Insured’s Name / Mailing Address:
Study USA-HealthCare™
Vijay Patel
4700 Dexter Dr., ste 100
Plano, TX 75093
USA
Welcome to coverage under Study USA-Healthcare, insured by Syndicate 4141 at Lloyd’s, London. Enrollment is administered by Travel Insurance
Services. Claims are administered by HCC Medical Insurance Services. These documents present instructional information as well as a page of
details about your coverage and an ID card to cover every person insured under this plan. Please be sure to read the Study USA-HealthCare
Description of Coverage, an summary of the plan provisions, attached to your confirmation e-mail. You can also find them online at
http://www.travelinsure.com/what/susadetails.asp.
This insurance coverage does not meet the minimum standards required by the US Patient Protection and Affordable Care Act. The policy
contains the plan benefits, including a lifetime maximum, that you have selected. Please review your chouce to ensure that you have sufficient coverage to meet your medical needs.
How to Use Your Insurance
In the event you need medical attention, present the identification card to your attending physician. The physician is welcome to submit bills directly
to HCC Medical Insurance Services. You will need to submit a Claimant’s Statement.
To file a claim, please submit the original, itemized bills, and payment receipts along with a Claimant’s statement and Authorization Form to:
HCCMIS Claims Department
P.O. Box 863
Indianapolis, IN 46206
Claims must be filed within 60 days of the termination date of your policy. You may obtain a Claimant’s Statement at the Travel Insurance Services
website at http://www.travelinsure.com/claimforms.
This insurance policy does contain pre-certification requirements. You need to notify HCC Medical Insurance Services in advance (within 48 hours
for emergencies) for any hospitalizations or surgeries as well as other items listed on your identification card or in the policy description. You may
pre-certify through Client Zone or by phoning HCC Medical Insurance Services at 1-888-627-6619 or 1-317-262-2132. Pre-certification is not a
guarantee of benefits; please review your policy carefully.
Please Note:
This insurance is extendable for up to 364 days and renewable for up to 3 consecutive periods of 364 days. Extensions
and renewals maby be completed online at http://www.travelinsure.com.
If you need to cancel your insurance, you must notify us in writing prior to the Effective Date of your coverage to receive
a refund. Notices can be e-mailed to susa@travelinsure.com.
For customer service questions, contact:
Travel Insurance Services
1-800-937-1387
http://www.travelinsure.com/
Study USA-HealthCare I.D. Card
Insured Person: Vijay Patel
Name of Plan: C
Certificate No.: 5100057
Effective Date: 12/15/2012
Termination Date: 12/17/2012
For pre-notification or questions regarding benefits,
eligibility or claims, contact:
HCC Medical Insurance Services
1-888-627-6619 or 1-317-262-2132
Policy Number: 121920-STU
• You are required to notify HCC Medical Insurance Services of any
of the following: surgeries, emergency evacuations, emergency
reunions, trip interruptions, repatriation of remains, computerized
tomography (CAT Scan), and Magnetic Resonance Imaging (MRI).
Failure to comply may result in a reduction of benefits.
• For pre-notification or general questions regarding Eligibility,
Benefits, or Claims, please call 1-888-627-6619, or 1-317-262-2132.
• Mail itemized bills including diagnosis to:
HCCMIS Claims Department
P.O. Box 863
Indianapolis, IN 46206.
• POSESSION OF THIS CARD DOES NOT GUARANTEE
COVERAGE
Study USA-HealthCare™ Confirmation of Insurance
Underwritten by Syndicate 4141 - Lloyd’s, London
Claims administered by HCC Medical Insurance Services
Actual effective and termination date and period may vary based on the provisions of this coverage.
Citizenship: India
Certificate No.: 5100057
Country of Assignment: United States
Passport No.: A123456
Insured’s Name/Mailing Address
Total Premium Paid: $7.08
Vijay Patel
4700 Dexter Dr., ste 100
Plano, TX 75093
USA
Next Payment Date: N/A
Next Payment Amount: N/A
Name(s) of Insured(s)
Plan Purchased
Vijay Patel
Florida
Effective Date
12/15/2012
Termination Date
12/17/2012 11:59pm
Limits of Coverage
Plan
Medical
Benefits
C
$300,000
Pre-Existing Condition
Emergency Medical Repatriation of
AD&D
Waiting Period
Evacuation
Remains
6 Months
$25,000
$500,000
$100,000
Medical Benefit Schedule
Deductible:
Claims in network/out-of-network
Coinsurance:
Claims in network
Coinsurance: Claims
out-of-network
Administered by:
$50 / $150
80% up to out of pocket
maximum, then 100% up to
certificate period maximum
70% up to out of pocket
maximum, then 100% up to
certificate period maximum
Prescription Drugs
$10 generic / $20 brand name
Emergency Room
$250 per incident
(unless admitted as inpatient)
3070 Riverside Drive Phone: (800) 937-1387
Columbus, OH 43221 FAX: (610) 537-9828
USA
email: susa@travelinsure.com
POLICYHOLDER/CERTIFICATE HOLDER NOTICE
U.S. Treasury Department’s Office of Foreign Assets Control (“OFAC”)
It is important to note that no coverage is provided by thie Policyholder/Certificate Holder Notice nor
can it be construed to replace any provisions of your plan. for complete information on provided
coverage, consult the plan itself and the Declaration page. This Policyholder/Certificate Holder Notice
is solely for providing information concenring the possible impact on your insurance coverage due to
directives issued by OFAC, and it is necessary that this notice be read carefully. OFAC administers
and enforces sanctions policy based on national emergency declarations made by the President and
has identified numerous countries, foreign agents, front organizations, terrorists, terrorist organizations, and narcotics Traffickers as “Specially Designated Nationals and Blocked Persons (“SDN”)”.
This list can be found on the United States Treasury’s web site - http://www.treas.gov/ofac. In
accordance with OFAC regulations, if it is determined that the insured or any person or entity claiming
the benefits of this insurance has been identified as a SDN or if a prohibited country as identified by
OFAC is involved, then the provisions of the insurance plan will immediately be subject OFAC
administration. Accordingly, certain limitations on premium payments and/or claim payments
may apply.