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Schedule of Benefits
Accidental Death
and Dismemberment
Up to $10,000 for Gold, Silver & Bronze Plans
Accident Medical
Gold Plan Accident Medical: $10,000 with a per occurrence deductible of $500
Silver Plan Accident Medical: $5,000
with a per occurrence deductible of $250
Bronze Plan Accident Medical: $2,500 with a per occurrence
deductible of $100
Air Evacuation / Repatriation*: $4,000 for Gold, Silver &
Bronze Plans
Assistance
Services*:
*Provided
by On-Call International
Accidental Death
and Dismemberment
If
accidental bodily injury causes the following losses within one year of the
date of the accident which are not otherwise excluded, FSG* will pay the
following benefits:
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Accidental
Loss of |
Benefit
Amount |
Life |
100% |
Speech
and Hearing |
100% |
Speech
and one of: Hand, Foot or Sight of an Eye |
100% |
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Accidental
Loss of |
Benefit
Amount |
Hearing and one of:
Hand, Foot or Sight of an Eye |
100% |
Both Hands, Both Feet,
Sight of Both Eyes or a combination of any two of a Hand, a Foot, or Sight of
an Eye |
100% |
One
Hand, One Foot, or Sight of an Eye |
50% |
Speech
or Hearing |
50% |
Thumb and Index Finger
of the same hand |
25% |
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If an Insured Person
suffers more than one loss under the Schedule of Benefits as the result of one
Accident, FSG* will pay only the single largest Benefit Amount applicable.
Additional Benefits
- The following benefits are payable in addition to all
other benefits payable under the policy.
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Excess Accident
Medical Expense
FSG* will pay up to the
Medical Expense Benefit Amount shown above if the Insured Member suffers a
Loss, requires medical care and treatment and incurs Medical Expenses.
Medical Expense means the
Reasonable and Customary charges for Medical Services that are Medically
Necessary for the care and treatment of Accidental Bodily Injuries sustained in
a covered Accident.Medically Necessary means
any medical or dental service, supply or course of treatment which
1) is ordered or prescribed by a Physician or a dentist;
2) is appropriate and consistent with the patient’s
diagnosis;
3) is in accord with current accepted medical or dental practice; and
4) could not be eliminated without adversely affecting the patient’s condition or
quality of medical or dental care.
Medical Services means
the costs for the following Medically Necessary services:
1) medical care and treatment by a Physician or a dentist;
2) hospital room and board and hospital care, both inpatient and outpatient;
3) diagnostic tests and x-rays;
4) use of a professional ambulance;
5) dental care due to injury of functional, natural teeth.
Other Plan means any:
group medical plan; group blanket plan, governmental plan or program; or
coverage provided or required by any law or statute, including automobile
"fault " and "no-fault" coverage
and Workers’ Compensation.
Reasonable and Customary
means the lesser of:
1) the usual charge made by Physicians or other health care providers for a given
service or supply; or
2) the charge we
determine to be the prevailing charge made by Physicians or other health care
providers for a given service or supply in the geographical area where it is
furnished; or
3) the amount negotiated by the insurer and the health care provider.
The Medical Expense
Benefit Amount is payable excess of any valid or collectable insurance. FSG*
will determine the Reasonable and Customary charge for the covered Medical
Expense.
We will then reduce that amount by amounts already paid or payable by
any Other Plan from which the Insured Person is entitled to receive benefits.
FSG* will pay the resulting amount, plus amounts paid by the Insured Member to
satisfy cash deductibles or coinsurance amounts. In no event will FSG* pay more
than the benefit amount shown above.
If, as a result of the
excess calculation a Benefit Amount is not payable under this Medical Expense
coverage, FSG* will reimburse the Insured Person, any amount the Insured Member
may have paid to satisfy cash deductibles, or coinsurance amounts. In no event
will we pay more than the benefit amount shown above.
Exclusions - Basic Plan
The Medical Expense
Benefit does not apply to the following charges and services:
1) charges for which the Insured Member has no obligation to pay;
2) eyeglasses,
contact lenses and other vision or hearing aids and artificial limbs;
3) any injury for which Worker’s Compensation benefits or occupational injury benefits
are payable.
4) Sickness of any kind
5) Travel in or upon:
(a) A snowmobile;
(b) Any two or three wheeled motor vehicle;
(c) Any off‑road motorized vehicle not requiring licensing as a motor vehicleThis Medical Expense coverage applies
only to Medically Necessary charges,
as defined above.
6) Skiing or Snowboarding
7) Base jumping or cliff jumping
8) Rock climbing
Exclusions – Plus Plan
The Medical Expense Benefit does not apply to the following charges and services:
1) charges for which the Insured Member has no obligation to pay;
2) eyeglasses, contact lenses and other vision or hearing aids and artificial limbs;
3) any injury for which Worker’s Compensation benefits or occupational injury benefits are payable.
4) Sickness of any kind
5) Travel in or upon:
(a) A snowmobile;
(b) Any two or three wheeled motor vehicle;
(c) Any off‑road motorized vehicle not requiring licensing as a motor vehicle
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Emergency Helicopter Rescue - for Gold plan members only
In the event that an eligible member suffers from a life threatening “certified injury” as a result of an accident that requires emergency medical transportation by helicopter in accordance with EMS protocols, the program will reimburse the participant or their provider up to a maximum of $4,000.00 per occurrence. Reimbursement includes expenses incurred from the cost of a “Medically Necessary” or “Life Threatening” situation for helicopter transportation from the scene of an accident to the nearest medical facility capable of treating the injuries, or from one medical facility to another medical facility. Claims for “Medically Necessary” transports from one medical facility to another medical facility are subject to review by Lifeguard’s Medical Officer. This benefit is only available with the gold plan.
Provisions
• One benefit will be paid per occurrence
• Benefit in excess of all other valid collectable insurance
• Coverage is worldwide
• Transportation by helicopter only
How To Use This Benefit
Call 911 or the local equivalent. Local EMS protocols will make the determination for necessity and type of medical transportation that best fits each situation.
To file a claim, please call Lifeguard at 800-446-7142. Certain terms and conditions apply.
THIS BENEFIT IS NOT AVAILABLE IN FLORIDA OR FOR RESIDENTS OF FLORIDA.
On-Call International Assistance Service
- While traveling away from home, Insured members can
have the peace of mind that comes from knowing there’s someone who can
assist in the event of a travel-related emergency. On-Call
International, a leading travelers assistance
provider that specializes in worldwide assistance, operates a twenty-four
hour, seven days a week, toll-free emergency telephone assistance
service. In the event of a travel-related emergency, On-Call will
provide the following emergency assistance services:
- Special assistance in replacing lost or stolen travel
documents, including passports.
- Emergency funds transfer.
- Special assistance in locating the nearest, most
appropriate medical care.
- Verification of insurance coverages facilitating entry and admissions into hospitals and other medical care
providers.
- Assistance in establishing contact with family,
personal physician, and employer as appropriate.
- Special assistance in the coordination of direct
claims payment.
- Management, arrangement, and coordination of
emergency medical transportation and evacuation as necessary.
- Translation services and referrals to local
interpreters as necessary.
- Knowledgeable legal referral assistance.
- Courtesy assistance in securing incidental aid and
other travel-related services.
- Coordination of securing bail bonds and other legal
instruments.
Maximum Limit of
Insurance/AggregateA maximum limit of
insurance of 5 lives applies per accident.
Exclusions
- Loss occurring while the insured is in, entering or
exiting any aircraft that is owned, leased or
operated by his or her employer or on behalf of the employer.
- Loss occurring while the insured is in any aircraft
while acting or training as a pilot or crew member.
- Loss caused by or resulting from the insured's
emotional trauma, mental or physical illness, disease, pregnancy,
childbirth or miscarriage, bacterial or viral infection or bodily
malfunctions.
- Loss resulting from suicide, attempted suicide or
loss that is intentionally self-inflicted.
- Loss caused by or resulting from a declared or
undeclared war, but war does not include acts of terrorism.
- While an Insured Person is participating in military
action in the Armed Forces of any country or established international
authority. However, orders to active military service
for sixty (60) consecutive days or less shall not constitute
service in the Armed Forces.
Loss caused by or
resulting from, directly or indirectly, an Insured Person’s commission or
attempted commission of any illegal act including but not limited to any
felony. Loss caused by or resulting
from an Insured Person being intoxicated, as defined by laws of the
jurisdiction where the loss occurred, or under the influence of any narcotic
unless taken on the advice of a Physician and used in accordance with the
prescription.
- Nuclear reaction or the release of nuclear energy.
- Dental Care unless required on the account of an
injury caused by a covered accident.
- Any accident where the Insured Member is the operator
of a motor vehicle and does not possess a current and valid motor
operator’s license.
- Blood or plasma.
- Cosmetic surgery.
- Artificial limbs.
- Hernia of any kind.
- Prescription medicines unless specifically provided
for under this Plan.
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Medical Evacuation / Repatriation
If accidental bodily injury, disease or illness causes an Insured Member to
require a physician ordered medical evacuation and/or repatriation, FSG* will
pay for covered expenses incurred up to the specified benefit amount. The
Assistance Services Administrator – On-Call International, must approve the
evacuation/repatriation. Covered expenses include costs for evacuation,
transportation, medical supplies and services. Covered expenses does not
include expenses incurred if travel is against the advice of a physician, for
the purpose of obtaining medical treatment or due to normal pregnancy or
resulting child birth.
Please note, that this is a description of coverage only. For a full review of the Plan’s benefits and exclusions, a copy of the full policy will be on file with the Association.
* Products underwritten by: Fairmont Premier Insurance Company & Fairmont Specialty Insurance Company under the management of Fairmont Specialty Group. Fairmont Specialty group is a division owned and operated by Crum and Forster Holding, Inc, a wholly owned, indirect subsidiary of Fairfax Financial Holdings, Limited.
Please note that Fairmont’s “Privacy Policy & Practices” and “Grievance Procedures” apply to the Plan You have purchased. If You would like to receive a copy of this information, please contact Coordinated Benefit Plans *Crum and Forster, based in Morristown, New Jersey, is a national commercial property and casualty insurance company in the United States, writing a broad range of commercial coverages. Since January 1, 2006 the specialty niche property and caualty and accident and health insurance is being carried on as the Fairmont Specialty division of Crumb and Forster. Crum and Forster is rated “A- (Excellent)” according to A.M. Best.
Financial size category: XIII (1.25 billion to 1.5 billion)
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To view our Terms and Conditions for membership: Click here
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