CET - WAT Insurance Info

8/13/2019 CET - WAT Insurance Info

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The Beacon Series Group Travel Medical Plan

Council for Educational TravelWorker Trainee Intern Program

Policy A92355005

Prepared by your Insurance Broker: Distributed & Administered by:Capistrano Insurance Services Inc.8780 19th Street 346Rancho Cucamonga, CA 91701Tel: (909) 472-3300Fax: (909) 472-3310

Azimuth Risk Solutions, LLC55 Monument Circle, Suite 1128Indianapolis, IN 46204Tel: (888) 201-8850Fax: (888) 201-8851


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EVIDENCE OF INSURANCETHE BEACON SERIES GROUP TRAVEL MEDICAL PLANThis Evidence of Insurance is issued by the Master Policy on behalf of the Master Policyholder, as so authorized byCertain Underwriting Members at Lloyd's who have hereunto subscribed their Names (The Underwriters) to thisEvidence of Insurance and the Master Policy; the Beacon Axis Series Group Insurance Trust (Anguilla). Assuch certain Underwriters at Lloyd's authorize Azimuth Risk Solutions, LLC.as the ( Scheme Administrator ) of theMaster Policy and all Evidence{s) of Insurance issued by the Master Policy.THIS DOCUMENT EVIDENCE OF INSURANCE) IS ISSUED AS NOTICE OF INSURANCE FORINFORMATION ONLY. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A LEGAL CONTRACT OFINSURANCE. THE CONTRACT IS THE MASTER POLICY HELD BY THE MASTER POLICYHOLDER), THEAPPLICATION, AND ANY APPLICABLE RIDER{S). THIS EVIDENCE OF INSURANCE IS FURNISHED INACCORDANCE WITH, AND IN ALL RESPECTS IS SUBJECT TO, THE TERMS AND CONDITIONS OF THEMASTER POLICY. THIS EVIDENCE OF INSURANCE REPLACES ANY OTHER EVIDENCE OF INSURANCEPREVIOUSLY ISSUED COVERING THE INSURANCE DESCRIBED HEREIN. PLEASE REFER TO YOURAPPLICATION FOR DETAILS ON THE SELECTED COVERAGE AMOUNTS AND DEDUCTIBLES.This insurance is provided under the Master Policy and is in accordance with the Terms and Conditions of theMaster Policy. The Master Policy is available upon request at any time by contacting the Scheme Administrator atseryl~@. lJmuthrisk.J:om or by calling LIS at (317)644-6291 (we accept collect calls) or (888)201-8850.

1. Master Policy Number: A923550052. Name of Master Policyholder: Beacon Axis Series Group Insurance Trust (Anguilla).3. PartiCipating Member: All partlcipants enrolled in the Beacon/Axis Series Group Insurance Trust

(Anguil la); under the Beacon Series Travel Medical Insurance Plan.4. Scheme Administrator: Azimuth Risk Solutions, LLC. 55 Monument Circle, 1128, Indianapolis, Indiana

46204, United States of America.5. Coverage Period: The coverage period will be that in which is shown on the Declaration Pageissued at the

time of approval.6. Cancellation: All cancellation requests must be submitted in writing to the Scheme Administrator. To be

eligible for a full refund, the request must be reeived prior to the requested effective date of coverage.Cancellation requests received after the requested effective date will be subject to the following:

a. A $25.00 cancellation fee; andb. Only the unused portion of the premium cost will be refunded; andc. Noclaims to beeligible for premium refund.

7. Filing a Claim: Notice of Claim should be submitted to: Korak Healthsource, Inc. c/o Azimuth RiskSolutions, LLC. P.O. Box 206, Forest Hill, MD 21050. The following items must be submitted to beconsidered a complete Proof of Claim eligible for consideration of payment:

a. A duly completed and signed Claim Form; andb. All original itemized bills from all Physicians, Hospitals and other healthcare or medical servie

providers involved with respect to the claim; andc. All original receipts for any expenses that have been incurred or paid by or on behalf of the

Participating Member(s) with respect to the claim(s).The Participating Member shall h ve ninety (90) days from the date the claim is incurred to submit a completeProof of Claim to the Scheme Administrator. The Scheme Administrator may deny coverage for any Proof of Claimsubmitted thereafter or for incomplete Proofs of Claims. All Claim decisions made by the Scheme Administrator oron behalf of the Scheme Administrator are with the express consent of the Underwriters.Schedule of Benefits/limits:

Subject to the Terms of this insurance, including without limitation the Deductible and Coinsurance (unlessotherwise expressly set forth to the contrary), and various limits and sub-limits set forth below, the SchemeAdministrator promises to provide the Participating Member the following benefits and coverage arising out ofInjury or Illness incurred while this Evidence of Insurance is in effect:

04EOI 09 BTI 1


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The Beacon Series Group Travel Medical Plan Schedule of BenefitsMaximum Limits $250,000Deductibles $100 per Coverage Period

The plan pays 80% of next $5,000 of Eligible Expenses, then 100% to the overallCoinsurance (Subject to Deductible) Maximum Limit for claims incurred in the US or Canada. (The Coinsurance iswaived if incurred in the US and within the Multi-Plan PPO). Plan pays 100% fo

claims incurred outside the US & Canada.Pre-Certification Penalty 50%Hospital Indemnity $150 per night; Inpatient Hospitalization (Outside the US & Canada)Hospital Room & Board Average Semi-private room rate.Intensive Care Unit Usual, Reasonable and Customary to selected Policy Maximum Limit.Local Ambulance Usual, Reasonable and Customary charges, when covered Illness or Injury resultsin Hospitalization as Inpatient.Physical Therapy $60 Maximum Limit per visit. Maximum 15 visits.

$20,000 Maximum Limit for Eligible Medical Expenses. Including EmergencySudden Onset of Pre-existing Condition Medical Evacuation (US Citizens Only). $1,000 Maximum Limit for EligibleMedical Expenses (all others).All Other Medical Expenses Usual, Reasonable and Customary Charges.Dental (Injury as result of Accident) $250 Maximum Limit per Coverage Period.nly available for Policies purchased for 90 days ormore.Emergency Medical Evacuation $150,000 Maximum LimitEmergency Reunion $15,000 Limit per Coverage PeriodReturn of Mortal Remains $30,000 Limit per Coverage PeriodReturn of Minor Children $5,000 Limit per Coverage PeriodQuick Trip Home Country Coverage 14 days cumulative Home Country Coverage (as defined by Policy). Subject to aMinimum 3 month purchase.Home Country Coverage Free 15 days with a 6 month purchase, or Free 30 days with a 12 month purchase(End of Trip) per Coverage Period.Lost Checked Luggage $250 per Coverage Period (not subject to Deductible or Coinsurance). As defmedin the Policy.Accidental Death & Dismemberment $30,000 for Insured or Insured spouse and $6,000 for Dependent Child(ren)(AD&D)Common Carrier Accidental Death & $50,000 per Member (age 18 and over) $30,000 per Member (under age 18)DismembermentTerrorism $50,000 Maximum Limit, Medical expenses only.Trip DelaylMissed Connection Maximum Limit of$100 a day after a minimum of 12 hour delay period. Asdefmed in the policy.Third Party Liability- Personal Liability $500 per Coverage PeriodThird Party Liability- Damage to Property $150,000 Maximum Limit personal liability and damage to property.

The Aggregate Limit for the Personal Liability Coverage per Participating Member equals the above Limit


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Frequently Asked Questions:

1. Who is Azimuth Risk Solutions?Azimuth Risk Solutions is the Managing Agency for Lloyds of London. From aparticipant prospective, theprovide claims and provider services.

2. What if I am sick, how do I see a doctor?Please go to the MultiPlan website, http://bit.lvmulti-plan, and choose either Doctor or Facility. Entersearch criteria and a list of doctors orfacilities will be provided to you. If making an appointment with adoctor, please call the doctors office to make an appointment.

3. What is a deductible?The deductible is the amount you are responsible to pay during apolicy period. This policy has a $100 poldeductible per coverage period.

4. What if there is not a provider in my area?MultiPlan has more than half a million healthcare providers under contract and in the event that there is nnetwork provider in the area, Azimuth will work with the individual regarding the co-insurance.

5. How do I file a claim?In some cases a doctor may request that payment be made therefore you must send in a claim form forreimbursement. To do so, please complete the attached claimor and mail the claimform and all originaitemized bills to:Azimuth Risk Solutions, LLC55 Monument Circle, Suite 1128Indianapolis, IN 46204

6. Is there an emergency claims number?Yes, that number is (888) 201-8850 and press option 9. For participants outside of the US, please call colle(317) 644-6291.

7. What is the difference between and In-Network provider and a Out-of-Network Provider?Azimuth has a network of medical providers which are apart of a PPO network called Multiplan with whomthey have negotiated discounted medical rates and these are considered In Network . If a provider isn'tpart of the PPO network then they are deemed Out of Network.

8. What if have an emergency?If you should have an emergency, please go to the hospital. Emergency hospital admissions must be reportewithin 48 hours by either the participant, provider or family member. Failure to comply may result in areduction of benefits.


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What is not covered?

Charges related to: Preexisting Conditions - Except for Sudden Onset of Pre-existing Condition, charges resulting directly or

indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance. Pregnancy - Charges related to Pregnancy, including but not limited to pre-natal care, child birth, post-

natal care, false labor, edema, prolonged labor and/or prescribed rest during the period of pregnancy,including newborn care.

Experimental treatments or surgery Weight modification treatment, plastic surgery unrelated to restoration after a covered injury or illness or

sex -change surgery. Injuries as a result of engaging in Hazardous Sports without the purchase of the Optional Sports Rider. Any injury or illness as a result of the consumption of alcohol or drugs; or for the treatment of substance

abuse.

This is a partial list and description of exclusions. For a full description, please contact CapistranoInsurance Services at (909) 472-3300 or by email [email protected].


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Part 3 Please fill out all applicable questions below, more information may be requested.(If you need additional space, please attach a separate sheet.)1. How did this condition/illness begin?

Please describe all symptoms.

2. When did the first symptom of the illness/condition begin? M/D/Y3. Have you ever been treated for this illness/condition before? aVes aNo4. List all the names and addresses of the providers you have seen for this

illness/ condition:

5. Is this illness/condition the result of an accident? aVes aNo

6. Is this illness/ condition related to a work accident?If yes, have you applied for workers compensation?

aVes (JNo(JVes (JNo

7. Did this illness/condition involve a motor vehicle? aVes aNoIf yes, please provide names of all parties involved, including insurance carriersand policy numbers including the dates of accident:

8. Was a police report filed? aVes (JNoIf yes, Name and Number of Police Department, and number of report:

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Part4 Please complete only if treatments occurred outside of the US.Country which ConcfItion(s)/DiaQnosis Physidan/Hospital/Clinic/Healtt l Caretreabnent occurred in? Provider Name(s), Address 8t Telephone Dat.e(s)of Total Charge Type of culTel1CTreatment paid/billed? paid/billed?

PartS A u th o ri za t io n p l ea s e c o m p le t e f o r all d a ims .I vaify aDirformaI:K:n c n n ta in e :: l i n t h i s f o on i s true a:x T E r t am a :r rp Ie te to th e te;t e X m y k n : :l w I a: tJ e .The IIImsiYiled cUhoiizes any dodDr, medc:aI practtionE l, hospiIaI,.di1ic:, heaIh faciIly, pha macy, gcM mment agenc.y,i1sI.IIanoe agenc.y, i1sI.IIanoe ml'npany, group policyholder, or insI.IIante or beneIi: admirdstiatDi or any other enII.y hailingirloonation as to the ~ ~ tleat:n1E J1l;. or physical or mental mlleition any family member isted on thisApplicationto release said iriom1ation toAzimuth RiskSoUions, LLC.1Ittte: My fa ls e s ta IB I lei It, ~ crfiau: 5001rerderthis i r s r a r K : e nuBard AX ard daim ; here..rder sM l b e f of eiB :IAut 0 izatb I: I aIAtnize J EY ITff i I: e X m : D c a I talEfis to th e d :x :J Ira -d he r ~ e X s ev k:e s ~ th e attached bIIs.Print Name of Primary Insured, Dale{Mo./DaV/Yr.)

Signature of Insured,Or Guardian, Date{Mo./DaV/Yr.)

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CET - WAT Insurance Info