:Global Secutive Booking System: German American Chamber of Commerce

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Travel Medical Insurance

Medical Maximum Benefit: USD 100.000

AGS021803-2164643 | 4376

2.67 USD per day

Details

Statement of Benefits

You are insured during your stay abroad for the period reported by your exchange organization. The insurance cover does not apply in your home country, except during the outward and return journey to or from your place of residence in the host country.

Please note: If you want to extend or shorten your insurance cover, please contact your organization.

Schedule of Benefits

The following benefits are per person per Policy period and subject to the Insured Person’s Policy period Deductible. After satisfaction of the Policy period Deductible, the Underwriter will pay the eligible benefits set forth in this Schedule at the Allowable Charge, which is defined as the Negotiated Rate or the Usual, Customary, and Reasonable (UCR). This is the lower of: a) the Provider’s usual charge for furnishing the treatment, service or supply; or b) the charge determined by the Underwriter to be the general rate charged by the others who render or furnish such treatments. services or supplies to persons who reside in the same country and whose Injury or Illness is comparable in nature and severity, or the rate that has been negotiated..

Benefits will be paid on a Usual, Customary, and Reasonable basis or a negotiated basis with the contracted providers. Subject to Policy exclusions. limitations and conditions. for the charges listed, if they are:

• Incurred as a result of sickness or accidental bodily injury, under the care of a Physician; and

• Medically Necessary; and

• Ordered by a Physician; and

• Delivered in an appropriate medical setting.

All benefits shown are in USD

Insured Amount per Person per Accident or Illness $ 100.000
Co-Payment: $ 0

Benefit Coverage	Covered Benefit
Hospital Room & Board Benefit: Subject to Semi-private room rate	100% URC
Intensive Care/Cardiac Care Unit Benefit	100% URC
Hospital Miscellaneous Expense Benefit	100% URC
Surgeon (In or Outpatient) Benefits	100% URC
Assistant Surgeon Benefit	100% URC
Pre-Admission Testing Benefit	100% URC
Anesthesia Benefit	100% URC
Day Surgery Miscellaneous Benefit	100% URC
Diagnostic X-Ray and Lab Benefit	100% URC
Ambulance Benefit	100% URC
Physician Visit Benefit (Inpatient)	100% URC
Physician Visit Benefit (Outpatient)	100% URC
Consultant Physician Benefit	100% URC
Radiation/Chemotherapy Benefit	100% URC
Emergency Room Benefi Triage is mandatory Co-Payment only applies to services rendered in the USA	100% URC, subject to a $350 Co-Payment, waived if admitted
Emergency Dental Expense Benefit	100% URC
Palliative Dental	100% up to $200 maximum benefit per tooth
Physiotherapy Expense Benefit - Inpatient	100% URC
Physiotherapy Expense Benefit - Outpatient	100%, up to $2,500 maximum
Durable Medical Equipment Expense Benefit	100% URC
Infants born following Complications of Pregnancy	100% URC up to $75,000 Maximum ($200,000 Maximum in the USA or Caribbean)
Emergency Medical Evacuation Expense Benefit	100% of actual expense
Emergency Medical Repatriation Expense Benefit	100% of actual expense
Emergency Reunion	100% of actual expense
Prescription Drug Benefit	100% URC
Return Ticket Benefit	100% URC, up to $5,000 per Policy Period

Accidental Death and Dismemberment Benefits

Principal Sum: $15,000.00

(Maximum Death benefit payable shall not exceed $5,000 for an Insured Person aged 17 years or younger)

Aggregate Limit: $500,000

Loss of: Benefit:

(Percentage of Principal Sum)

Loss of Life: 100%

Loss of Both Hands: 100%

Loss of Both Feet: 100%

Loss of Entire Sight of Both Eyes: 100%

Loss of One Hand and One Foot: 100%

Loss of One Hand: 50%

Loss of One Foot: 50%

Loss of Entire Sight of One Eye: 50%

Loss of Thumb and Index Finger of the Same Hand: 25%

Part B: Travel Arrangements Benefits

Trip Interruption Benefit 100% of actual expense

Pre-Authorization Services

Pre-Authorization is required to assure your treatment will be covered under the plan and to arrange for direct billing with the hospital. The following list of services must be Pre-Authorized:

•     Hospitalization
•     Outpatient Surgery
•     Inpatient Private Duty Nursing
•   Air Ambulance - services will be coordinated by the Underwriter’s Air Ambulance Provider.
•   All Assistance Services
•     Specialty Treatments and Highly Specialized Drugs
•       Physical Therapy and Rehabilitation Services
• Any condition, including Chronic Conditions. which do not meet the above criteria, but are, expected to accumulate over $5,000 of medical treatment per Policy year

For a detailed representation, including all restrictions and exemptions. please read the detailed insurance terms and conditions.

This policy is underwritten by AXA GROUP and serviced by Global Benefits Group.

GACC - Virtual Care - Individual

Maximum Benefit: USD

129494|Y3 | 4375

0.41 USD per day

Details

Please Confirm:

I hereby confirm that I booked this insurance for the entire duration of my academic/intern program in the host country, starting on the date I leave my home country and ending on the date I arrive back in my home country. These enrollment dates do not exceed 30 days prior to the start of my academic/intern program or 30 days after the end of my academic/intern program. If I need to change my insurance dates after this booking is completed, I understand that I can cancel any days in the future and receive a pro-rated refund only if I have not submitted any claims. Premium refunds will not be considered if a claim has been filed during the Period of Insurance. If Global Secutive staff cancels my plan or changes my dates at my request, I will be charged a 25 USD / EUR fee. Once the policy period I purchase is complete, I cannot retroactively cancel any part of the policy for a full or pro-rated refund, even if no claims were submitted.

I am actively enrolled in a minimum of 9 credits or the equivalent in a college, university, language or trade school OR I am actively enrolled in a cultural exchange program holding a valid valid F, J, M, Q, or H2B visa. Services are only available in the USA. I am at least 18 years of age. I understand that eligibility may be checked at time of service. I understand that once the plan is purchased it cannot be cancelled and refunds are not issued. I understand this is NOT an insurance policy and I am enrolled in an active insurance policy for the duration of this virtual care service. I understand that I will not be able to use the virtual care services until up to 48 hours after my enrollment in the program.

I understand that if the coverage applied for in this application is approved and insurance coverage issued, the contract entered into will require the processing of sensitive personal information. Processing of such data is necessary for carrying out the obligation of providing benefits under this policy. In accordance with the General Data Protection Regulation (GDPR) of the European Union (EU), and other applicable laws and regulations, I hereby provide consent for this information to be collected, stored and shared the with insurance company and understand that the insurance company is committed to protecting sensitive personal information.

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First Name
Last Name
Date of Birth	/ /
Gender	Male Female
Start Date
End Date
Home Country
Travel Destination

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What's included in the individual Plan?

(Note: This is not medical insurance. This is a virtual medical and mental health counseling service.)

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Selected insurance coverage	Travel Medical Insurance Medical Maximum Benefit: USD 100.000 [AGS021803-2164643] Rate per person / travel day: 2.67 USD GACC - Virtual Care - Individual Maximum Benefit: USD [129494\|Y3] Rate per person / travel day: 0.41 USD
Total Cost: