CONNECTICUT GENERAL LIFE INSURANCE COMPANY HARTFORD, CONNECTICUT A STOCK INSURANCE COMPANY PART I - INSURING AGREEMENTS

Transcription

1 CONNECTICUT GENERAL LIFE INSURANCE COMPANY HARTFORD, CONNECTICUT A STOCK INSURANCE COMPANY Travel Accident Policy Policy No. : 04837B Effective Date: January 1, 2011 through December 31, 2011 Anniversary Date: January 1st PART I - INSURING AGREEMENTS In consideration of the payment of premiums as provided herein, and subject to the terms, conditions and limitations herein contained, Connecticut General Life Insurance Company (the Company ) AGREES WITH Nortel Networks Inc East Chapel Hill-Nelson Hwy. P. O. Box Research Triangle Park, NC (the Policyholder ) TO INSURE those persons described in Schedule I, each herein called the Insured, and subject to all of the Exclusions, General Limitations, Provisions and other terms of this Policy, against loss resulting from Injuries which arise out of the hazards described in Schedule II and are sustained by the Insured on an approved employer business trip, during the term of this Policy, herein called "Such Injuries," to the extent provided herein. EFFECTIVE DATE AND POLICY TERM This Policy takes effect as of 12:01 A.M Eastern Standard Time on the Effective Date, and shall continue in effect as long as the premium is paid on or before the premium due date as herein agreed, unless and until either the Policyholder or the Company terminate the Policy in accordance with the provision entitled Termination of the Policy or as otherwise stated in the Policy. Policy years shall be determined from the Policy Anniversary Date as specified above. Forms attached to and forming part of this Policy on its date of issue are: Form IT-TA-APP[1,2]-DE IT-TA-SCH1-DE IT-TA-SCH2-DE IT-TA-SCH3-DE IT-TA-MED1,2,3,4-DE IT-TA-CC-DE IT-TA-EVAC1,2-DE IT-TA-PAC-DE Title Application Schedule I: Persons Insured - Amounts of Insurance Schedule II: Description of Hazards Schedule III: Premium Calculation Medical Expense Amendatory Rider Conditional Claim/Subrogation Evacuation/Repatriation Benefits Rider Pre-Admission Certification and Continued Stay Review Requirements Rider IT-TA-1.0-DE

2 Coverage A - Death, Dismemberment or Loss of Sight If within ninety (90) days from the date of accident Such Injuries shall result in death of the Insured, dismemberment or loss of sight, the Company will pay for: Loss of Life or Two or more Members... The Principal Sum; Loss of Speech and Hearing... The Principal Sum; Loss of Speech or Hearing... One-half (1/2) the Principal Sum; Loss of One member... One-half (1/2) the Principal Sum; Thumb and index finger from the same hand... One-fourth (1/4) the Principal Sum. Such payment shall be in addition to any other indemnity payable as of the date of loss, but only one (1) amount, the larger applicable amount, shall be payable for all such losses resulting from one accident. The "Principal Sum" is the amount specified as such in Schedule I. "Member" shall mean a hand, foot, or eye. "Loss" shall mean, with respect to hands and feet, actual severance through or above wrist or ankle joints; with respect to eyes, entire and irrecoverable loss of sight; with respect to speech, the total and irrecoverable loss of speech which does not allow audible communication in any degree; with respect to hearing, the total irrecoverable loss of hearing which cannot be corrected by any hearing aid or device. Loss of a thumb and index finger means complete severance through or above the metacarpophalangeal joints, (the joints between the fingers and the hand). Coverage B - Medical Expense If, on account of Such Injuries, the Insured shall require treatment by a Physician, the Company will pay the actual expense incurred within ninety (90) days from the date of accident which is in excess of the deductible amount (if any) specified in Schedule I, but not more than the maximum amount specified in Schedule I. PART II - EXCLUSIONS This Policy does not cover loss caused by or resulting from any one or more of the following: A. Intentionally self-inflicted injuries, suicide or any attempt thereat, while sane, or insane; B. Accident occurring while the Insured is serving on full-time active duty in the Armed Forces of any country or international authority (any premium paid to be returned by the Company pro-rata for any such period of full-time active duty); C. Sickness, disease, pregnancy, childbirth, miscarriage, or any bacterial infection other than bacterial infection occurring in consequence of any accidental cut or wound; D. Travel or flight in any vehicle or device for aerial navigation; except to the extent such travel or flight is provided in Schedule II; E. Claim payments which are illegal under applicable law; F. Declared or undeclared war or any act thereof, riot, civil commotion, or police action. PART III - PAYMENT OF CLAIMS Claim Procedures: Notice of Claim - If any covered loss occurs or begins, the insured or beneficiary must send the Company written notice within thirty (30) days, or as soon after that as is reasonably possible. This notice should state the Insured s name and the Policy number. This notice should be sent to the Company at the following address: Connecticut General Life Insurance Company, P.O. Box 15111, Wilmington, DE or by courier to 590 Naamans Road, Claymont, DE The Company will then send the Insured applicable claim forms. Claim Procedures: Proof of Loss - The claim forms must be sent back to the Company no more than ninety (90) days after a covered loss occurs or ends, or as soon after that as is reasonably possible. If the Company has not provided claim forms within fifteen (15) days after the notice of claim, the Insured or beneficiary should send the Company other proof of loss by the date claim forms would be due. This proof of loss should include written proof of the occurrence, type and amount of loss. Payment of Claims: When Paid - Claims will be processed and paid upon the Company s receipt of due proof of loss. IT-TA-2.0-DE

3 Payment of Claims: To Whom Paid - Benefits paid on account of an Insured's death will be paid to the beneficiary designated by the Insured. This beneficiary designation must be in writing and filed with the Company. If the Insured has not designated a beneficiary, or if there is no beneficiary alive when the Insured dies, the Company will pay benefits as follows: 1) to the Insured s spouse, if living; 2) if not, in equal shares, to the Insured s living children; 3) if there are none, in equal shares to the Insured s living parents; 4) if there are none, in equal shares to the Insured s living brothers and sisters; 5) if there are none, to the Insured s estate. Payment of Claims: Other Benefits - All other benefits will be paid to the Insured, if the Insured is living. If not, the Company will pay the Insured s beneficiary or estate. Selection or Change of Beneficiary; Assignment - The Insured has the right to select or change the beneficiary. Provided such is not required by applicable law, the Insured does not need the consent of the beneficiary to make such a change, to assign rights or benefits, or to change coverage. The Company will not be bound by an assignment, or by a selection or change of beneficiary, unless it receives a signed copy of such assignment. The Company is not responsible for its validity or sufficiency. PART IV - GENERAL PROVISIONS Entire Contract; Changes - This Policy (including the endorsements and attached papers) is the entire contract. The application, and the applications of persons for coverage (if any), are a part of this Policy. No change in this Policy is valid unless it has been approved by one of the Company s executive officers. This approval must be attached to or endorsed on this Policy. No agent may change this Policy or waive any of its provisions. Termination of the Policy - The Policyholder may terminate this Policy at any time on or after the first (1 st ) anniversary of its Effective Date, by sending the Company advanced written notice. The Policy will be terminated on the date that the Company receives such notice, or later if the Policyholder so specifies. The Company will return pro rata the unearned portion (if any) of the premiums that were paid. The Company may terminate this Policy as of any Anniversary Date, by sending the Policyholder at least 31 days advanced written notice. This Policy can also be terminated by the Company if renewal premiums (see Schedule III) are not paid by the end of the grace period or within thirty (30) days of their due date, whichever is later. Termination will not affect a claim for a loss which occurs while this Policy is in force. Premium Calculation - If the Company determines that the number of weeks of travel is materially inaccurate, the Company may adjust the premium rate accordingly. Grace Period - After payment of the first premium, this Policy will have a 31-day grace period. This means that if a premium is not paid on or before it is due, it may be paid during the 31-day grace period. During this time, the Policy will stay in force. The Policyholder is liable for the payment of any premium while coverage is in force. Physical Examination and Autopsy - At the Company s expense, the Company may have an Insured examined as often as reasonably necessary while a claim is pending. The Company may also make an autopsy in case of death where it is not prohibited by applicable law. Governing Law - This Policy shall be governed by and construed under the laws of the State of Delaware, without reference to Delaware s conflict of laws principles and rules. Records Maintained; Examination And Audit - The Policyholder or agent of the Policyholder shall keep records showing the essential facts of each Insured s coverage. During normal business hours and upon five (5) business days advanced notice, the IT-TA-3.0-DE

4 Company may examine these records at any time that this Policy is in force, within three (3) years after this Policy is terminated, or later if claims are still pending. Not in Lieu of Workers Compensation - This Policy is not in lieu of and does not affect requirements for coverage under any Workers Compensation law. Certificates of Insurance - If required by state law, the Company will give the Policyholder or the agent of the Policyholder certificates of insurance. These will contain the major provisions of this Policy. These shall be sent to all Insureds by the Policyholder. Examination of the Policy - This Policy shall be available for inspection by Insureds during normal business hours at Policyholder s office or the office of the administrator. IN WITNESS WHEREOF, CONNECTICUT GENERAL LIFE INSURANCE COMPANY has caused this Policy to be signed by its President or Secretary in Hartford, Connecticut, but said Policy shall not be binding upon the Company unless countersigned by a duly authorized representative of the Company. Registrar IT-TA-4.0-DE

5 SCHEDULE I The insurance under this Policy applies only to the group of Insureds described and only with respect to those coverages for which an amount is specified. The amount so specified shall apply to each Insured, subject to all terms of the Policy having reference thereto. Description of the Insureds (includes all persons coming within the scope of such descriptions at any time during the Policy term): All full-time active employees who are traveling on the business of or at the expense of the Policyholder outside their country of residence or permanent assignment. Persons for whom coverage is prohibited under applicable law will not be considered eligible for this policy. Principal Sum Evacuation/Repatriation Maximum Amount Medical Expense Maximum Amount Deductible (if any) Coverage A $100, Coverage B 100% of incurred covered expenses. $100,000 per occurrence $300,000 per Calendar Year $0 per Calendar Year Aggregate Limit of Liability Each Covered Aircraft Accident: $500,000 for all Covered Persons Attached to and forming a part of Policy: 04837B The Company shall not be liable for any amount in excess of the above stated Aggregate Limit of Liability. If this aggregate amount does not allow all Covered Persons to be paid the amounts the specified benefits otherwise provide, the amount paid for each Covered Person is the proportion each Loss bears to the Aggregate Limit of Liability. Covered Aircraft Accident means a Covered Accident involving a scheduled or chartered flight in an Aircraft. Effective date of this Schedule is January 1, 2011 IT-TA-SCH1-DE

6 SCHEDULE II - DESCRIPTION OF HAZARDS Page 1 of 2 The hazards against which insurance is granted under this Policy are: 24 HOUR ACCIDENT PROTECTION - BUSINESS ONLY Excluding Policyholder Owned or Leased Aircraft The Company will pay the benefits described in the Policy for any accident which occurs anywhere in the world while an Insured is on a business trip, is traveling or making a short stay: a) outside the Insured s country of permanent assignment; and b) on business and in the course of Policyholder s business. All such trips must be authorized by the Insured s employer. This coverage does not apply: a) while the Insured is commuting between the Insured s home and place of work or place of permanent assignment; or b) during personal deviations made by the covered person; or c) while the Insured is on the Policyholder s premises in the country of permanent assignment. Personal Deviation as used herein, means an activity that is not reasonably related to the Employer s business, and not incidental to the business trip. This coverage will start at the actual start of a trip when the destination is outside the Insured s country of permanent assignment. It does not matter whether the trip starts at the Insured s home, place of work, or other place. This coverage will end when the Insured: a) arrives at the Insured s home or place of work in the Insured s country of permanent assignment, whichever happens first; or b) makes a personal deviation. If an Insured travels to another country, and is expected to remain there for more than 180 days, this shall be deemed a change in the Insured s country of permanent assignment. Exposure And Disappearance - This coverage includes exposure to the elements, after the forced landing, stranding, sinking or wrecking of a vehicle in which the Insured was traveling on business for Policyholder. An Insured will be presumed to have died, for purposes of this coverage, if: a) the Insured is in a vehicle which disappears, sinks, or is stranded or wrecked, in the course of a trip which would be covered by the Policy; and b) the Insured s body is not found within one year of the accident. Aircraft Restrictions - If the accident happens while an Insured is riding in, or getting on or off of, an Aircraft, the Company will pay benefits, but only if: a) the Insured is riding as a passenger only, and not as a pilot or member of the crew; and b) the Aircraft has a valid certificate of airworthiness; and c) the Aircraft is flown by a pilot with a valid licensed; and d) the Aircraft is not being used for: (i) crop dusting, spraying, or seeding; fire fighting; sky writing; sky diving or hang gliding; pipeline or power line inspection; aerial photography or exploration; racing, endurance tests, stunt or acrobatic flying; or (ii) any operation which requires a special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on); and e) a military aircraft, other than transport aircraft flown by the U.S. Military Airlift Command (MAC), or a similar air transport service of another country. IT-TA-SCH2-DE

7 SCHEDULE II - DESCRIPTION OF HAZARDS Page 2 of 2 Owned Aircraft Not Covered The Company will not pay benefits if the Aircraft is owned, leased or controlled by Policyholder, or any of Policyholder s subsidiaries or affiliates. An Aircraft will be deemed to be controlled by Policyholder if Policyholder may use it as Policyholder wishes for more than ten (10) consecutive days, or more than fifteen (15) days in any calendar year. Unless otherwise provided, the Company will pay benefits only once for any covered loss, even if it was caused by more than one covered hazard. Attached to and forming a part of Policy: 04837B Effective date of this Schedule is January 1, 2011 IT-TA-SCH2.1-DE

8 SCHEDULE III - PREMIUM CALCULATION The Company reserves the right to change the applicable premium rates for a future Anniversary Date; provided the Company gives the Policyholder at least 31 days advanced written notice of such change. The Policyholder is required to remit a Flat Annual Premium payment of $$$$$$ Such shall be due and payable in one (1) lump sum in accordance with the terms and conditions of this Policy. Payment is due upon receipt of invoice. At the end of each Policy Year, the Policyholder is required to submit an annual travel report to be used to calculate the following year s premium. Attached to and forming a part of Policy: 04837B Effective date of this Schedule is January 1, 2011 IT-TA-SCH3-DE

9 MEDICAL EXPENSE AMENDATORY RIDER (Page 1 of 4) In consideration of the premium charged, it is hereby agreed that: 1. Exclusion C - Part II of the Policy is deleted with respect to Coverage B - Medical Expense only. 2. The description of Coverage B - Medical Expense under Policy Part I is amended to include the following: Coverage B - Sickness Medical Expense If Sickness requires treatment of an Insured by a Physician, the Company will pay the Insured the expenses incurred in excess of the deductible amount (if any), set forth in Schedule I within ninety (90) days from the date of Sickness for any of the services listed under this Policy section which are recommended and approved by the attending Physician, but not to exceed the maximum benefit as set forth in Schedule I, as the result of any one Sickness. Covered Expenses The term Covered Expenses means the expenses incurred by or on behalf of the Insured or covered dependent for the charges listed below if they are incurred after he becomes insured for these benefits. All Covered Expenses are subject to the General Limitations and the Pre-Existing Condition Limitations of the Policy. Certain Covered Expenses are also limited as described within this section. An expense is incurred on the date of the treatment, service or purchase. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician and Medically Necessary for the care and treatment as determined by the Company. Covered Expenses: 1) Charges made by a Hospital, on its own behalf, for Bed and Board, but not more than Hospital's most common semi-private room rate to a maximum of $1, per day outside the United States and not more than the Hospital s average semi-private rate per day of confinement inside the United States. 2) Charges made by a Hospital, on its own behalf, for confinement in an intensive care unit, payable in place of expenses covered in (1) above up to a maximum of $2, per day outside the United States and not more than the Hospital s average intensive care unit rate per day inside the United States. 3) Charges made by a Hospital for Necessary Services and Supplies. 4) Charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient. 5) Charges made by a Free-Standing Surgical Facility, on its own behalf, for medical care and treatment. 6) Charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided. 7) Charges made by a Physician for professional services. 8) Charges made by a Nurse for professional nursing services. 9) Charges made for anesthetics and their administration, diagnostic x-ray and laboratory examinations, microscopic tests, or any lab tests or analysis made for diagnosis or treatment. 10) The following supplies while Hospital confined or prescribed upon release from hospital confinement: a) drugs and medicines which require the written prescription of a Physician; b) blood transfusions and blood not donated or replaced; c) prosthetic appliances (not including replacement of these items); d) casts, splints, crutches, and braces (not including replacement of these items); e) oxygen and other gases and their administration; f) rental of a wheel chair or hospital bed. 11) Physiotherapy and Chiropractic Services. 12) Any care furnished to a newborn child including Hospital nursery expenses prior to discharge from the Hospital. 13) Medical expenses related to pregnancy. IT-TA-MED1-DE

10 MEDICAL EXPENSE AMENDATORY RIDER (Page 2 of 4) General Limitations This Policy will not pay benefits for expenses incurred for any of the following: 1) Injury or Sickness which results from or in the course of an Insured's regular occupation for wage or profit. (This does not apply to a corporate officer, partner or sole proprietor who is not insured under Workers' Compensation Employer's Liability Law or similar law). 2) Injury or Sickness for which an Insured is entitled to benefits under Workers' Compensation Law, Employer's Liability Law or similar law. 3) Sickness occurring while the Insured is serving on full-time active duty in the Armed Forces of any country or international authority (any premium paid to be returned by the Company pro-rata for any such period of full-time active duty); 4) Hospital confinement, surgery, treatment, service or supply for which: a) the charge is payable or reimbursable by or through a plan or program of any governmental agency; or b) charges which would not have been made if the person had no insurance. 5) To the extent that payment is unlawful where the person resides when the expenses are incurred. 6) To the extent that they are more than Reasonable and Customary Charges. 7) Injury as a result of a commission of a felony. 8) Attempted suicide or intentionally self-inflicted Injury, while sane or insane. 9) Eyeglasses, contact lenses, hearing aids, or examinations for prescription or fitting thereof. 10) Cosmetic or plastic surgery except; a) when necessary as a result of an Injury or Sickness occurring while Insured; or b) reconstructive surgery when such service is incidental to or follows surgery resulting from Injury or Sickness. 11) Hospital confinement, care or treatment which is not recommended and approved by a Physician. 12) Treatment or care of a person by a Physician or Nurse, if the Physician or Nurse is a member of the Insured's immediate family or ordinarily resides with the Insured. 13) Private Duty Nursing. 14) Physical examinations unless required because of Injury or Sickness. 15) Dental Expenses unless the result of an accident to sound natural teeth, then the benefit is limited to $1, per accident. 16) Expenses related to alcoholism, chemical dependency or drug addiction. 17) Expenses for treatment of mental illness. 18) Expenses incurred during vacation travel when not in conjunction with a business trip, unless Personal Deviation coverage is purchased as shown on Schedule II. 19) Claim payments which are illegal under applicable law. 20) Medical treatments or procedures deemed not Medically Necessary as determined by the Company; provided such are not mandated by applicable law. 22) Injury or Sickness caused by war, or an act of war, whether declared or undeclared, riot, civil commotion or police action. IT-TA-MED2-DE

11 MEDICAL EXPENSE AMENDATORY RIDER (Page 3 of 4) DEFINITIONS 1) The term Bed and Board includes all charges made by a Hospital on its own behalf for room and meals and for all general services and activities needed for the care of registered bed patients. 2) The term Free-Standing Surgical Facility means an institution which meets all of the following requirements: it has a medical staff of Physicians, Nurses and licensed anesthesiologists; it maintains at least two operating rooms and one recovery room; it maintains diagnostic laboratory and x-ray facilities; it has equipment for emergency care; it has a blood supply; it maintains medical records; it has agreements with Hospitals for immediate acceptance of patients who need Hospital Confinement on an inpatient basis; and it is licensed in accordance with the laws of the appropriate legally authorized agency. 3) The term "Hospital" means: an institution licensed as a hospital, which: (i) maintains, on the premises, all facilities necessary for medical and surgical treatment; (ii) provides such treatment on an inpatient basis, for compensation, under the supervision of Physicians; and (iii) provides 24-hour service by Registered Graduate Nurses; an institution which qualifies as a hospital, or a tuberculosis hospital and a provider of services under Medicare, if such institution is accredited as a hospital by the Joint Commission on the Accreditation of Hospitals; and is licensed in accordance with the laws of the appropriate legally authorized agency; a Free-standing Surgical Facility; or a licensed birthing center. The term Hospital will not include an institution which is primarily a place for rest, a place for the aged, or a nursing home. 4) The term Injury means an accidental bodily injury. 5) The term Medically Necessary means health care services and supplies that are determined by the Company to be: required to meet the Insured s essential health needs; consistent in type, frequency and duration of treatment with scientifically based guidelines as determined by medical research; required for purposes other than the convenience of the provider or the comfort and convenience of the patient and rendered in the least intensive setting that is appropriate for the delivery of health care. 6) The term Necessary Services and Supplies includes: any charges, except charges for Bed and Board, made by a Hospital on its own behalf for medical services and supplies actually used during hospital confinement; any charges, by whomever made, for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided; and any charges, by whomever made, for the administration of anesthetics during hospital confinement. The term Necessary Services and Supplies will not include any charges for special nursing fees, dental fees or medical fees. 7) The term Nurse means a Registered Graduate Nurse, a Licensed Practical Nurse or a Licensed Vocational Nurse who has the right to use the abbreviation "R.N.," "L.P.N." or "L.V.N." IT-TA-MED3-DE

12 MEDICAL EXPENSE AMENDATORY RIDER (Page 4 of 4) 8) The term "Physician" means a licensed medical practitioner who is practicing within the scope of his license and who is licensed to prescribe and administer drugs or to perform surgery. It will also include any other licensed medical practitioner whose services are required to be covered by law in the locality where the policy is issued if he is: operating within the scope of his license; and performing a service for which benefits are provided under this policy when performed by a Physician. 9) The term Pre-Existing Condition indicates a condition in which an Insured receives treatment, incurs expenses or receives a diagnosis from a Physician during the 90 days prior to the date of travel. 10) The term Reasonable and Customary means a charge that: is the normal charge made by the provider for a similar service or supply; and does not exceed the normal charge made by most providers of such service or supply in the geographic area where the service is rendered, as determined by the Company. 11) The term "Sickness" means a physical illness. It also includes pregnancy. Expenses incurred for routine care of a newborn child prior to discharge from the Hospital nursery will be considered to be incurred as a result of Sickness. Attached to and forming a part of Policy: 04837B Effective date of this Rider is January 1, 2011 IT-TA-MED4-DE

13 CONDITIONAL CLAIM/SUBROGATION EXPENSES FOR WHICH A THIRD PARTY MAY BE LIABLE This policy does not cover expenses for which another party may be responsible as a result of having caused or contributed to the Injury or Sickness. If the Insured incurs a Covered Expense for which, in the opinion of the Company, another party may be liable: 1. The Company shall, to the extent permitted by law, be subrogated to all rights, claims or interests which the Insured may have against such party and shall automatically have a lien upon the proceeds of any recovery by the Insured from such party to the extent of any benefits paid under the Policy. The Insured or the Insured s representative shall execute such documents as may be required to secure the Company s subrogation rights. 2. Alternatively, the Company may, at its sole discretion, pay the benefits otherwise payable under the Policy. However, the Insured must first agree in writing to refund to the Company the lesser of: a. the amount actually paid for such Covered Expenses by the Company; or b. the amount the Insured actually receives from the third party for such Covered Expenses; at the time that the third party's liability is determined and satisfied, whether by settlement, judgment, arbitration or award or otherwise. Attached to and forming a part of Policy: 04837B Effective date of this Section is January 1, 2011 IT-TA-CC-DE

14 EVACUATION/REPATRIATION BENEFITS RIDER Page 1 of 2 NOTIFICATION International SOS, acting as the Company s evacuation coordinator, must approve any evacuation or repatriation. If an Insured needs an emergency evacuation or repatriation as the result of an Injury or Sickness, International SOS or the Company must be notified by the end of the first scheduled workday after the Injury or Sickness. Expenses incurred for an Insured s evacuation or repatriation without the approval and authorization of International SOS will not be considered Covered Expenses (See General Limitations/Exclusions For Evacuation/Repatriation Benefits.) Emergency Evacuation or Repatriation If an Insured suffers an Injury or sudden, life-threatening Illness, and International SOS determines that adequate medical facilities are not available locally, International SOS will arrange for an emergency evacuation or repatriation to the nearest facility capable of providing adequate care. Although International SOS will be providing the service, to access International SOS, an Insured must call the CIGNA International Service Center at (Inside the U.S. and Canada) or outside the U.S. and Canada call collect at In making their determinations, International SOS will consider the nature of the emergency, an Insured s condition and ability to travel, as well as other relevant circumstances including airport availability, weather conditions, and distance to be covered. Transportation will be provided by private medically equipped aircraft, helicopter, commercial airline, train or ambulance. All evacuations or repatriations are carried out under the medical authorization or intervention of International SOS. The Company will pay, based on recommendation of International SOS, for one of the following: 1) If it is deemed medically necessary, an Insured will be transferred to an Insured s permanent residence via a one-way economy airfare. If an Insured s transportation needs to be medically supervised, a qualified medical attendant will escort an Insured. 2) Following an Insured s evacuation or repatriation, a one-way economy airfare will be provided to return to the point of evacuation or original work location. Emergency Family Travel Arrangements and Confinement Visitation If family members need to join an Insured when he is evacuated, and subsequently hospitalized, emergency travel arrangements for an Insured s family members will be coordinated. The costs of the travel services, however, are the responsibility of an Insured or the Insured s family members. If an Insured requires hospitalization in excess of 7 days at the location to which the Insured was evacuated, an economy round-trip airfare will be provided to the place of hospitalization for an individual chosen by an Insured. If dependent coverage is provided and an Insured s covered dependent child is evacuated, one economy round-trip airfare will be provided to a parent or legal guardian regardless of the number of days that the Dependent child is hospitalized. Return of Dependent Children If Dependent children are left unattended as a result of an Insured s Injury or Sickness, a one-way economy airfare will be provided to their place of residence. Furthermore, the accompaniment of a qualified attendant will be provided at no charge, if required. Repatriation of Mortal Remains The costs associated with the transportation of mortal remains from the place of death to the home country will be covered. In addition, assistance will be provided for organizing and obtaining the necessary clearances for the repatriation of mortal remains. Return of Traveling Companion If an Insured is hospitalized or evacuated, and a traveling companion's air ticket is no longer usable, a one-way economy airfare will be provided to the original point of departure. IT-TA-EVAC1-DE

15 EVACUATION/REPATRIATION BENEFITS RIDER Page 2 of 2 GENERAL LIMITATIONS/EXCLUSIONS FOR EVACUATION/REPATRIATION BENEFITS No payment will be made for charges for: Services rendered without the authorization or intervention of International SOS; Non-emergency, routine or minor medical problems, tests and exams where there is no clear or significant risk of death or imminent serious Injury or harm to the Insured; a condition which would allow for treatment at a future date convenient to the Insured and which does not require emergency evacuation or repatriation; Expenses incurred if the original or ancillary purpose of the Insured s trip is to obtain medical treatment; Services provided for which no charge is normally made; Expenses incurred while the Insured is serving on full-time active duty in the Armed Forces of any country or international authority; Transportation for the Insured s vehicle and/or other personal belongings involving intercontinental and/or marine transportation; Service provided other than those indicated in this Policy; Injury or Sickness caused by war, or an act of war, whether declared or undeclared, riot, civil commotion or police action; Death caused by war, or an act of war, whether declared or undeclared, riot, civil commotion or police action; Claim payments that are illegal under applicable law; or Charges in excess of the amount listed in Schedule I. Attached to and forming a part of Policy: 04837B Effective date of this Rider is January 1, 2011 IT-TA-EVAC2-DE

16 PRE-ADMISSION CERTIFICATION AND CONTINUED STAY REVIEW REQUIREMENTS PAC/CSR REQUIREMENTS This provision is applicable to an Insured or an Insured s covered dependents who elect to receive medical treatment in the United States. Pre-Admission Certification (PAC) and Continued Stay Review (CSR) refer to the process used to certify the Medical Necessity and length of a hospital confinement when an Insured or his covered dependent, if dependent coverage is provided under the policy, require treatment in a Hospital as a registered bed patient. The insured or his dependent should request PAC prior to any non-emergency treatment in a Hospital. CSR should be requested, prior to the end of the certified length of stay, for continued inpatient hospital confinement. Covered Expenses incurred will not include the first $300 of Hospital charges made for each separate admission to the Hospital unless PAC is received: (a) prior to the date of admission; or (b) in the case of an emergency admission, by the end of the first scheduled work day after the date of admission. Covered Expenses incurred for which benefits would otherwise be payable under this policy for the charges listed below will be reduced by 50%: Hospital charges for Bed and Board, for treatment for which PAC was performed, which are made for any day in excess of the number of days certified through PAC or CSR; and any Hospital charges for treatment for which PAC was requested, but which was not certified as Medically Necessary. In any case, those expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses incurred for the purpose of any other part of this policy. PAC and CSR are performed through a utilization review program by a Review Organization with which the Company has contracted. Attached to and forming a part of Policy: 04837B Effective date of this Rider is January 1, 2011 IT-TA-PAC-DE