This is a temporary major medical insurance plan intended for indemnification of eligible expenses from injuries or illnesses which
occur within a specified geographical area. Benefits may be assignable once validated. Until then, benefits are paid directly to you to
reimburse you for necessary medical expenses which have been paid by you, subject to covered expenses as outlined in the certificate.
THE INTERNATIONAL MAJOR MEDICAL PLAN DESCRIPTION OF AVAILABLE BENEFITS
DEDUCTIBLE 
Choice of $100, $250, $500, $1,000, or $2,500
COINSURANCE
After Deductibles are paid, Underwriters will reimburse 80% of the next $5,000 in eligible expenses and then 100% of eligible expenses up to the Maximum Benefit
MAXIMUM BENEFIT
(See Limitations)
SUMMARY OF BENEFITS
The insurance being described is a temporary major medical insurance plan. Eligible expenses caused by an illness or injury and are incurred from any doctor or any hospital within a specified geographical area will be reimbursed to you. Benefits may be assignable directly to the providers once a Claim Review has been completed.
ELIGIBLE EXPENSES
Hospital Expenses: All medically necessary expenses while hospitalized.
Physician Services: All medically necessary expenses for treatment.
Skilled Nursing Facilities: All medically necessary expenses if confinement begins following a medically necessary hospital confinement
of 3 days or longer.
Home Health Care: All medically necessary expenses if hospitalization would have been required if Home Health Care was
not provided and the care is provided in accordance with a written plan established, approved and followed by a physician.
Ambulance Services Expenses: To and from a hospital within 100 miles in the same geographic area.
Prescription Drugs: Covered during and following a period of hospitalization.
Repatriation of Remains: In the event of death, Underwriters will reimburse the cost of delivery of your remains to a mortuary
nearest your home.
Common Accident Provision: In the event that you and any additional insured family members suffer injuries from the
same accident, only one deductible and coinsurance shall be applied.
Global Medical Transportation: All medically necessary expenses for stabilization and transportation to the facility nearest your home, which can provide the appropriate care.
Lost Luggage: In the event that your checked on luggage is completely and totally lost, Underwriters shall reimburse you to a maximum of $500, excess of any and all other valid and collectible coverages.
Emergency Return Home: If, after You have departed, You learn of the death of an Immediate Family Member, or You learn of the substantial destruction of Your home by fire, wind, flood, or earthquake, Underwriters shall reimburse You the cost of an economy one way air or ground transportation ticket for You to Your home, up to a maximum of $5,000.
Trip Cancellation Benefit: If within two weeks prior to Your pre-paid ticketed or vouchered trip departure Your trip must be canceled
due to 1) Your death, illness or injury causing hospitalization or outpatient surgery, or 2) the death of an Immediate Family member, or 3) the substantial destruction of Your home due to fire, wind flood, or earthquake, any unused and non-refundable portion of expenses, shall be reimbursed up to a maximum of $1,000, excess of $100 each and every loss and excess of all other valid Insurances.
$25,000 Accidental Death: Double indemnity ($50,000 total) if accidental death occurs while riding as a passenger of a common carrier.
This is not intended to be a complete outline of coverage. Actual wording may change without notice. Underwriters reserve the right to modify terms and benefits at time of underwriting.
Age$50,000 Sum Insured $100,000 Sum Insured$250, 000 Sum Insured$500,000 Sum Insured$1,000,000 Sum Insured
$50,000 Sum Insured $100,000 Sum Insured$250, 000 Sum Insured$500,000 Sum Insured$1,000,000 Sum InsuredChild^$21$24 $29 $30 $34
$21$24 $29 $30 $340-18 $34$40 $47 $50 $56
$34$40 $47 $50 $5619-29 $37$43 $55 $56 $64
$37$43 $55 $56 $6430-39 $47$56 $71 $72 $82
$47$56 $71 $72 $8240-49 $72$81 $105 $107 $120
$72$81 $105 $107 $12050-59 $102 $124 $141 $149 $174
$102 $124 $141 $149 $17460-64 $120 $148 $175 $192 $210
$120 $148 $175 $192 $21065-69 $137 $177 $192 $224 $229
$137 $177 $192 $224 $22970-74 $208 * $268 * $339 *N/AN/A
$208 * $268 * $339 *N/AN/A75-79 $309 * $399 *N/A N/AN/A
$309 * $399 *N/A N/AN/A80-84 $456 ** N/A N/A N/A N/A
$456 ** N/A N/A N/A N/A^ If applying in conjunction with an adult, otherwise use 0-18 rate. * $1,000 minimum deductible.
** $2,500 deductible only. Reminder: multiply by 0.875 for this deductible.
TO CALCULATE
1) Determine the benefit desired.
2) Using actual age, add up the total 1-month premium for each person to be insured.
3) Multiply the 1-month premium by the total months of coverage needed (to 12 months maximum. For 2 weeks or less. multiply the 1-month premium total by 0.70).
4) Sub-total (1)
5) Determine the deductible you want:
- For $100 deductible multiply Sub-total (1) by 1.375
- For $250 deductible multiply Sub-total (1) by 1.250
- For $500 deductible multiply Sub-total (1) by 1.125
- For $1,000 deductible multiply Sub-total (1) by 1.000
- For $2,500 deductible multiply Sub-total (1) by 0.875
6) Sub-total (2)
7) Add any optional coverage's to this sub-total (2)
-Recreational Snow Skiing = add 10% of Sub-total (2) or $80, whichever is greater
-Recreational scuba diving = add 10% of Sub-total (2) or $80, whichever is greater
- All other Hazardous Sports = call
8) Sub-total (3)
9) Add a $100 processing fee
10) Do not send money until AFTER approval by Underwriters
WHY DO YOU NEED THE INTERNATIONAL MAJOR MEDICAL PLAN?
Health care costs are different in the United States than other countries around the world. The United States health care system is
principally funded through private insurance. Access to socialized health care are typically restricted to United States Veterans,
Medicare recipients and legal residents using Medicaid.
Reciprocity between some countries which both have socialized health care does not occur in the United States.
There are three basic types of people who need The Original International Major Medical plan:
1) The Foreign National visiting or temporarily residing in the USA
A trip, regardless of business or pleasure, can be ruined by an unexpected health problem. Although this plan cannot prevent an accident or sickness from occurring, it can pay for the majority of expenses which will occur.
2) The Returning United States Resident
A United States citizen or permanent resident who has been residing outside of the United States for an extended period of time, will
discover that all traditional medical plans will require a period of residency in the USA for 6 months to 5 years, before they will become
eligible for medical insurance.
The Original International Major Medical plan can provide the temporary coverage needed until you become eligible for permanent
medical insurance.
3) The Non-USA citizen working for a USA company, even in another country
USA companies many times employ citizens from all over the world. Many USA companies want to offer all employees various benefits including medical insurance.
The Original International Major Medical plan can offer coverage to non-USA citizens who are working for a USA company, even in his or her home country.
The Original International Major Medical plan provides needed medical coverage for only a few dollars a day regardless of if you need coverage for a few days or a few years.
LIMITATIONS
Expenses which have limitations are as follows: .
1) Services and supplies for Cardiac Related Conditions and Cancer Related Conditions are limited to either (i) the medical costs of stabilizing your condition and the transportation costs of returning you to your Home Country or (ii) a maximum reimbursement for Eligible Expenses of $25,000, at the option of Underwriters.
2) The maximum Eligible Expense for Repatriation of Remains or Global Medical Transportation is $100,000 in the aggregate.
3) The maximum Eligible Expense for room and board charges is $450 per day.
4) The maximum Eligible Expense room and board charge for an intensive care unit is the lesser of three times the Provider's semi-private room and board charge or $1350 per day.
5) Insured age 70-74 is limited to $250,000.00 maximum benefit or as shown on the Schedule of Benefits page, whichever is the least. All other terms and conditions apply.
6) Insured age 75-79 is limited to $100,000.00 maximum benefit or as shown on the Schedule of Benefits page, whichever is the least. All other terms and conditions apply.
7) Insured age 80-84 is limited to $50,000.00 maximum benefit or as shown on the Schedule of Benefits page, whichever is the least. All other terms and conditions apply.
PREEXISTING CONDITIONS LIMITATIONS
A Preexisting Condition will not be covered until the insurance described in this certificate has been in effect for a period of 12 months. A preexisting condition is one in which an insured sought medical attention or was advised to seek medical attention during the 12 month period preceding the effective date of the policy.
EXCLUSIONS
Expenses which are not eligible for reimbursement are as follows:
1) Any expense which you are not legally obligated to pay.
2) Services which are not Medically Necessary or are not furnished by and under supervision of a Physician .
3) Expenses for services and supplies for which you are entitled to benefits, services or reimbursement through the Veterans' Administration, Workers' Compensation insurance, any private health plan or from any other source except Medicaid.
4) Expenses in excess of usual, customary and reasonable (UCR) fees.
5) Outpatient drugs, except following a hospitalization if prescribed for the same Illness or Injury.
6) Self-inflicted injuries while sane or insane.
7) Treatment for alcoholism, drug addiction, allergies, and/or mental or nervous disorders.
8) Rest cures, quarantine or isolation.
9) Cosmetic surgery unless necessitated by an accidental injury.
10) Dental exams, dental x-rays and general dental care except as a result of an accidental injury.
11) Eye glasses or eye examinations.
12) Hearing aids or hearing examinations.
13) General or routine examinations.
14) Injuries sustained from participation in Hazardous Sports or Activities which in part include mountaineering, snow skiing, scuba diving, hang gliding, sky diving, racing of any kind, and all professional or semi-professional sports.
15) Pregnancy and pregnancy-related conditions including but not limited to fertility, pre-natal care, childbirth, miscarriage, abortion or complications from pregnancy to either mother or baby.
16) Injuries due to war or any act of war whether declared or undeclared. (Note: Terrorism however is included in the base policy of benefits.)
17) Injuries sustained while committing a criminal or felonious act.
18) Expenses incurred for or resulting from pain which is not supported by medical diagnosis.
19) Cataract surgery or any elective surgery.
20) Custodial Care.
21) Expenses for supplies and services that were not incurred within the specified Geographic Area.
This is not intended to be a complete outline of coverage. Actual wording may change without notice. Underwriters reserve the right to modify terms and benefits at time of underwriting.
GIC Insurance along with Petersen International Underwriters wants you to understand how we protect the confidentiality of non-public personal information we collected about you.
Information We Collect
We collect non-public information about you from numerous sources including, but not limited to:
a) Information we receive from you on applications and other forms;
b) Information about your transactions with our affiliates, others or us;
c) Information we receive from consumer-reporting agencies; and
d) Financial and medical sources.
Information We Disclose
We do not disclose any non-public information about you to anyone except as is necessary in order to provide
our products or services to you or otherwise as we are required or permitted by law (e.g. subpoena, fraud
investigation, regulatory reporting, etc.).
Right to access or correct your personal information
You have a right to request access to or correction of your personal information in our possession.
Confidentiality and Security
We restrict access to non-public personal information about you to our employees, our affiliates’ employees or
others who need to know that information to service your account. We maintain physical, electronic and
procedural safeguards to protect your non-public personal information.
Contacting Us
If you have any further questions about this privacy statement or would like to learn more about how we protect
your privacy, please contact:
GIC Insurance Agency
P.O. Box 291
Fair Grove, Mo. 65648
Phone: (417) 207-9996
Fax: (417) 459-4870
e-mail: info@gicinsurance.org
or Petersens International Underwriters:
23929 Valencia Boulevard, Suite 215
Valencia, California 91355
(800)345-8816
e-mail: piu@piu.org
Note: that the information above can change at anytime. Information above is registered & copyrighted material from Petersen International Underwriters, Inc. and under exclusive use on this page for marketing by GIC Insurance Agency.
