|Summary of Coverage||Passport Medical Client Coverage Summary|
|Coverage provided by Certain Underwriters at Lloyd’s, London. Contract #PUSNA1101288|
|Accidental Death & Dismemberment||N/A|
|Disability Income Benefit for Permanent Total Disability||N/A|
|*Emergency Medical Transportation||$50,000.00|
|Repatriation of Mortal Remains||$5,000.00|
|24 Hour Assistance Service provided for assistance with Worldwide Covered Emergencies||Included|
|*Emergency Medical Coverage – Accidental Injury and subject to a $250.00 Deductible||$25,000.00|
|*Included for sudden accidents while traveling for an approved medical procedure and not related to a complication of the procedure.|
|BELOW COVERAGES APPLY TO ENROLLEE/PATIENT ONLY|
|Additional Medical or Surgical Treatment as a result of a covered complication||$10,000.00|
|Additional Medical or Surgical Treatment for Thrombosis as a result of a covered complication||$5,000.00|
|Additional Expenses of Travel, Meas, and Accommodations required for a covered corrective procedure||$5,000.00|
|Dependent Care/Family Coordination expenses incurred as a result of a covered additional medical treatment||$2,500.00|
|Physiotherapy and Rehabilitation||$10,000.00|
|Loss of Reproductive Function||N/A|
|Notes||Please Note: This brief summary is not an insurance policy, rather, it outlines some of the features of this coverage. For specific details, please consult the Master Policy.
Also Note: This is not a major medical policy.This is and accident policy which includes complications as a result of an accident. It is not meant to cover failed or undesirable outcomes.
|Rate||Your rate has been included in your pricing from Passport Medical for the above limits. You have an option to increase your limit for Additional Medical or Surgical Treatment to $15,000 or $25,000. Please ask Passport Medical for the cost associated with an increased limit.|
|Eligibility||Coverage eligibility is based on approved procedures and qualified facilities. These criteria are confirmed at claim time. If you need specific confirmation that you are having an approved procedure at an approved facility, please contact us. Please note, coverage will not extend beyond 30 days of departure without prior additional consideration by the underwriter.|
|Enrollment Procedure||Passport Medical is gathering all the data needed to enroll you in the plan. However, we will need a signed or acknowledged participation agreement and a physician’s release that you are fit to travel and have the procedure you have elected.|
|Custom Assurance Placement, Ltd.
P.O. Box 5736, Columbia, South Carolina 29250-5736 USA
Phone: (803) 799-1770 – Fax: (803) 799-1877 – www.customassurance.com