Page 2 - AtlasEssential
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SPECIMENCONTENTS SCHEDULE OF BENEFITS AND LIMITS ....................... 6
U.S. PREFERRED PROVIDER ORGANIZATION (PPO)
PATIENT PROTECTION AND AFFORDABLE CARE REQUIREMENTS ........................................................... 7
ACT (“PPACA”) DISCLOSURE STATEMENT.................3 CLAIM PROCEDURES ................................................... 7
DESCRIPTION OF COVERAGE SUMMARY..................3
IMPORTANT FEATURES OF YOUR TRAVEL PROOF OF CLAIM .................................................. 8
INSURANCE....................................................................3 CLAIMS COOPERATION ........................................ 8
ACCESS TO ADDITIONAL MATERIALS ................ 8
CANCELLATION ......................................................3 OTHER INSURANCE .............................................. 8
U.S. PREFERRED PROVIDER ORGANIZATION ARBITRATION......................................................... 8
(PPO)........................................................................3 APPEAL AND COMPLAINTS PROCEDURE.................. 8
CLAIMS ....................................................................4 APPEALING A CLAIM ............................................. 8
APPEALS AND COMPLAINTS ................................4 COMPLAINTS PROCEDURE.................................. 9
DEFINITIONS ...........................................................4 PRE-EXISTING MEDICAL CONDITIONS ...................... 9
PRE-EXISTING CONDITIONS .................................4 MEDICAL & REPATRIATION EXPENSES ..................... 9
DATA PROTECTION................................................4 MEDICAL EXPENSES........................................... 10
RIGHTS OF THIRD PARTIES ..................................4 EMERGENCY MEDICAL EVACUATION............... 11
LAW AND JURISDICTION .......................................4 REPATRIATION OF REMAINS ............................. 11
TOKIO MARINE HCC MEDICAL INSURANCE LOCAL BURIAL OR CREMATION ........................ 12
SERVICES GROUP (“MIS GROUP”) .......................4 TERRORISM................................................................. 14
MEMBER ELIGIBILITY ....................................................5 GENERAL EXCLUSIONS ............................................. 15
CERTIFICATE EFFECTIVE & TERMINATION DATES...5 DEFINITIONS ............................................................... 16
CERTIFICATE EFFECTIVE DATE ...........................5
CERTIFICATE TERMINATION DATE ......................5
BENEFIT PERIOD & HOME COUNTRY COVERAGE ....5
BENEFIT PERIOD....................................................5
INCIDENTAL HOME COUNTRY COVERAGE.........5
2 Atlas Essential Description of Coverage | Tokio Marine HCC - MIS Group
U.S. PREFERRED PROVIDER ORGANIZATION (PPO)
PATIENT PROTECTION AND AFFORDABLE CARE REQUIREMENTS ........................................................... 7
ACT (“PPACA”) DISCLOSURE STATEMENT.................3 CLAIM PROCEDURES ................................................... 7
DESCRIPTION OF COVERAGE SUMMARY..................3
IMPORTANT FEATURES OF YOUR TRAVEL PROOF OF CLAIM .................................................. 8
INSURANCE....................................................................3 CLAIMS COOPERATION ........................................ 8
ACCESS TO ADDITIONAL MATERIALS ................ 8
CANCELLATION ......................................................3 OTHER INSURANCE .............................................. 8
U.S. PREFERRED PROVIDER ORGANIZATION ARBITRATION......................................................... 8
(PPO)........................................................................3 APPEAL AND COMPLAINTS PROCEDURE.................. 8
CLAIMS ....................................................................4 APPEALING A CLAIM ............................................. 8
APPEALS AND COMPLAINTS ................................4 COMPLAINTS PROCEDURE.................................. 9
DEFINITIONS ...........................................................4 PRE-EXISTING MEDICAL CONDITIONS ...................... 9
PRE-EXISTING CONDITIONS .................................4 MEDICAL & REPATRIATION EXPENSES ..................... 9
DATA PROTECTION................................................4 MEDICAL EXPENSES........................................... 10
RIGHTS OF THIRD PARTIES ..................................4 EMERGENCY MEDICAL EVACUATION............... 11
LAW AND JURISDICTION .......................................4 REPATRIATION OF REMAINS ............................. 11
TOKIO MARINE HCC MEDICAL INSURANCE LOCAL BURIAL OR CREMATION ........................ 12
SERVICES GROUP (“MIS GROUP”) .......................4 TERRORISM................................................................. 14
MEMBER ELIGIBILITY ....................................................5 GENERAL EXCLUSIONS ............................................. 15
CERTIFICATE EFFECTIVE & TERMINATION DATES...5 DEFINITIONS ............................................................... 16
CERTIFICATE EFFECTIVE DATE ...........................5
CERTIFICATE TERMINATION DATE ......................5
BENEFIT PERIOD & HOME COUNTRY COVERAGE ....5
BENEFIT PERIOD....................................................5
INCIDENTAL HOME COUNTRY COVERAGE.........5
2 Atlas Essential Description of Coverage | Tokio Marine HCC - MIS Group
