidental Injury or Sickness. Emergency Evacuation:The Insurer will pay, subject to the limitations set out herein, for Covered Emergency Evacuation Expenses reasonably incurred if You suffer an Injury or Emergency Sickness that warrants Your Emergency Evacuation while You are on a Trip. Benefits payable are subject to the maximum amount per person shown on the Schedule of Coverage and Services for all Emergency Evacuations due to all Injuries from the same Accident or all Emergency Sicknesses from the same or related causes. A legally licensed Physician, in coordination with the Assistance Company, must order the Emergency Evacuation and must certify that the severity of Your Injury or Emergency Sickness warrants Your Emergency Evacuation to the closest adequate medical facility. In the sole discretion of the Assistance Company, it must be determined that such Emergency Evacuation is required due to the inadequacy of local facilities. The certification and approval for Emergency Evacuation must be coordinated through the most direct and economical conveyance and route possible, such as air or land ambulance, or commercial airline carrier. ”Emergency Evacuation” means Your medical condition warrants immediate transportation from the place where You are injured or sick to the nearest Hospital where appropriate medical treatment can be obtained. Transportation means any land, sea or air conveyance required to transport You during an Emergency Evacuation. Transportation includes, but is not limited to, Common Carrier, air ambulances, land ambulances and private motor vehicles. ”Covered Emergency Evacuation Expenses” are those for Medically Necessary Transportation, including Reasonable and Customary Charges for medical services and supplies incurred in connection with Your Emergency Evacuation. Expenses for Transportation must be:
”Emergency Sickness” means an illness or disease, diagnosed by a legally licensed Physician, which meets all of the following criteria:
The Pre-Existing Conditions Exclusion does not apply to Emergency Evacuation and Repatriation of Remains. All Transportation must be authorized and arranged by the Assistance Company. The Excess Insurance Limitation does not apply to Part C if You purchased the Medical Upgrade. PART D - TRAVEL ACCIDENT PROTECTIONAccidental Death & Dismemberment: If You sustain an Injury while on the Trip, which results in loss of life; actual severance of limb; or entire and irrecoverable loss of: eyesight, speech, or hearing; within 180 days of the date of the Accident, the Insurer will pay the largest applicable amount as follows: the full benefit amount is paid for
Exposure: The Insurer will pay benefits for covered losses which result from You being unavoidably exposed to the elements due to an Accident. Disappearance: The Insurer will pay benefits for loss of life if Your body cannot be located one year after the disappearance of the conveyance in which You were a passenger due to forced landing, stranding, sinking, or wrecking. Accidental Death and Dismemberment Common Carrier (Air Only): Air Common Carrier benefit applies to Injury sustained by You:
Exposure: The Insurer will pay benefits for covered losses which result from You being unavoidably exposed to the elements due to an Accident. Disappearance: The Insurer will pay benefits for loss of life if Your body cannot be located one year after the disappearance of the Common Carrier in which You were a passenger due to forced landing, stranding, sinking, or wrecking. PART E - COLLISION DAMAGE WAIVER (Not available for the residents of Oregon, Texas and Washington State): If You rent a car while on the Trip, and the car is damaged due to collision, theft, vandalism, windstorm, fire, hail, flood or any cause not within Your control while in Your possession, the Insurer will pay the lesser of:
Benefits provided in Parts A, B, C and Collision Damage Waiver shall be in excess of all other valid and collectible insurance or indemnity. If at the time of the occurrence of any loss there is other valid and collectible insurance or indemnity in place, the Insurer shall be liable only for the excess of the amount of loss, over the amount of such other insurance or indemnity, and applicable deductible. The Excess Insurance Limitation does not apply to Part C if You purchase the Medical Upgrade. TRAVEL ASSISTANCE SERVICESThe Travel Assistance feature provides a variety of travel related services. Services offered include:
24/7 Worldwide Assistance Services Travel Assistance, Medical Emergency, Concierge Service and ID Theft Service CALL TOLL FREE: (Within the United States and Canada) 800-494-9907 OR CALL COLLECT 202-659-7775 (From all other locations) Travel assistance services are provided by an independent organization and not by Arch Insurance Company or Travel Insured International. There may be times when circumstances beyond the Assistance Company’s control hinder their endeavors to provide travel assistance services. They will, however, make all reasonable efforts to provide travel assistance services and help You resolve Your emergency situation. AVAILABILITY OF SERVICESYou are eligible for informational and concierge services at any time after you purchase this plan. The Emergency Assistance Services become available when you actually start your trip. Emergency Assistance, Concierge and Informational Services end the earliest of: midnight on the day the program expires; when you reach your return destination; or when you complete your trip. The Identity Theft Resolution Services become available on your scheduled departure date for your trip. Services end 180 days (six months) from the date of your scheduled departure date for your trip. Identity Theft Resolution does not guarantee that its intervention on behalf of you will result in a particular outcome or that its efforts on behalf of you will lead to a result satisfactory to you. Identity Theft Resolution does not include and Identity Theft Resolution shall not assist you for thefts involving non-US bank accounts.DESCRIPTION OF IDENTITY THEFT RESOLUTION SERVICES ASSISTANCE SERVICES ARE PROVIDED BY TRAVEL INSURED’S DESIGNATED PROVIDER.If you believe you are victim of Identity Theft, please contact our assistance provider at 800-494-9907. A brief description of the service and terms of use are provided below. The assistance provider treats each “Identify Theft” as an emergency and, subject to the limitations set forth in this Program Description, performs, for you any or all of the following steps necessary to attempt to undo or prevent further damage upon receipt, by you, of a duly completed and executed “Authorization Form”.
Concierge Services are provided by Travel Insured’s designated provider. There is no charge for the services provided by Provider. You are responsible for the cost of services provided and charged for by third parties and for the actual cost of merchandise, entertainment, sports, tickets, food and beverages and other disbursement items. Services offered include:
Any loss or damage to:
To facilitate prompt claims settlement: TRIP CANCELLATION/ TRIP INTERRUPTION: Contact the travel supplier and Travel Insured as soon as possible after the event causing the need to cancel. Obtain medical statements from the doctors in attendance in the country where Sickness or Accident occurred. These statements should give complete diagnosis, stating that the Sickness or Accident prevented traveling on dates contracted. Provide all unused transportation tickets, official receipts, etc. TRIP DELAY/MISSED CONNECTION: Obtain any specific dated documentation, which provides proof of the reason for delay (airline or Cruise line forms, medical statements, etc). Submit this documentation along with Your Trip itinerary and all receipts from additional expenses incurred. MEDICAL EXPENSES: Obtain receipts from the providers of service, etc., stating the amount paid and listing the diagnosis and treatment: submit these first to other medical plans. Provide a copy of their final disposition of Your claim. BAGGAGE: Obtain a statement from the Common Carrier that Your Baggage was delayed or a police report showing Your Baggage was stolen along with copies of receipts for Your purchases. BENEFICIARY: Your estate, unless written notice of a designated beneficiary is provided to the Plan Administrator. GENERAL PROVISIONSCONTRACT. The policy, applications, riders, and endorsements, if any, make up the entire contract. No change in the policy is valid unless it is signed by an executive officer of the Insurer. No agent has the power to change this policy.CLERICAL ERRORS. The Insurer will not deny or cancel coverage on You because of clerical error by the participating organization or by the Insurer. After an error is found, the Insurer will take appropriate action. This may include adjusting, collecting, or refunding premium. LEGAL ACTIONS. No legal action for a claim can be brought against us until sixty (60) days after we receive proof of loss. No legal action for a claim can be brought against us more than two (2) years after the time required for giving proof of loss. CONTROLLING LAW. Any part of this policy that conflicts with the state law where the policy is issued is changed to meet the minimum requirements of that law. MISREPRESENTATION AND FRAUD. Coverage as to You shall be void if, whether before or after a loss, You have concealed or misrepresented any material fact or circumstance concerning this policy or the subject thereof, or the interest of You therein, or if You commit fraud or false swearing in connection with any of the foregoing. SUBROGATION. To the extent the Insurer pays for a loss suffered by You, the Insurer will take over the rights and remedies You had relating to the loss. This is known as subrogation. You must help the Insurer to preserve its rights against those responsible for the loss. This may involve signing any papers and taking any other steps the Insurer may reasonably require. If the Insurer takes over Your rights, You must sign an appropriate subrogation form supplied by the Insurer. ASSIGNMENT. This policy is not assignable but benefits may be assigned. WHEN YOUR COVERAGE BEGINS. All coverage (except Trip Cancellation) will take effect at 12:01 A.M. local time, at Your location, on the Scheduled Departure Date provided:
WHEN YOUR COVERAGE ENDS. Your coverage ends at 11:59 P.M. local time on the date which is the earliest of the following:
AMOUNT OF PREMIUM. The amount of premium due from the participating organization is calculated by multiplying the number of Insureds in each class by the amounts due for the benefits for that class and adding the total amounts due for each class. The amount of premium due for each Insured is obtained by adding the total rate charged for each benefit provided for that Insured. MODE OF PREMIUM: Insured: The required premium must be paid to the participating organization or its authorized representative prior to the Scheduled Departure Date of the Covered Trip. Participating Organization: The Participating Organization will pay the premium according to the schedule noted in the travel protection policy application. ARBITRATION. Notwithstanding anything in this policy to the contrary, any claim arising out of or relating to this contract, or its breach, will be settled by arbitration administered by the American Arbitration Association in accordance with its Commercial rules except to the extent provided otherwise in this clause. Judgment upon the award rendered in such arbitration may be entered in any court having jurisdiction thereof. All fees and expenses of the arbitration shall be borne by the parties equally. However, each party will bear the expense of its own counsel, experts, witnesses, and preparation and presentation of proofs. The arbitrators are precluded from awarding punitive, treble, or exemplary damages, however so denominated. If more than one Insured is involved in the same dispute arising out of the same policy and relating to the same loss or claim, all such Insureds will constitute and act as one party for the purposes of the arbitration. Nothing in this clause will be construed to impair the rights of the Insureds to assert several, rather than joint, claims or defenses. This section does not apply to Kansas residents. CLAIMS. Death claims will be paid to Your estate, unless we receive a written request from You designating a named beneficiary. All other claims will be paid to You. In the event You are a minor, incompetent, or otherwise unable to give a valid release for the claim, the Insurer may make arrangement to pay claims to Your legal guardian, committee, or other qualified representative. Any payment made in good faith will discharge the Insurer’s liability to the extent of the claim. The Claimant (either You or someone acting for You) must notify the Insurer or its designated agent in writing about the claim. Correspondence should be sent to the administrative office, at the address shown on the cover page of the policy or Your designated agent. Such notification should include Your name and the plan number. The Claimant should notify the Insurer within twenty (20) days after a covered loss occurs or as soon as reasonably possible. NOTICE OF CLAIM. Written notice of claim must be given to the Insurer or its designated representative within twenty (20) days after a covered loss first begins or as soon as reasonably possible. Notice should include Your name and policy number. PROOF OF LOSS. The claimant must send the Insurer, or its designated representative, proof of loss with ninety (90) days after a covered loss occurs or as soon as reasonably possible. PAYMENT OF CLAIMS. The Insurer, or its designated representative, will pay a claim after receipt of acceptable proof of loss. Benefits for loss of life are payable to Your beneficiary. If a beneficiary is not otherwise designated by You benefits for loss of life will be paid to the first of the following surviving preference beneficiaries:
PHYSICAL EXAMINATION AND AUTOPSY. The Insurer, or its designated representative, at their own expense, have the right to have You examined as often as reasonably necessary while a claim is pending. The Insurer, or its designated representative, also have the right to have an autopsy made unless prohibited by law. The following provisions apply to Baggage/Personal Effects and Baggage Delay coverage only: NOTICE OF LOSS. If Your property covered under this policy is lost, stolen, or damaged, You must:
SETTLEMENT OF LOSS. Claims for damage and/or destruction shall be paid after acceptable proof of the damage and/or destruction is presented to the Insurer and the Insurer has determined the claim is covered. Claims for lost property will be paid after the lapse of a reasonable time if the property has not been recovered. You must present acceptable proof of loss and the value involved to the Insurer. VALUATION. The Insurer will not pay more than the Actual Cash Value of the property at the time of loss. Damage will be estimated according to Actual Cash Value with proper deduction for depreciation. At no time will payment exceed what it would cost to repair or replace the property with material of like kind and quality. DISAGREEMENT OVER SIZE OF LOSS. If there is a disagreement about the amount of the loss, either You or the Insurer can make a written demand for an appraisal. After the demand, You and the Insurer will each select Your own competent appraiser. After examining the facts, each of the two appraisers will give an opinion on the amount of the loss. If they do not agree, they will select an arbitrator. Any figure agreed to by 2 of the 3 (the appraisers and the arbitrator) will be binding. The appraiser selected by You is paid by You. The Insurer will pay the appraiser they choose. You will share equally with the Insurer the cost for the arbitrator and the appraisal process. BENEFIT TO BAILEE. This insurance will in no way inure directly or indirectly to the benefit of any carrier or other bailee. Plan is designed by Travel Insured International, Inc. This Insurance, under policy #LTP 2007 is underwritten by: Arch Insurance Company, with its principal place of business in New York, NY STATE EXCEPTIONSALABAMA RESIDENTS:The Legal Actions Provision is deleted in its entirety and replaced with the following: LEGAL ACTIONS. The time period by which a legal action relating to this policy must be filed is governed by Alabama law. ARKANSAS RESIDENTS:The Arbitration Provision is deleted in its entirety and replaced with the following:ARBITRATION. Upon the mutual agreement of the Company and Insured, at the time of a loss, any claim arising out of or relating to the Policy, or its breach, will be settled by non-binding arbitration administered by the American Arbitration Association in accordance with its Commercial rules except to the extent provided otherwise in this clause. Judgment upon the award rendered in such arbitration may be entered in any court having jurisdiction thereof. All fees and expenses of the arbitration shall be borne by the parties equally. However, each party will bear the expense of its own counsel, experts, witnesses, and preparation and presentation of proofs. The arbitrators are precluded from awarding punitive, treble or exemplary damages, however so denominated. If more than one Insured is involved in the same dispute arising out of the same Policy and relating to the same loss or claim, all such Insureds will constitute and act as one party for the purposes of the arbitration. Nothing in this clause will be construed to impair the rights of the Insureds to assert several, rather than joint, claims or defenses and nothing in this clause will impair the rights of the insured or Company to seek settlement in a court of jurisdiction. The following Definition is added. “Punitive Damages” and “Exemplary Damages” mean damages imposed to punish a wrongdoer and to deter others from similar conduct. ILLINOIS RESIDENTS:The following definitions are revised: “Accidental Injury” means Bodily Injury caused by an accident being the direct and independent cause in the loss. “Bodily Injury” means identifiable physical injury which:
INSURANCE WITH OTHER COMPANIES. If there is other valid coverage, not with this company, providing benefits for the same loss on other than an expense-incurred basis and of which this company has not been given written notice prior to the occurrence or commencement of loss, the only ability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the company had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro-rata portion for the indemnities thus determined. ARBITRATION. An arbitration provision is not a substitute for a person’s right to maintain a legal action if they so desire; and in no way affects or limits a person’s ability to take legal action in a court of law, prior to voluntarily agreeing to enter into an arbitration proceeding. Any controversy or claim arising out of or relating to this contract, or the breach thereof, may be settled by arbitration. The arbitration will be conducted pursuant to the applicable rules of the American Arbitration Association and in accordance with the Uniform Arbitration Act within reasonable time limit (30 days after the parties agree to arbitrate their dispute is a reasonable time limit for selected and appointing independent arbitrators, 15 days is a reasonable time limit for an expedited review provision). The arbitration may be binding on both parties, but in all instances must be entered into on a voluntary basis. Arbitrators must be fair, impartial, and free of any conflicts of interest or the appearance of a conflict of interest. By voluntarily agreeing to enter into an arbitration proceeding, the parties should be aware and understand that they may be giving up certain rights to have their dispute settled in a court of law, except to the extent that Illinois law may provide for judicial review of arbitration proceedings. TIME PAYMENT OF CLAIMS. Claims payable under this policy shall begin to be paid in period payments no later than the 30th day after You received notice of a health care selection. All subsequent payments will be made in accordance with the monthly periodic cycle. Failure to pay within such period shall entitle the payee to interest at the rate of 9% per annum from the 30th day after receipt of such proof of loss to the date of late payment, provided that interest amounting to less than one dollar need not be paid. Any required interest payments shall be made within 30 days after the payment. The following Exclusion is deleted (3) participating in bodily contact sports. Exclusion (2) shall read: “War, invasion, hostilities between nations (whether declared or not), civil war; KANSAS RESIDENTS: The Subrogation provision does not apply to medical, surgical, Hospital, or funeral expenses. Legal Actions is revised as follows: “No legal action for a claim can be brought against us more than five (5) years after the time required for giving proof of loss.” A Claim Forms provision was added: “The Insurer, upon receipt of a 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 policy as to proof of loss upon submitting within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character, and the extent to the loss for which claim is made.” A Time of Payment of Claims provision was added to the policy: “Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid monthly, and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.” A definition of “Usual, Customary, and Reasonable” was added to the policy: “charges commonly Used by Physicians in the locality in which care is furnished, as determined by the Administrator’s database (Ingenix, Medicaid, other) and updated at least every 6 months.” The definition of Family Member is revised to read “Family Member” means Your
KENTUCKY RESIDENTS:The Arbitration Provision is deleted in its entirety and replaced with the following:ARBITRATION. If the Company and the Insured agree to Arbitration at the time of a loss, a claim arising out of or relating to the Policy, or its breach, will be settled by arbitration administered by the American Arbitration Association in accordance with its Commercial rules except to the extent provided otherwise in this clause. Judgment upon the award rendered in such arbitration may be entered in any court having jurisdiction thereof. All fees and expenses of the arbitration shall be borne by the parties equally. However, each party will bear the expense of its own counsel, experts, witnesses, and preparation and presentation of proofs. The arbitrators are precluded from awarding punitive, treble or exemplary damages, however so denominated. If more than one Insured is involved in the same dispute arising out of the same Policy and relating to the same loss or claim, all such Insureds will constitute and act as one party for the purposes of the arbitration. Nothing in this clause will be construed to impair the rights of the Insureds to assert several, rather than joint, claims or defenses MAINE RESIDENTS:The MISREPRESENTATION AND FRAUD Provision is revised as follows:MISREPRESENTATION AND FRAUD. Coverage as to an Insured shall be denied or cancelled if, whether before or after a loss, the Insured has concealed or misrepresented any material fact or circumstance concerning the Policy or the subject thereof, or the interest of the Insured therein, or if the Insured commits fraud or false swearing in connection with any of the foregoing. MARYLAND RESIDENTS:If this policy is financed by a premium financed by a premium finance company and we (the Insurer) or the premium finance company or the first named Insured cancels the policy, the refund will be pro rata excluding any expense constant, administrative fee, or nonrefundable charge filed with and approved by the insurance commissioner. Legal Actions provision in the policy was revised to provide 3 years (not 2) for an Insured to file a legal action against the insurance company. The Cancellation and Nonrenewal provision in the policy is revised to provide at least 45 days notice of cancellation by the company for any reason other than non-payment of premium. The provision is also revised to state that “All notices will be sent to the Insured by certificate of mailing.”MISSOURI RESIDENTS:“Bodily Injury” means identifiable physical Injury which:
NEW YORK RESIDENTS:“Domestic Partner” means a person who has registered as a Domestic Partner in a municipality that requires such registration or has provided Us with a signed and notarized Affidavit of Partnership in municipality that do not require such registration. The Affidavit will attest to the following:
The definition of “Complication of Pregnancy” is revised to read: “Complication of Pregnancy” means:
NORTH CAROLINA RESIDENTS:The Legal Action Provision is deleted in its entirety and replaced with the following:LEGAL ACTIONS. No legal action for a claim can be brought against the Company until sixty (60) days after the Company receives proof of loss. No legal action for a claim can be brought against the Company more than three (3) years after the time required for giving proof of loss. The Subrogation provision is deleted. The Excess Insurance Limitation is deleted in the entirety and replaced by the following: EXCESS INSURANCE LIMITATION The Insurance provided by the Policy shall be in excess of all other valid and collectible insurance or indemnity other than private passenger auto no-fault benefits or third part liability insurance. If at the time of the occurrence of any loss there is other valid and collectible insurance or indemnity in place, the Company shall be liable only for the excess of the amount of loss, over the amount of such other insurance or indemnity, and applicable deductible. The definition of “Pre-Existing Condition” is deleted in the entirety and replaced by the following: "Pre-Existing Condition" means any injury, sickness or condition of You, a Traveling Companion, or You and/or Your Traveling Companion's Family Member for which within the one hundred eighty (180) day period prior to the effective date under the Policy
Exclusion 2 is deleted in its entirety and replaced by the following: 2. War, whether declared or not declared. OKLAHOMA RESIDENTS:The following Fraud Statement is added:Warning: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, makes any claim for proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of felony. WHEN YOUR COVERAGE ENDS provision is deleted in its entirety and replaced by the following: WHEN YOUR COVERAGE ENDS. Your coverage will end at 12:01 am Standard Time on the date which is the earliest of the following:
The Legal Actions provision is deleted and replaced by the following: LEGAL ACTIONS - No legal action for a claim can be brought against the Company until sixty days the Company receives written proof of loss. No legal action for a claim can be brought against the Company more than three (3) years after the time required for giving written proof of loss. The following is added to the definition of “Dependent Child(ren)” Subject to the age limits stated above, and subject to providing the Company with written notice within 31 days of obtaining custody, a Dependent child also means the Insured Person’s adopted child from the date the child is placed in the custody of the Insured Person and/or a child in the temporary care of the Insured Person pursuant to an interlocutory decree issued under Title 10 of the Oklahoma statutes during the pendency of an adoption proceeding regardless of whether a final decree of adoption is ultimately issued. Exclusion 2 is deleted and replaced by the following: 2. War or any act of war whether declared or undeclared while serving in military service or any auxiliary thereto; Exclusion 8 is deleted. For exclusions that apply to Baggage/Personal Effects, Baggage Delay, Lost Baggage: the phrase “war or any act of war whether declared or not” is deleted and replaced by the following: “War or any act of war whether declared or undeclared while serving in military service or any auxiliary thereto.” OREGON RESIDENTS:Trip Cancellation and Interruption: (d) is deleted Trip Cancellation (g) is revised to read as follows: “A politically motivated Terrorist Attack outside the United States unless You deliberately traveled to such destination after the United States Government issued a ‘do not travel’ advisory for such destination.” Trip Interruption (g) is revised to read as follows: If there is a politically motivated Terrorist Attack in the City of Your program; coverage is provided for the cost of an economy one-way coach ticket not to exceed $250, for the additional transportation required returning the covered person back to the City of departure. Once the program has begun, there is no provision for recovery of transportation, tuition, room and board, or other fees; Exclusion #2 is revised to read: “War or act of war (whether declared or not);” The following General Provisions sections are deleted: Records, Clerical Errors, Contesting This Policy, Legal Actions, Controlling Law, Cancellation and Non-Renewal, Policy Term, Premium, Amount of Premium, Mode of Premium, Premium Rate Change, and Claims. The following General Provisions sections have been revised: MISREPRESENTATION AND FRAUD: All statements and descriptions in any enrollment form for this policy by or in behalf of You or any other Insured, shall be deemed to be representations and not warranties. Misrepresentations, omissions, concealments of facts and incorrect statements shall not prevent a recovery under the policy unless the misrepresentations, omissions, concealments of fact, and incorrect statements:
NOTICE OF CLAIM: Written notice of claim must be given by the Claimant (either You or someone acting on Your behalf) to the Insurer or its designated representative within fifteen (15) days after a covered loss first begins or as soon as reasonably possible. Notice should include Your name and the plan number. Notice should be sent to the Insurer’s administrative office, at the address shown on the cover page of the policy, or to the Insurer’s designated representative. DISAGREEMENT OVER SIZE OF LOSS: If there is a disagreement about the amount of the loss either You or the Insurer can make a written demand for an appraisal. Such request for appraisal will be by mutual consent and take place in Oregon according to Oregon law. After the demand, You and the Insurer will each select Your own competent appraiser. After examining the facts, each of the two appraisers will give an opinion on the amount of the loss. If they do not agree, they will select an arbitrator. Any figure agreed to by 2 of the 3 (the appraisers and the arbitrator) will be binding. You pay for the appraiser selected by You. The Insurer will pay the appraiser they choose. You will share equally with the Insurer the cost for the arbitrator and the appraisal process. PENNSYLVANIA RESIDENTS:The last paragraph of the CANCELLATION Provision is deleted and replaced by the following: The Company will mail all notices of cancellation for nonpayment of premium thirty (30) days in advance prior to cancellation.TEXAS RESIDENTS:The Legal Actions provision is revised to permit suits against the insurers within 2 years and one day after the loss. The Cancellation and Nonrenewal provision is revised so that it states “The Insurer cannot cancel or refuse to renew a policy or contract of insurance based solely on the fact that the policyholder in question is an elected official.” The following definitions are revised as follows: “Physician” means a licensed practitioner of medical, surgical, the healing arts, or dental services acting within the scope of his/her license. The treating Physician may not beYou, a Traveling Companion, or a Family Member. Medical Evacuation/Repatriation benefit has been revised so that pre-approval is not required and cannot be a reason for denial of the benefit, but a 50% or $500 penalty is permitted. |