A sudden, unintentional and unexpected occurrence directly caused by external, visible means and resulting in physical Injury to the Insured Person. The cause or one of the causes of such Accident must be external to the Insured Person's own body and must occur beyond the Insured Person's control.
Death of the Insured Person resulting from an Accident.
Complete severance from the body of one or more limbs or eyes resulting from an Accident. For purposes of the Accidental Dismemberment benefits provided by this insurance, the term “limb” shall mean: the arm, when the severance is at or above (toward the elbow) the wrist, or the leg, when the severance is at or above (toward the knee) the ankle. Loss of eye(s) shall include complete, permanent and irrevocable loss of sight.
Act of Terrorism
An act, including without limitation, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear
Actual Cash Value
The replacement cost of an item, less proper deduction for depreciation at the time of the loss.
Acute Onset of Dental Pain
Sudden and unexpected experience of severe pain in the teeth, gums or bones supporting the teeth.
Acute Onset of Pre-existing Condition
A sudden and unexpected outbreak or recurrence of a Pre-existing Condition which occurs: (1) spontaneously and without advance warning in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires Emergency medical care; and (2) after the Certificate Effective Date; and (3) prior to the age indicated in the Schedule of Benefits and Limits contained herein. Treatment by a Physician must be obtained within the twenty-four (24) hours beginning on the date and at the time of the sudden and unexpected outbreak or recurrence.
A sporting activity undertaken for the purposes of recreation or an unusual experience or excitement, typically performed outdoors, and involving a medium degree of risk, including only the following:
Downhill and/or cross-country snow skiing and snowboarding and snowmobiling, provided that such activity is not in any violation of applicable laws, rules or regulations or away from prepared and marked in-bound, patrolled territories or against the advice of the local ski school or local authoritative body.
Hot air ballooning
Kitesurfing and Kiteboarding
Mountaineering below 4,500 meters from ground level
Motorcycle riding as a driver or passenger
Scuba diving or sub-aqua pursuits at less than depth of 50 meters
Whitewater kayaking or whitewater rafting in water less than Class V difficulty
Acquired Immune Deficiency Syndrome as that term is defined by the United States Centers for Disease Control and Prevention
An amateur or other non-professional sporting, recreational or athletic activity that is organized, sponsored and/or sanctioned, and/or involves regular or scheduled practices, games and/or competitions. Amateur Athletics includes, without limitation, intercollegiate, interscholastic and intermural sports. Amateur Athletics does not include athletic activities that are non-organized, non-contact, and engaged in by the Insured Person solely for recreational, entertainment or fitness purposes.
All Hospital services for a patient other than room and board and professional services. Laboratory tests and radiology are examples of Ancillary Services.
AIDS Related Complex as that term is defined by the United States Centers for Disease Control and Prevention.
The organization indicated on the Master Policy Declaration.
The individual named in the Insured Person's Application to be the recipient of any Accidental Death or Common Carrier Accidental Death benefit. For Insured Persons age 18 and older who do not designate a Beneficiary on the Application, the Beneficiary is automatically as follows: 1) Spouse (if any), 2) Children (if any) equally, 3) Estate of the Insured Person. For Insured Persons who are under age eighteen (18) who do not designate a Beneficiary on their Application, the Beneficiary is automatically as follows: 1) Custodial parent(s) (if any), 2) Siblings (if any) equally, 3) Estate of the Insured Person.
One hundred eighty (180) consecutive days beginning on the first day of treatment by a Physician of a covered Injury or Illness that occurs during the Certificate Period.
The document, including the Certificate Declaration, which is issued to Insured Persons and is a summary of this Master Policy and evidence of the Insured Person’s coverage hereunder.
The document that is attached to the Certificate issued to Insured Persons.
Certificate Effective Date
The date and time coverage under this insurance begins with respect to an Insured Person.
The period of time beginning on the Certificate Effective Date and ending on the Certificate Termination Date.
Certificate Termination Date
The date and time coverage under this insurance ends with respect to an Insured Person.
The payment by or obligation of the Insured Person for payment of covered expenses at the percentage specified in the Schedule of Benefits and Limits.
A company or organization that holds itself out to the public as engaging in the business of transporting persons from place to place by air, rail, bus and/or water for compensation, offering its scheduled services to the public generally, and is licensed by a recognized and approved government authority to transport fare-paying passengers. The term Common Carrier does not include taxi, motorcar, motorcycle or limousine services, or transportation by animal or human means (for example, horse, camel, elephant or riskshaw).
A physical abnormality, defect or medical condition existing at or before birth, regardless of cause or when diagnosed or treated.
A sport in which the participants purposely hit or collide with each other,
inanimate objects, the ground or water, with force, including without limitation:
High diving and cliff diving
Fighting or combat sports, including without limitation, boxing, wrestling, martial arts, mixed
martial arts, fencing and kickboxing
Hockey, including ice and field hockey
Covered Electronics and Communication Equipment
The following items exclusively: mobile phones, tablets and laptop computers.
Covered Personal Equipment
Covered Sports Equipment, Covered Photography Equipment and Covered Electronics and Communication Equipment exclusively.
Covered Photography Equipment
The following items exclusively: cameras, camera flash accessories and camera lenses.
Covered Sports Equipment
The following items exclusively: skis, ski boots, ski poles, snowboards, snowboard boots, golf clubs, golf bags, tennis rackets.
That type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist an Insured Person in performing the activities of Daily Living. Custodial Care also includes non-acute care for the comatose, semi- comatose, paralyzed or mentally incompetent patients until they are fit to return home.
A twenty-four (24) hour period during which an Insured Person engages in normal daily activities including but not limited to eating, drinking and washing.
The dollar amount of Eligible Medical Expenses, specified in the Master Policy, that the Insured Person must pay before receiving benefits or coverage hereunder, not including any applicable Coinsurance.
Treatment and/or supplies relating to the care, maintenance or repair of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.
A member of the species felis catus, which is ordinarily kept as an indoor pet.
A member of the species canus lupus familiarus, which is ordinarily kept as an
Durable Medical Equipment
Exclusively a standard basic hospital bed and/or a standard basic wheelchair.
Educational or Rehabilitative Care
Care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy. Eligible Medical Expenses: Expenses for services and supplies for treatment of Injury or Illness.
Eligible Medical Expenses
Expenses for services and supplies for treatment of Injury or Illness which are covered under this insurance.
A medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s life or limb in danger if medical attention is not provided within twenty-four (24) hours based upon reasonable medical certainty. Immediate medical intervention and attention is required as a result of a severe, life threatening or potentially disabling condition.
A licensed, formal establishment which operates as a boarding kennel where the Insured Person’s pet is housed temporarily, following the Insured Person’s Hospitalization for a covered Injury or Illness and who charges boarding fees.
That part of a Hospital designated for the immediate care of Emergency medical conditions.
Extended Care Facility
An institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation facility by the jurisdiction in which it operates; and is regularly engaged in providing twenty-four (24) hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a Physician; and provides each patient with active treatment of an Illness or Injury. Extended Care Facility does not include a facility primarily for rest, the aged, Substance Abuse treatment, Custodial Care, nursing care or for care of Mental Health Disorders or the mentally incompetent.
A sporting activity, including practice, preparation and actual sporting events, which involves a high degree of risk. These activities often involve speed, height, a high level of physical exertion and/or highly specialized gear, and often carry the potential risk of serious or permanent physical Injury and even death. These activities include, without limitation, the following and any combination or derivative of the following:
Back country snow skiing, snowboarding or snowmobiling
Downhill mountain biking
Free running and Parkour
Racing any vehicle or animal, including mountain bikes, motocross, motorcycle racing, motor rally, snowmobile racing, truck racing, horse racing, boat racing
Mountaineering above elevation of 4,500 meters from ground level
Piloting a commercial or non-commercial aircraft
Snow skiing, snowboarding or snowmobiling off piste
Scuba diving or sub-aqua pursuits below a depth of 50 meters
Whitewater kayaking or whitewater rafting Class V or higher difficulty (Class V = A section of a river, stream or other waterway or watercourse where the current moves with enough speed or force to meet, but not to exceed, the qualifications of Class V as determined by the International Scale of River Difficulty or as commonly published by a local authority or government agency.)
All Relatives of an Insured Person.
Laboratory evidence defined by the United States Centers for Disease Control and Prevention as being positive for Human Immunodeficiency Virus infection.
The country where the Insured Person principally resides as declared on the Insured Person’s Application, except for US citizens and Lawful Permanent Residents of the US. For US citizens, including those with dual citizenship, the US is always your Home Country. For non-US citizens who are Lawful Permanent Residents of the US, the US is always your Home Country.
Home Health Care Agency
A public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse, and maintains a daily record on each patient, and provides each patient with a planned program of observation and treatment prescribed by a Physician.
Home Nursing Care
Services provided by a Home Health Care Agency and supervised by a Registered Nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of Medically Necessary Inpatient care in a Hospital.
An institution which operates as a Hospice, is licensed by the state or country in which it operates; and operates primarily for the reception, care and palliative control of pain for terminally ill persons who have, as certified by a Physician, a life expectancy of not more than six (6) months.
An institution which operates as a Hospital pursuant to law, and is licensed by the State or Country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as Inpatients; and provides twenty-four (24) hour nursing service by Registered Nurses on duty or call; and has a staff of one or more Physicians available at all times; and provides organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, long-term care facility, Extended Care Facility, nursing, rest, Custodial Care or convalescent home, a place for the aged, drug addicts or abusers, alcoholics or runaways; or similar establishment.
Confined and/or treated in a Hospital as an Inpatient.
The country being visited by the Insured Person, or where the Insured Person resides temporarily. Host Country does not include the Insured Person’s Home Country.
A sickness, disorder, pathology, abnormality, ailment, disease or any other medical, physical or health condition. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.
Incidental Trip Home
A period of time not to exceed fourteen (14) days during a Certificate Period during which an Insured Person is covered for Eligible Medical Expenses incurred in his or her Home Country. An Incidental Trip Home begins on the date and time the Insured Person departs his or her Host Country to return to his or her Home Country, and ends on the next date and time the Insured Person departs his or her Home Country, subject to a maximum of 14 days. The Incidental Trip Home benefit is only available to Insured Person’s with Certificate Periods of ninety (90) days or more.
Identifiable physical harm to the body caused by an Accident that requires medical treatment.
A patient who occupies a Hospital bed for more than twenty-four (24) hours for medical treatment and whose admission was recommended by a Physician.
An individual who meets the Eligibility requirements herein, and has completed the Application and been accepted for coverage hereunder.
Insured Person's Application; Application
The fully answered and signed (including electronic signatures) form that is submitted by or on behalf of the Insured Person for acceptance into the insurance provided under this Master Policy, submitted to the Plan Administrator and maintained on file with the Plan Administrator. Any insurance agent/broker or other person or entity assigned to, soliciting, or assisting with the Application is the agent and representative of the applicant/Insured Person and is not and shall not be deemed or considered as an agent or representative for or on behalf of Underwriters or the Plan Administrator.
Intensive Care Unit
A Cardiac Care Unit or other unit or area of a Hospital that meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations for Special Care Units.
Interfacility Ambulance Transfer
Movement of the patient locally from one licensed health care facility to another licensed health care facility via air or land ambulance.
Investigational, Experimental or for Research Purposes
Terms used to describe procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current medical practice.
Lawful Permanent Resident(s) of the US; US Resident(s)
An individual who is not a citizen of the US who is living in the US under legally recognized and lawfully recorded permanent residence as an immigrant.
Transportation and accompanying treatment provided by licensed, qualified professional emergency personnel from the location of a covered Accident, Injury or acute Illness to a Hospital or other appropriate health care facility.
Master Policy Declaration
The document that is attached to and forms a permanent part of this Master Policy.
Master Policy Period
The period of time beginning on the Effective Date and ending on the Termination Date indicated on the Master Policy Declaration attached hereto.
Medically Necessary or Medical Necessity
A service or supply which is necessary and appropriate for the diagnosis or treatment of an Illness or Injury based on generally accepted current medical practice as determined by Underwriters. A service or supply will not be considered Medically Necessary if it is provided only as a convenience to the Insured Person or Medical Provider, and/or is not appropriate for the Insured Person's diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment of an Illness or Injury.
A Hospital, Physician or other person or organization which provides medical services and/or supplies.
Mental Health Disorder(s)
A mental, nervous or emotional Illness which generally denotes an Illness of the brain with predominant behavioral symptoms; or an Illness of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. Mental Health Disorders include, without limitation, those psychiatric Illnesses listed in the current edition of the International Classification of Diseases as published by the US Department of Health and Human Services and those psychiatric and other mental Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.
Widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm or other storm, landslide or other natural catastrophe or event resulting in immigration of human population for its safety. The occurrence must be a disaster that is due entirely to forces of nature and could not reasonably have been prevented.
Infants under the age of thirty-one (31) days.
An Insured Person who receives Medically Necessary treatment by a Physician for Injury or Illness who is not admitted as an Inpatient, regardless of the hour the Insured Person arrived to the Hospital, whether a bed was used or whether the Insured Person remained in the Hospital past midnight.
A Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DDM), Doctor of Podiatry (DPM) or a licensed Physical Therapist or Physiotherapist. Physician 40 also includes a Certified Nurse Practitioner (CNP), a Certified Registered Nurse Anesthetist (CRNA), Nurse Midwife or Physician Assistant (PA) under the direction of a medical doctor. Physician does not include a Doctor of Chiropractic (DC), a Doctor of Osteopathy (DO), a Doctor of Psychology (Ph.D), a Doctor of Psychiatry (Psy.D) or any other degree or designation. A Physician must be currently licensed by the jurisdiction in which the services are provided, and the services provided must be within the scope of that license. A Physician must be a person other than the Insured Person, the Insured Person’s Relative, or one who ordinarily resides with the Insured Person.
The Plan Administrator for this insurance is Point Comfort Underwriters, Inc., 306 Prospect Street, Indianapolis, Indiana, 46225. As the Plan Administrator, Point Comfort Underwriters, Inc. acts solely as the disclosed and authorized agent and representative for and on behalf of Underwriters, and does not have, and shall not be deemed, considered or alleged to have any direct, indirect, joint, several, separate, individual or independent liability, responsibility or obligation of any kind under this Master Policy, including the Master Policy Declaration and any exhibits, schedules, and/or endorsements attached hereto, or any Certificates, including Certificate Declarations, issued to Insured Persons, or to any other person or entity, including without limitation, any Physician, Hospital or Medical Provider or supplier.
Political Evacuation and Repatriation
Transportation of an Insured Person to an alternative country or location, and/or to the Insured Person’s Home Country, which becomes necessary due to Political Threat in the proximity of the Insured Person.
Political and/or military events which have created a situation in which the Insured Person is in danger of or has incurred serious bodily harm.
Any (1) condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the two (2) years immediately preceding the Certificate Effective Date; (2) condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the two (2) years immediately preceding the Certificate Effective Date; (3) Injury, Illness, sickness, disease, or other physical, medical, mental, or nervous condition, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of the Insured Person’s Application or within the two (2) years immediately preceding the Certificate Effective Date.
A group, individual or a government health plan (Medicaid, Medicare and V.A. health plans are considered Primary Insurance) that is the first pay or of claims for an Insured Person, in effect prior to the Certificate Effective Date and in effect at the time of any claim hereunder. Such plans must have coverage limits of at least $250,000 per incident or per year to be considered Primary Insurance for the purpose of determining the amount of benefits available with respect to an Acute Onset of Pre-existing Condition.
The location, indicated on the Insured Person's Application, where the Insured Person ordinarily resides, not including locations in the Host Country. If more than one location meets this criteria, the Principal Residence is the location that meets this criteria and is listed on the Insured Person’s Application.
A sporting activity, including practice, preparation and actual sporting events, for any individual or organized team that is a member of a recognized professional sports organization, is a member of a playing league that is directly supported or sponsored by a professional team or professional sports organization, or has any athlete receiving for his or her participation any kind of payments or compensation, directly or indirectly, from a professional team or professional sports organization.
Proof of Claim
A completed and signed Claimant’s Statement and Authorization form, together with any/all required attachments, original itemized bills from Physicians, Hospitals and other Medical Providers, original receipts for any expenses which have already been paid by or on behalf of the Insured Person, and any other documentation that is deemed necessary by the Underwriters.
A graduate nurse who has been registered or licensed to practice by the local authority Board of Nurse Examiners or any other authority, and who is legally entitled to place the letters “RN” after his or her name.
Biological or stepparent or grandparent; biological or stepchild or grandchild; current spouse; biological or stepsibling; parent, children, or sibling in law; aunt, uncle or cousin; fiancé or betrothed individual.
Routine Physical Exam
Examination of the physical body by a Physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition.
Sexually Transmitted Diseases
Syphilis, gonorrhea, lymphogranuloma venereum, chancroid, granuloma inguinale, chlamydiosis, pelvic inflammatory disease, trichomoniasis, genital candidiasis, genital herpes, genital warts, amebiasis, viral hepatitis, scabies, crab lice, cervical dysplasia, and bacterial vaginitis.
Alcohol, drug or chemical abuse, overuse or dependency.
Surgery; Surgical Procedure
An invasive diagnostic procedure, or the treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
Travel Warning; Emergency Travel Advisory
Published statement or website document issued by the US Department of State, Bureau of Consular Affairs, Centers for Disease Control and Prevention, United Nations, World Health Organization or similar government or nongovernmental agency of the Insured Person’s Home Country, warning that travel to specified countries, regions or locations poses serious risks to safety and security or exposes the Insured Person to a greater likelihood of life-threatening risks, including, without limitation, US Department of State Travel advisory levels “3 – Reconsider travel” and “4 – Do not travel”.
United States; US
The United States of America including all states, districts, territories and possessions.
Urgent Care Center
A stand-alone facility, or a facility located inside a Hospital that staffs Physicians. Urgent Care Centers provide medical services for Injuries and Illnesses that are not life-threatening. Urgent Care Centers have onsite x-ray equipment and provide treatment for more severe urgent care services, such as broken bones, burns and other non-emergent conditions that Walk-in Clinics are unable to treat.
Usual, Reasonable and Customary
A typical and reasonable amount of expenses for similar services, medicines or supplies within the area in which the charge is incurred, so long as those expenses are reasonable. What is defined as Usual, Reasonable and Customary charges will be determined by Underwriters. In determining the typical and reasonable amount of expense, Underwriters may, in their reasonable discretion, consider one or more of the following factors, without limitation: the amount charged by the provider, the amount charged by similar providers or providers in the same or similar locality, the amount paid by other payers for the same or comparable services, medicines or supplies in the same or similar locality, whether the services or supplies were unbundled or should have been included in the allowance of another service, the amount charged by other providers for the same or comparable services, medicines or supplies in other parts of the country, the cost to the provider of providing the service, medicine or supply, the level of skill, extent of training, and experience required to perform the procedure or service, the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the length of time required to perform the procedure or services as compared to national standards and/or benchmarks, the severity or nature of the Illness or Injury being treated, and such other factors as Underwriters, in the reasonable exercise of discretion, determine are appropriate.
Veterinary Emergency Care
A veterinary condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s pet’s life in danger if veterinary attention is not provided within twenty-four (24) hours, based upon reasonable veterinary certainty. Immediate veterinary intervention and attention is required as a result of a severe, life threatening condition.
A professional who practices veterinary medicine by treating diseases, disorders, illnesses and injuries in animals. A Vet must have the prerequisite qualifications and/or licensures necessary to practice veterinary medicine in the location where the service is performed. If there are no prerequisite qualifications and/or licensure required in the location where the service is performed, the prerequisite qualifications applicable to the nearest location having such requirements will apply.
A medical facility that provides medical services for minor Injury or Illness. The clinics are often found in or near retail establishments or pharmacies. The staff providing medical services are usually nurse practitioners and Physician assistants.