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SPECIMEN11. Drugs which require prescription by a physician for treatment of a covered injury or illness, but
not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and
for a maximum supply of 60 days per prescription.
12. Care in a licensed extended care facility upon direct transfer from an acute care hospital.
13. Home nursing care in bed by a qualified licensed professional, provided by a home health care
agency upon direct transfer from an acute care hospital and only in lieu of medically necessary
inpatient hospitalization.
14. Emergency local ambulance transport necessarily incurred in connection with injury or illness
resulting in inpatient hospitalization.
15. Emergency dental treatment and dental surgery necessary to restore or replace sound natural
teeth lost or damaged in an accident which was covered under this insurance.
16. Emergency dental treatment necessary to resolve acute onset of pain, provided treatment is
obtained within 24 hours of the acute onset of pain.
17. Emergency Eye Exam if your prescription corrective lenses are lost or damaged due to a
covered loss and an exam is required to obtain a lens prescription for medically necessary
correction lenses, but not for the replacement cost of prescription corrective lenses or contact
lenses.
18. Medically necessary rental of durable medical equipment (consisting of a standard basic
hospital bed and or a standard basic wheelchair) up to the purchase prices.
19. Outpatient physical therapy or chiropractic care if prescribed by a physician who is not affiliated
with the physical therapy or chiropractic practice, necessarily incurred to continue recovery from a
covered injury or illness.
20. Injury or illness resulting from participation in sports or athletic activities not otherwise excluded
under this insurance.
YOU ARE NOT COVERED IF:
1. Expenses arise directly or indirectly from anything in the General Exclusions.
EMERGENCY MEDICAL EVACUATION
YOU ARE COVERED:
1. Emergency air transportation to a suitable airport nearest to the hospital where you will receive
treatment; and
2. Emergency ground transportation necessarily preceding emergency air transportation; and from
the destination airport to the hospital where you will receive treatment.
YOU ARE NOT COVERED unless you fulfill the following conditions:
1. The evacuation is recommended by the attending physician who certifies that it is medically
necessary and that transportation by any other method would result in the loss of your life or limb;
and
2. The evacuation is agreed upon by you or your relative; and
3. Travel arrangements, excluding Emergency Local Ambulance, are approved in advance and
coordinated by us.
YOU ARE NOT COVERED IF:
1. The illness or injury giving rise to the expense is not covered under this insurance; or
2. Medically necessary treatment, services and supplies can provided locally; or
3. If transportation by any other method would not result in the loss of your life or limb; or
4. The condition giving rise to the Emergency Medical Evacuation did not occur spontaneously and
without advance warning, either in the form of physician recommendation or symptoms which
would have caused a prudent person to seek medical attention prior to the onset of the
emergency; or
5. Expenses are directly or indirectly from anything in the General Exclusions.
We will provide Emergency Medical Evacuation only to the nearest hospital that is qualified to
provide the medically necessary treatment, services and supplies to prevent your loss of life or limb.
13 Atlas Group Description of Coverage | Tokio Marine HCC - MIS Group
not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and
for a maximum supply of 60 days per prescription.
12. Care in a licensed extended care facility upon direct transfer from an acute care hospital.
13. Home nursing care in bed by a qualified licensed professional, provided by a home health care
agency upon direct transfer from an acute care hospital and only in lieu of medically necessary
inpatient hospitalization.
14. Emergency local ambulance transport necessarily incurred in connection with injury or illness
resulting in inpatient hospitalization.
15. Emergency dental treatment and dental surgery necessary to restore or replace sound natural
teeth lost or damaged in an accident which was covered under this insurance.
16. Emergency dental treatment necessary to resolve acute onset of pain, provided treatment is
obtained within 24 hours of the acute onset of pain.
17. Emergency Eye Exam if your prescription corrective lenses are lost or damaged due to a
covered loss and an exam is required to obtain a lens prescription for medically necessary
correction lenses, but not for the replacement cost of prescription corrective lenses or contact
lenses.
18. Medically necessary rental of durable medical equipment (consisting of a standard basic
hospital bed and or a standard basic wheelchair) up to the purchase prices.
19. Outpatient physical therapy or chiropractic care if prescribed by a physician who is not affiliated
with the physical therapy or chiropractic practice, necessarily incurred to continue recovery from a
covered injury or illness.
20. Injury or illness resulting from participation in sports or athletic activities not otherwise excluded
under this insurance.
YOU ARE NOT COVERED IF:
1. Expenses arise directly or indirectly from anything in the General Exclusions.
EMERGENCY MEDICAL EVACUATION
YOU ARE COVERED:
1. Emergency air transportation to a suitable airport nearest to the hospital where you will receive
treatment; and
2. Emergency ground transportation necessarily preceding emergency air transportation; and from
the destination airport to the hospital where you will receive treatment.
YOU ARE NOT COVERED unless you fulfill the following conditions:
1. The evacuation is recommended by the attending physician who certifies that it is medically
necessary and that transportation by any other method would result in the loss of your life or limb;
and
2. The evacuation is agreed upon by you or your relative; and
3. Travel arrangements, excluding Emergency Local Ambulance, are approved in advance and
coordinated by us.
YOU ARE NOT COVERED IF:
1. The illness or injury giving rise to the expense is not covered under this insurance; or
2. Medically necessary treatment, services and supplies can provided locally; or
3. If transportation by any other method would not result in the loss of your life or limb; or
4. The condition giving rise to the Emergency Medical Evacuation did not occur spontaneously and
without advance warning, either in the form of physician recommendation or symptoms which
would have caused a prudent person to seek medical attention prior to the onset of the
emergency; or
5. Expenses are directly or indirectly from anything in the General Exclusions.
We will provide Emergency Medical Evacuation only to the nearest hospital that is qualified to
provide the medically necessary treatment, services and supplies to prevent your loss of life or limb.
13 Atlas Group Description of Coverage | Tokio Marine HCC - MIS Group
