- Affordable Health Insurance Plans For Non-US Citizens in America

Table of contents

1. Monthly Individual Rates
2. Summary Schedule of Benefits
3. Eligibility
4. Medical Expense Benefits
5. Pharmacy Benefit
6. Preferred Provider Organization (PPO)
7. Definitions
8. Period of Coverage
9. Medical Evacuation
10. Repatriation of Remains
11. Accidental Death & Dismemberment
12. Enrollment Procedure
13. Exclusions and Limitations
14. Claim Procedure
15. Underwriter
16. How to Contact Your Providers
17. Premium refunds

3. Eligibility

You are eligible if you have a current passport, entered the U.S. with a valid visa and are temporarily residing outside your home country/country of permanent residency. This insurance is valid in the U.S. for individuals who are not U.S. passport holders or Permanent residents (Green Card) and their dependents. Covered individuals and their dependent children traveling in the U.S. or outside of the U.S. during the term of this policy will be covered for medically necessary expenses according to the terms and limitations of each Benefit.

For purposes of this insurance, Coverage is only provided while the Eligible Insured is outside their country of permanent residence and or country of citizenship. The Company maintains its right to investigate to verify that the policy eligibility requirements have been met.

4. Medical Expense Benefits

When a covered Injury or Sickness requires treatment by a Physician, this Policy will provide benefits for the Reasonable and Customary Charges for Medically Necessary Covered Medical Expenses which exceed the deductible per person for each Injury or Sickness. Payment for any Covered Medical Expense will be no more than the Benefit Limit shown for it and will be subject to the deductible amount set forth. The total payable for all Covered Medical Expenses will be no more than the Maximum Benefit Limit per Sickness or Injury. Benefits are subject to the Excess Provision. Outpatient benefits are applicable only to US NetCare Guard and Safety and not for US NetCare Necessity.

Covered Medical Expenses will be paid under the Schedule of Benefits for loss:

1. Due to Injury to an Insured Person provided that treatment by a Physician: a) begins within 30 days after date of Injury; and b) is received within 26 weeks after date of Injury; or
2. Due to Sickness of an Insured Person provided Covered Medical Expenses are incurred within 26 weeks after the date of first treatment for such Sickness.

   If a benefit is not specifically designated in the Schedule of Benefits, but is a valid Medical incurred charge as authorized by a certified and licensed health care practitioner, the expense will be subject to the deductible per accident or sickness as listed above and benefits will be paid as per the benefit schedule listed above.

Covered Medical Expenses include:

1. Room and Board Expense: 1) daily semi-private room rate when Hospital Confined; and 2) general nursing care provided and charged for by the Hospital.
2. Intensive Care.
3. Hospital Miscellaneous Expenses: 1) while Hospital Confined; or 2) for pre-admission expenses for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.
4. Physiotherapy following an accident or insured sickness inpatient and outpatient (only Guard and Safety): $4,000 Per Year for Guard and $3,000 for Safety and Necessity.
5. Surgery: Physician’s fees for inpatient surgery. Payment will be made based upon the annual Medical Expenses maximum as specified in the Schedule of Benefits. Covered medical expenses will be paid under the Policy benefit schedule.
6. Anesthetist Services: in connection with surgery.
7. Private Duty Nurse’s Services: 1) private duty nursing care only; 2) while Hospital Confined; 3) ordered by a licensed Physician; and 4) a Medical Necessity. General nursing care provided by the Hospital is not covered under this benefit.
8. Pre-admission Testing: limited to routine tests such as: complete blood count; urinalysis; and chest x-ray. If otherwise payable under this policy, major diagnostic procedures such as: cat-scans; NMR’s; and blood chemistries will be paid under the Medical Expenses benefit and is subject to the deductible per accident or sickness.
9. Mental and Nervous Disorder (inpatient): 50% of eligible expenses with a maximum of $1,000 Benefits are limited to one Physician’s visit per day.
10. Surgery (outpatient): Physician’s fees for outpatient surgery. Payment will be made based upon the Schedule of Benefits. Covered medical expenses will be paid under this benefit.
11. Day Surgery Miscellaneous (Outpatient): in connection with outpatient day surgery; excluding non-scheduled surgery, and surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and x-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies.
12. Anesthetist (Outpatient): in connection with outpatient surgery.
13. Physician’s Visits (Outpatient): Includes injections administered during visit. Benefits do not apply when related to surgery or Physiotherapy. Covered medical expenses will be paid as per the Schedule of benefits above and are subject to per accident or sickness deductible.
14. Medical Emergency Expenses (Outpatient): only in connection with a Medical Emergency as defined. Benefits will be paid for the use of the emergency room and supplies.
15. Radiation Therapy (Outpatient)
16. Chemotherapy (Outpatient)
17. Prescription Drugs (Outpatient)
18. Mental and Nervous Disorder (Outpatient): Annual maximum of $500 for Guard and $250 for Safety. Benefits are limited to one Physician’s visit per day. Deductibles apply, $25 for Guard and $50 for Safety.
19. Ambulance Service.
20. Braces and Appliances: 1) when prescribed by a Physician; and 2) a written prescription accompanies the claim when submitted. Replacement braces and appliances are not covered. Braces and appliances include durable, medical equipment which is equipment that: 1) is primarily and customarily used to serve a medical purpose; 2) can withstand repeated use; and 3) generally is not useful to a person in the absence of Injury or Sickness. No benefits will be paid for rental charges in excess of purchase price.
21. Consultant Physician Fees: when requested and approved by the attending Physician. Subject to the deductibles per event or sickness.
22. Dental Treatment: 1) performed by a Physician; and 2) made necessary by Injury to Sound, Natural Teeth. Routine dental care and treatment to the gums are not covered. Maximum coverage is $200 for Guard and $150 for Safety & Necessity plans.
23. Alcoholism/Drug Abuse Treatment: the benefits and the maximum amounts are payable under the Mental or Nervous Disorder benefit in the Schedule of Benefits and are subject to the applicable deductible and benefit limits.
24. Benefits are payable only for those Covered Medical Expenses incurred while the policy is in effect for the Insured Person. No benefits are payable for any expenses incurred after the date insurance terminates, except if an Insured Person is hospitalized on the date his insurance terminates. Benefits will continue to be paid until the completion of the hospital stay, but not to exceed a period of 31 days from the termination date, or the Maximum Policy Benefit, whichever occurs first.
25. Maternity Benefit (only available in the GUARD Plan): Coverage for maternity expenses which are medically necessary and which are incurred during the period of insurance are subject to the yearly maximum as stated in the schedule of benefits. Coverage is not available if conception is within 12 months of coverage placement. The last menstrual period will be used to determine the date of loss.
26. Any child born to the Insured on or after the effective date, will be covered under the policy for the first 31 days after birth. Coverage for such child will be for injury or Sickness including medically diagnosed congenital defects, birth abnormalities, prematurity, and nursery care when the child is sick or injured. To continue coverage beyond 31 days, written application and payment of any required premium must be made to US NetCare and forwarded to the Underwriting Company.

Excess Provision: All benefits shall be in excess of all other valid and collectible insurance and shall apply only when such benefits are exhausted. If an Insured's Injury or Sickness is due to an act or omission of another, benefits payable by this plan are subject to recovery from amounts eventually paid to the Insured by or on behalf of, the other person.

Conformity with State Statutes: Any provision of this Policy which, on its effective date, is in conflict with the statutes of the state in which it is issued, is hereby amended to conform to the minimum requirements of such statutes.

5. Pharmacy Benefit

Only medications which are prescribed by a physician, and which would not be available without such prescription are covered.

Pharmacy Network

For pharmacy locations and questions call Medco (800) 400-0136 or visit www.medcohealth.com.

Pharmacy co-payment (outpatient)

6. Preferred Provider Organization (PPO)

Persons insured under this plan may choose to be treated within or outside of the leading PPO networks: First Health & Beech Street. Both PPO networks consists of hospitals, doctors and other health care providers organized into a network for the purpose of delivering quality health care at affordable rates. Reimbursement rates will vary according to the source of care as described under the Summary Schedule of Benefits herein.

In order to use the services of a Network provider, you must present an Identification card that is given to all covered individuals in this insurance plan. Utilization of a network provider does not guarantee eligibility or right to Injury and Sickness benefits under this plan. Providers may be periodically added or deleted as participants in the PPO networks. Not all doctors practicing at a hospital elect to participate in the PPO networks. Insured's are responsible to verify that a provider is a participant prior to services being rendered.

First Health – to search for participating doctors or hospitals call (800) 226-5116 or www.myfirsthealth.com.

Beech Street – to search for participating doctors or hospitals call  (800) 432-1776 or  www.beechstreet.com.

7. Definitions

For the purpose of the Policy and Certificate, reference to “he”, “him” or “his” refers to both the male and female gender.

Covered Expenses means expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed of ordered by a Physician; Reasonable and Customary charges; incurred while insured under this Policy;

Dependent means the spouse who is legally married to the Primary Insured Person; the Primary Insured Person’s unmarried Child from birth until his/her 19th birthday; or the Primary Insured Person’s unmarried Child who is over 18 years old but not older than 25 years old and is enrolled as a full-time student at an accredited school or college and is not employed on a full-time basis and is dependent on the Primary Insured Person for his/her support and maintenance. The age limits that apply to Dependent Child(ren) will not apply to any insured Child of the Primary Insured Person who remains dependent on the Primary Insured Person for support and maintenance because he a she becomes incapable of working due to a physical handicap or retardation which occurs: before reaching the age limit; and while insured under this Policy or any prior plan, provided such Child was insured on the date of termination of the prior plan.

Hospital a Hospital (other than an institution for the aged, chronically ill or convalescent, resting or nursing homes) operated pursuant to law for the care and treatment of sick or Injured persons with organized facilities for diagnosis and Surgery and having 24-hour nursing service and medical supervision. Means a place that 1.) is legally operated for the purpose of providing medical care and treatment to sick or injured persons for which a charge is made that the Insured is legally obligated to pay in the absence of insurance 2.) provides such care and treatment in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) operates under the supervision of a staff of one or more Doctors. Hospital also means a place that is accredited as a hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Heath Care Organizations (JCAHO). Hospital does not mean: a. convalescent, nursing, or rest home or facility, or a home for the aged; b. place mainly providing custodial, educational, or rehabilitative care; or c. a facility mainly used for the treatment of drug addicts or alcoholics.

Injury means Accidental bodily Injury or Injuries caused by an Accident. The Injury must be the direct cause of the Loss, independent of disease or bodily infirmity. Any Loss due to Injury must begin after the Effective Date of this Policy.

Insured Person(s) means a person eligible for coverage under the Policy who has applied for coverage and is named on the application and for whom the company has accepted premium. This may be the Primary Insured Person or Dependent(s).

Physician means a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed, however, such definition will exclude chiropractors and physiotherapists.

Pre-existing Condition for the purposes of this Policy means a condition for which manifestation, medical advice, diagnosis, care or treatment was recommended, received or noticed during the 12 months prior to the Effective Date of coverage under this Policy

Reasonable and Customary means the maximum amount that the Company determines is Reasonable and Customary for Covered Expenses the Insured Person receives, up to but not to exceed charges actually billed. The Company’s determination considers: 1) amounts charged by other Service Providers for the same or similar service in the locality were received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; 2) any usual medical circumstances requiring additional time, skill or experience; and 3) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale.

For a Service Provider who has a reimbursement agreement, the Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company.

If a Service Provider accepts as full payment an amount less than the negotiated rate under a reimbursement agreement, the lesser amount will be the maximum Reasonable and Customary charge.

The Reasonable and Customary charge is reduced by any penalties for which a Service Provider is responsible as a result of its agreement with the Company.

Sickness means illness or disease contracted and causing loss commencing while the policy is in force as to the Insured Person whose Sickness is the basis of claim. Any complication or any condition arising out of a Sickness for which the Covered Person is being treated or has received Treatment will be considered as part of the original Sickness.

8. Period of Coverage

Coverage will begin at 12:01 AM on the latest of the following dates:

1. The Effective Date of the policy; or
2. The Named Insured’s departure from his home country/country of permanent residence; or
3. The date the application and premium are received by the Company, or its authorized representative; or
4. The date the application and premium are accepted by the Company, or its authorized representative; or
5. The date requested on the application.

Coverage will terminate on the earliest of the following:

1. The last day for which premium has been paid; or
2. The date the policy terminates (unless the Company and Policyholder agree, in writing, to permit coverage to continue to the end of the period for which premiums have been paid in lieu of a return of
   unearned premiums); or
3. The date the Named Insured returns to his Home country/country of permanent residence; or
4. The date the Named Insured becomes a United States citizen or is considered a US permanent resident or
5. The date the Named Insured is no longer eligible for this insurance; or
6. The date of entry into active duty military service.

9. Medical Evacuation

The Company will pay benefits for covered expenses incurred up to a maximum of what is listed in the schedule of benefits; if an Injury or Sickness commencing during the period of coverage results in the necessary emergency evacuation of the Insured Person.

Emergency Evacuation means:

1. The Insured Person's medical condition warrants immediate transportation from the place where the Insured Person is injured or sick to the nearest Hospital where appropriate medical treatment can be obtained; or
2. After being treated at a local Hospital, the Insured Person's medical condition warrants transportation to home country / country of residence to obtain further medical treatment or to recover.
3. Both a) and b) above

Covered expenses must be: a) ordered by the attending Physician who certifies the severity of injury or sickness; b) required by the standard regulations of the conveyance transporting the Insured Person; and c) authorized in advance by
On Call International .

The Company reserves the right to determine the benefits payable, including reductions, if it is not reasonably possible to contact On Call International.

Benefits are subject to the Excess Provision.

On Call International
US or Canada: (866) 509-7715, International: (603) 328-1728
E-mail for emergencies to mail@oncallinternational.com 

10. Repatriation of Remains

The Company will pay the reasonable covered expenses incurred to return the Insured Person's body to the Insured Person’s Home country/country of permanent residence if he or she dies, not to exceed the maximum listed above in the schedule of benefits. On Call International must make all arrangements and must authorize all expenses in advance for any Repatriation of Remains benefits to be payable. Covered expenses include, but are not limited to, expenses for embalming, cremation, coffins and transportation

11. Accidental Death & Dismemberment

The Company shall pay an indemnity determined from the Table of Losses if an Insured Person sustains a loss stated therein resulting from Injury, provided that:

1. such loss occurs within 365 days after the date of accident causing such loss;
2. the indemnity payable for any such loss shall be the amount stated opposite such loss in said Table, and the Principal Sum stated above; and
3. if more than one loss stated in said Table is sustained as the result of one accident, only one of the amounts so stated in said Table, the largest, shall be payable.

Table of Losses

The term “loss” as used herein shall mean with regard to hands and feet, actual severance through or above wrist or ankle joints, and with regard to eyes, entire irrecoverable loss of sight. “Loss” of hearing in an ear means total and irrecoverable loss of the entire ability to hear in that ear. “Loss” of speech means total and irrecoverable loss of the entire ability to speak. “Loss” of thumb and index finger means complete severance through or above the metacarpophalangeal joint of both digits.

Disappearance
If the body of an Insured Person has not been found within one year of the disappearance, forced landing, stranding, sinking or wrecking of a conveyance in which such person was an occupant, then it shall be deemed, subject to all other terms and provisions of the policy, that such Insured Person shall have suffered loss of life within the meaning of the policy.

12. Enrollment Procedure

An Eligible Person may enroll for monthly periods of coverage, subject to the following rules: three months premium is the minimum acceptable premium; twelve months premium is the maximum acceptable premium; and the full premium is payable at the time of enrollment. Any partial month of coverage will be charged as full month of premium.
If coverage is initially purchased for a minimum of three months, coverage may be renewed, if available, for additional periods at the premium rate in force at the time of renewal. The minimum total period of coverage for any one Insured Person is three (3) months and cannot exceed twelve months maximum. 

13. Exclusions and Limitations

No benefits will be paid for loss or expense caused by, contributed to, or resulting from:

1. Pre-existing Conditions; however, a Pre-Existing Condition will be covered after the person has been continuously insured for 12 months under this policy issued to the Policyholder, provided continuous insurance is maintained; acute onset of pre-existing benefit limit of $2,500 lifetime benefit (Guard only).
2. No benefits will be paid for loss or expense caused by, 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;
3. For routine physical, immunizations or other examination where there are no objective indications or impairment in normal health, and laboratory diagnostic or X-ray examination except in the course of a disability established by the prior call or attendance of a physician;
4. Eye examinations; prescriptions or fitting of eyeglasses and contact lenses;
5. Hearing examinations or hearing aids; or other treatment for hearing defects and problems;
6. Dental treatment, except as the result of Injury to Natural Teeth as stated in the Covered Medical Expenses;
7. Professional services rendered by a member of the Insured Person's immediate family, or anyone who lives with the Insured Person;
8. Services or supplies not necessary for the medical care of the patient's Injury or Sickness;
9. Weak, strained or flat feet, corns, calluses, or toenails;
10. Cosmetic surgery, or treatment for congenital anomalies (except a specifically provided), except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness;
11. 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;
12. Injury sustained while participating in an amateur, club, intramural, interscholastic, intercollegiate, professional or semi-professional sports;
13. Injury or Sickness for which benefits are paid or payable under any Worker's Compensation or Occupational Disease Law or Act, or similar legislation;
14. Organ transplants;
15. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rate premium will be refunded upon request for such period not covered);
16. Participation on a riot or civil disorder; commission of or attempt to commit a felony in the country in which it was attempted or committed;
17. Suicide or attempted suicide (including drug overdose) while sane or insane (while sane in Missouri); or intentionally self-inflicted Injury (may vary by state);
18. Charges of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;
19. Treatment of nervous or mental disorders, except as stated in the Schedule of Benefits, or treatment of alcoholism or drug abuse, except as provided for treatment of mental or nervous disorders, according to the Schedule of Benefits;
20. Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;
21. Duplicate services actually provided by both a certified nurse-midwife and Physician;
22. Expenses payable under any prior policy which was in force for the person making the claim;
23. Expenses incurred during a Hospital emergency room visit which is not of an emergency nature;
24. Expenses incurred for outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
25. Pregnancy or childbirth (except when loss occurs while covered under the Guard policy. The last menstrual period will be used to determine the date of loss); elective abortion; elective cesarean section; pregnancy or childbirth for a dependent when dependent child of an Insured Person (except for complications arising there from),Maternity Expenses in the first 12 months of the effective date are also excluded;
26. Expenses covered by any other valid and collectible medical, health or accident insurance;
27. Expenses incurred after the date insurance terminates for an Insured Person except as may be specifically provided;
28. Expenses incurred for injuries resulting from the use of alcohol or intoxicants, or any drugs unless prescribed by a Physician;
29. For services, supplies or treatment, including any period of hospital confinement, which were not recommended, approved and certified as necessary and reasonable by a physician;
30. For miscarriage resulting from accident, which exceed $500;
31. For the ordinary cost of a one way airplane ticket used in the transportation back to the Insured's country where an air ambulance benefit is provided and medically necessary;
32. For specific named hazards: motorcycling, scuba diving, jet, snow or water skiing, ski activity, snowboarding, mountain climbing (where ropes or guides are used), sky diving, professional or amateur racing, piloting an aircraft, bungee jumping, spelunking, whitewater rafting, surfing (unless part of a school credit course), and parasailing;
33. Treatment paid for or furnished under any other individual or group policy, or other service or medical pre-payment 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;
34. Treatment of Acne;
35. Vaccinations, Acupuncture, or other holistic treatments, routine medical treatment and any routine check-ups for pregnancy, cosmetic or plastic surgery (except as the result of an Accident);
36. Elective Surgery and Elective Treatment For details on what is determined to be Elective Surgery and Elective Treatment contact Klais at (800) 331-1096;
37. Covered medical expenses for which the Covered Person would not be responsible for in the absence of the Policy;
38. Conditions that are not caused by a Covered Accident or Sickness.

14. Claim Procedure

In the event of Sickness or Injury, you should report to the nearest physician or hospital. Persons insured under this plan may choose to be treated within or outside First Health or Beech Street Networks. Reimbursement rates will vary according to the source of care as described under the Summary Schedule of Benefits and covered medical expenses.

The completed claim form, all itemized bills, statements and receipts must be sent to the claims administrator no more than 90 days after a covered loss occurs or end, or as soon after that as is reasonably possible. Please mail the completed claim form and accompanying documentation to the claims administrator, Klais & Company, Inc., 1867 West Market Street, Akron, OH 44313.

Should it become necessary to check upon the status of your filed claim, you may call the claims administrator at (800) 331-1096 between 9:00 A.M. and 5:00 P.M. Monday through Friday EST. or e-mail at usnetcare@klais.com. On line claims status via the internet is available 24 hours a day at www.klais.com.

15. Underwriter

This brochure provides you with benefits of Guard, Safety and Necessity medical insurance plans, as underwritten by United States Fire Insurance Company, by Fairmont Specialty, a part of Crum Forster. The terms of the policies brochure (UDL3337S, UDL3338S, UDL3339S) will govern in all cases.

16. How to Contact Your Providers

• Plan administrator - US NetCare (800) 453-8648 or (212) 262-8918. Email:info@usnetcare.com.
• PPO directory of doctors & hospitals - First Health (800) 226-5116 www.myfirsthealth.com; or Beech Street (800) 432-1776 or www.beechstreet.com.
• Questions regarding benefits and claims – Klais & Company Inc. (800) 331-1096 or e-mail at usnetcare@klais.com. Online claims status via the internet is available 24 hours a day at www.klais.com.
• Emergency medical assistance - On Call International 
• US or Canada: (866) 509-7715  International: (603) 328-1728 E-mail for emergencies to mail@oncallinternational.com 

17. Premium refunds

Premium refunds, less a processing fee, will be considered only for entry into the armed forces. Unearned funds will be refunded, less a $50 processing fee, for the number of full months only . The refund request must be in writing and your Medical Insurance ID card must be returned with your request. Premium refunds will not be considered if a claim has been filed during the Period of Coverage. All refunds are subject to approval of the administrator.