Youth For Understanding USA Emergency Travel Assistance Health Insurance Plan Summary Private Liability Insurance Plan Summary

Transcription

1 Youth For Understanding USA Emergency Travel Assistance Health Insurance Plan Summary Private Liability Insurance Plan Summary Underwritten by: Nationwide Mutual Insurance Company Policy Number NWT Administered by: Consolidated Health Plans (CHP) A Berkshire Hathaway Company

2 TABLE OF CONTENTS Version 1.2 Contact Information... 3 Emergency Travel Assistance (Europ Assistance USA)... 3 Medical Claims Procedures (Nationwide/CHP)... 4 Frequently Asked Questions... 4 Coverage Summary... 5 Description of Benefits... 6 Plan Definitions Exclusions and Limitations Plan Provisions Nationwide Privacy Statement Personal Liability Insurance (Generali Versicherungen) Exclusions and Limitations Liability Claims Procedure Liability Claim Form

3 CONTACT INFORMATION FOR EMERGENCY 24-HOUR MEDICAL & TRAVEL ASSISTANCE Europ Assistance USA (toll-free) (collect) 7 days a week / 24 hours a day MEDICAL CLAIMS Consolidated Health Plans On behalf of Nationwide Mutual Insurance Company and Affiliated Companies 2077 Roosevelt Avenue Springfield, MA Phone: (800) customerservice@consolidatedhealthplan.com PERSONAL LIABILITY INSURANCE Generali Versicherungen Policy Number 615FKH Find liability claims procedure starting on page 21 of this brochure. TRAVEL ASSISTANCE SERVICES: This program includes the following services that are available to you during your covered trip: Medical evacuation Rebooking services Medically necessary repatriation Repatriation of remains Medical or legal referral Hospital admission assistance Translation service Lost baggage retrieval Lost document assistance Worldwide medical information Passport/visa information Emergency cash advance Prescription drug/eyeglass replacement Legal referral/bail bond Embassy and consular services NOTE: Any expenses incurred for services rendered while not on a covered trip will be your responsibility. These services are provided by an independent organization and not by Nationwide Mutual Insurance Company or its affiliated companies. There may be times when circumstances beyond the assistance company s control hinder their endeavors to provide travel assistance services. They will, however, make all reasonable efforts to provide travel assistance services and help you resolve your emergency situation. 3

4 MEDICAL CLAIMS PROCEDURES (NATIONWIDE/CHP) How to use your health plan before you visit a Provider (doctor, hospital, pharmacy or specialist): Step 1: Understanding your plan may prevent you from paying unexpected out-of-pocket fees. Step 2: Be sure to present your Nationwide Health Insurance Card when visiting a Medical Provider. Step 3: Determine whether the Medical Provider is a PHCS (Private Healthcare Systems) In-Network Provider. You can locate an In-Network Provider online at or by calling PHCS is the largest proprietary Preferred Provider Organization (PPO) in the country, and includes approximately 370,000 medical `providers and more than 3,500 medical facilities. Step 4: If you are being treated by a PHCS Provider, they will submit your claim to Nationwide. If you require emergency dental care, tell your dental provider to submit claims to Nationwide. Limited dental coverage is included in your medical insurance and is not a stand-alone plan. If you are being treated by a Non-Network Provider, ask how your claim will be filed by the Medical Provider. The Provider may ask for payment immediately. If the Provider does not file the claim directly with Nationwide, then you must file the claim by submitting an itemized bill immediately after treatment to Nationwide. Your name, ID number and Youth For Understanding USA should be written clearly on all medical bills. Always retain copies for your records. Please send all claim forms and bills for reimbursement to: CHP Claims Department 2077 Roosevelt Avenue customerservice@consolidatedhealthplan.com Fax: Springfield, MA Step 5: CHP will send payment to the medical provider or send payment to the student if he/she submits a payment receipt with the claim. Payment will be for covered services only. Once a claim is processed, an Explanation of Benefits (EOB) Statement will be mailed to you explaining the benefit paid to the Provider. The Provider will then send you a statement indicating if a balance is due. Note: All Customer Service inquiries, including Provider Network questions, should be directed to CHP by calling FREQUENTLY ASKED QUESTIONS Is it my responsibility to file a medical claim? If you visit a PHCS In-Network Provider, they should file a medical claim on your behalf. In the event that the provider does not submit a claim for you, see Steps 1-5 above for claim instructions. How do I choose a doctor or hospital? Go to and you can search for doctors, hospitals and specialists by specialty or location. How are covered prescription charges paid? You must pay the prescription charges for covered benefits and submit a claim form for reimbursement, per the directions in Step 4 above. 4

5 COVERAGE SUMMARY All Coverages and Benefits are in U.S. Dollar Amounts Medical Maximums: Accident Medical & Sickness Medical Deductible Per Injury or Sickness $0 ER Deductible Only applies if ER is used for other than an Emergency (see Plan Definitions section) Benefit Period Mental Illness Per Lifetime: $1,000,000 Primary Insured $250 per visit Period of Coverage Inpatient: Payable at 80% up to $10,000, up to a max of 40 days Outpatient: Payable at 80% up to $5,000 Alcohol and Drug Abuse Inpatient/Outpatient: Payable at 50% up to $1,000 Injuries from a Motor Vehicle Accident Wellness Benefit Sports Physical Sports-related Injuries Up to Policy Maximum Up to $50 per Insured Person per Policy Period Up to Policy Maximum Dental (Emergency) Up to $250 per tooth to a maximum of $500 Dental (Palliative) Emergency Medical Evacuation Repatriation of Mortal Remains Emergency Medical Reunion Emergency Home Leave Benefit Baggage Loss Accidental Death & Dismemberment Aggregate Limit of Indemnity per Accident Up to $500 per Policy Period Up to $250,000 per Policy Period Up to $25,000 per Policy Period Up to $6,250 per Policy Period Up to $4,000 per Policy Period Up to $500 per Policy Period Principal Sum: $25,000 per Insured Five times the Principal Sum to a maximum Aggregate of $125,000 Home Country Coverage 30 days of coverage up to a maximum of $1,000 Home Country Extension of Benefits Up to $1,000, expenses must be incurred within 30 days of returning to your Home Country Unexpected Recurrence of a Pre-existing Condition: Assistance Up to a maximum of $10,000 per policy period 24 hours Worldwide 5

6 DESCRIPTION OF BENEFITS Medical Expenses: This Plan shall pay Reasonable and Customary charges for Covered Expenses, excess of the Deductible and Coinsurance up to the Medical Maximum, incurred by you due to a covered Injury or Sickness which occurred during the Period of Coverage outside your Home Country (except as provided under the Home Country Coverage). All bodily disorders existing simultaneously which are due to the same or related causes shall be considered one Disablement. If a Disablement is due to causes which are the same or related to the cause of a prior Disablement, the Disablement shall be considered a continuation of the prior Disablement and not a separate Disablement. The initial Treatment of an Injury or Sickness must occur within 30 days of the date of Injury or onset of Sickness. Only such expenses which are specifically enumerated in the following list of charges are incurred within the Period of Coverage, and which are not excluded shall be considered Covered Expenses: 1) Charges made by a Hospital for semi-private room and board, floor nursing and other services inclusive of charges for professional service and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the Hospital s average charge for semi-private room and board accommodation. 2) Charges made for Intensive Care or Coronary Care charges and nursing services. 3) Charges made for diagnosis, Treatment and Surgery by a Physician. 4) Charges made for an operating room. 5) Charges made for Outpatient Treatment, same as any other Treatment covered on an Inpatient basis. This includes ambulatory surgical centers, Physicians Outpatient visits/examinations, clinic care, and surgical opinion consultations. 6) Charges made for the cost and administration of anesthetics. 7) Charges for Medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood, transfusions, iron lungs, and medical Treatment. 8) Charges for physiotherapy as the result of Covered Accident, to a maximum of $600, if recommended by a Physician for the Treatment of a specific Disablement following hospitalization and administered by a licensed physiotherapist. 9) Charges for physiotherapy as the result of Covered Sickness, if recommended by a Physician for the Treatment of a specific Disablement following hospitalization and administered by a licensed physiotherapist. 10) Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or Surgeon. 11) Local transportation to or from the nearest hospital or to and from the nearest hospital with facilities for required Treatment. Such transportation shall be by licensed ambulance only to a limit of $2,500. 6

7 Extension of Benefits Your coverage will be extended if you are Hospital confined for a Covered Injury or Illness and under the care of a Physician on the termination date of your Period of Coverage. Coverage will terminate on the earlier of the following: 1) 30 days from the end of you Period of Coverage; or 2) The maximum benefit has been paid; or 3) Your release from the hospital or Physician care Hospitalization Notification: For each scheduled hospital admission or emergency hospital confinement, you or someone on your behalf should contact Europ Assistance USA at (toll-free) or (collect) or by at ops@europassistance-usa.com. This will ensure that you are receiving the best care possible. For emergency hospital Confinement, you or someone on your behalf should notify Europ Assistance USA as soon as possible. Mental Illness: Benefits are paid for Treatment or medication for Mental Illness, which are not excluded and covered under this policy, shall be considered a Covered Expense. Inpatient Care shall be payable at 80% to $10,000, subject to a maximum of 40 days of Inpatient care. Outpatient care shall be payable at 80% up to a maximum of $5,000. Alcohol and Drug Abuse: Benefits are paid for Treatment or medication for Alcohol and Drug Abuse, which are not excluded and covered under this policy, shall be considered a Covered Expense. Benefits shall be payable up to the maximum, as stated in the Schedule of Benefits. Wellness Benefit Sports Physical: The Company will pay expenses, as per the limits stated in the Schedule of Benefits, Wellness Benefit Sports Physical. Coverage is limited to the following expenses incurred subject to the Exclusions and Limitations. In no event shall the Company s maximum liability exceed the maximum stated in the Schedule of Benefits, Wellness Benefit Sports Physical as to expenses during any one period of individual coverage. Covered wellness expenses include: 1) Routine Sports physical examinations Emergency Dental Treatment: Benefits are paid for Reasonable and Customary expenses in excess of the Deductible and Coinsurance of $250 per tooth up to a maximum of $500, for the emergency repair or replacement to sound, natural teeth damaged as the result of a Covered Accident. Dental Emergency Relief of Pain: This plan shall pay in excess of the Deductible and Coinsurance up to a maximum of $500, for emergency treatment for the relief of pain to natural teeth. Emergency Medical Evacuation/Repatriation: Benefits are paid for Covered Expenses incurred up to the maximum, as stated in the Schedule of Benefits, for any covered Injury or Sickness commencing during the Period of Coverage that result in a Medically Necessary Emergency Medical Evacuation or Repatriation. The decision for an Emergency Medical Evacuation or Repatriation must be pre-approved and arranged by Europ Assistance USA in consultation with your local attending Physician. 7

8 Emergency Medical Evacuation or Repatriation means: a) your medical condition warrants immediate transportation from the place where you are located (due to inadequate medical facilities) to the nearest adequate medical facility where medical Treatment can be obtained; or b) after being treated at a local medical facility, your medical condition warrants transportation with a qualified medical attendant to your Home Country to obtain further medical Treatment or to recover; or c) both a) and b) above. Covered Expenses are expenses for transportation, medical services and medical supplies necessarily incurred in connection with Emergency Medical Evacuation or Repatriation. All transportation arrangements must be by the most direct and economical route. Expenses for special transportation and medical supplies and services must be: a) pre-approved and ordered by Europ Assistance USA and b) required by the standard regulations of the conveyance transportation. Transportation means any land, water or air conveyance required to transport you. Special transportation includes, but is not limited to, licensed ground and air ambulances, commercial airlines, and private motor vehicles. Return of Mortal Remains: Benefits will be paid for Reasonable and Customary Covered Expenses incurred up to the maximum, as stated in the Schedule of Benefits, to return your remains to your Home Country, if you should die. Covered Expenses include, but are not limited to, expenses for embalming or Cremation, a minimally necessary container appropriate for transportation, shipping costs, and the necessary government authorizations. All Covered Expenses in connection with a Return of Mortal Remains or Cremation must be pre-approved and arranged by Europ Assistance USA. Emergency Medical Reunion: In the event of Death or if attending physician says Your death is imminent, or if You are hospitalized for more than five (5) days, or if You are eligible for a covered Emergency Medical Evacuation or Repatriation, Europ Assistance USA will arrange and pay for roundtrip economy-class transportation for one individual selected by You from Your Home Country to the location where You are hospitalized and then return to the current Home Country. The benefits payable will include: 1) The cost of a round-trip economy air fare up to the maximum stated in the Schedule of Benefits; 2) Reasonable and Customary travel and accommodation expenses incurred in relation to the Emergency Medical Reunion up to the maximum stated in the Schedule of Benefits; 3) Meals and accommodations subject to daily maximum of $150, maximum of 5 days. All transportation in connection with an Emergency Medical Reunion must be pre-approved and arranged by Europ Assistance USA. Emergency Home Leave Benefit: Europ Assistance USA will arrange and pay for the cost of a round-trip ticket to the maximum stated in the Schedule of Benefits for You if Your Family Member incurs death or serious Illness. Europ Assistance USA will organize and pay for expenses related to the travel for Yourself from the Host Country to Your Home Country and back to the Host Country. With regards to serious Illness or Illness causing death of a Family Member, the following conditions apply: 1) The serious Illness, or Illness causing death, must manifest itself during the time You are traveling outside Your Home Country; and 2) Attending physician says death of Family Member is imminent, or Family Member has been or is expected to be hospitalized for 7 days. 8

9 Baggage Loss: This Plan will reimburse you for loss, theft or damage to your baggage or personal effects, checked with a Common Carrier provided you have taken all reasonable measures to protect, save and/or recover your property at all times. This Plan is secondary to any coverage provided by a Common Carrier and all other valid and collective insurance. This Plan will pay the lesser of: 1) The actual cash value (cost less proper deduction for depreciation at the time of loss, theft or damage); 2) The cost to repair or replace the article with material of a like kind and quality; or 3) $50 per article. Accidental Death & Dismemberment: Benefits shall be paid to you if you sustain an accidental Injury. The Injury must occur during the Period of Coverage and death or dismemberment as a result of that accident must occur within 365 days from the date of Accident. Benefits payable for any such loss shall be in accordance with the following table: If you incur more than one Loss stated in the following Table as the result of one Accident, only the largest amount, shall be payable. Description of Loss Percent of Principal Sum Life 100% Both Hands or Both Feet or Sight of Both Eyes 100% One Hand and One Foot 100% Either Hand or Foot and Sight of One Eye 100% Either Hand or Foot 50% Sight of One Eye 50% Quadriplegia 100% Paraplegia (total paralysis of both lower limbs) 75% Hemiplegia (total paralysis of upper and lower limbs of one side of the body) 50% Uniplegia (total paralysis of one limb) 20% Home Country Coverage: The Plan shall pay up to the maximum as stated in the Schedule of Benefits, for Covered Expenses incurred in your Home Country related to an Injury or Sickness which occurred, was diagnosed and treated inside your Home Country during your Period of Coverage, not to exceed thirty (30) days per twelve (12) months of coverage. Home Country Extension of Benefits The Plans shall pay up to the maximum, as stated in the Schedule of Benefits, for Covered Expenses incurred in your Home Country related to an Injury or Sickness which occurred, was diagnosed and treated outside your Home Country during your period of coverage. Only those covered expenses incurred within 30 days of your return to your Home Country shall be considered eligible. Unexpected Recurrence of a Pre-existing Condition: This Plan shall pay, up to the maximum as stated in the Schedule of Benefits subject to the Deductible and Coinsurance, for Covered Expenses resulting from a sudden, unexpected recurrence of a Pre- Existing Condition. 9

10 PLAN DEFINITIONS Accident shall mean an event, independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person. Benefit Period shall mean the allowable time period you have to receive Treatment for a Covered Injury or Sickness. Coinsurance shall mean the percentage amount of Covered Expenses, after the Deductible, which is your responsibility to pay. Company means Nationwide Mutual Insurance Company. Deductible shall mean the amount of Covered Expenses which is your responsibility to pay before benefits under the Plan are payable. Emergency shall mean a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person s life or limb in danger if medical attention is not provided within twenty-four (24) hours. Family Member shall mean a spouse, parent, sibling or child of the Insured Person. Home Country shall mean the country where you have your true, fixed and permanent home and principal establishment. Illness shall mean sickness or disease of any kind contracted and commencing while this Policy is in force as to the Insured Person whose Illness is the basis of claim. Any complication or any condition arising out of an Illness for which the Insured Person is being treated or has received Treatment will be considered as part of the original Illness. Injury shall mean accidental bodily injury or injuries caused by an accident which occurs after the Effective Date of this Policy. The Injury must be the direct cause of the loss, independent of disease, bodily infirmity or other causes. Inpatient shall mean if you are confined in an institution and are charged for room and board. Medically Necessary shall mean services and supplies received by the Insured Person that are determined by the Company to be: 1) Appropriate and necessary for the symptoms, diagnosis, or direct care and treatment of the Insured Person s medical conditions; 2) Within the standards the organized medical community deems good medical practice for the Insured Person s condition; 10

11 3) Not provided primarily for the convenience of the Insured Person, the Insured Person s Physician or another Service Provider or person; 4) Not Experimental/Investigational or unproven, as recognized by the organized medical community, or which are used for any type of research program or protocol; and 5) Not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person is receiving or the severity of the Insured Person s condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe, order, recommend, or approve a service, supply, or level of care does not, of itself, make such treatment Medically Necessary or make the charge of a Covered Expense under this Plan. Outpatient shall mean if you receive care in a hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician s office, for an Injury or Sickness, but who is confined and is not charged for room and board. Pre-existing Condition shall mean any condition for which a licensed Physician was consulted, or for which Treatment or Medication was prescribed, or for which manifestations or symptoms would have caused a person to seek medical advice six (6) months prior to the Effective Date of coverage under the Plan. Reasonable and Customary shall mean the maximum amount that the Plan determines is Reasonable and Customary for Covered Expenses you receive, up to but not to exceed charges actually billed. The determination considers: 1) amounts charged by other Service Providers for the same or similar service in the locality where received, considering the nature and severity of the bodily Injury or Sickness in connection with which such services and supplies are received; 2) any usual medical circumstances requiring additional time, skill or experience; and 3) other factors included but not limited to, a resource based relative value scale. Treatment means a specific in-office or hospital physical examination of or care rendered to you, consultation, diagnostic procedures and services, Surgery, medical services and supplies including medication prescribed or provided by a Service Provider. You, Your or Insured shall mean Insured Person. 11

12 EXCLUSIONS AND LIMITATIONS No Benefit shall be payable for Accident Medical, Sickness Medical, Mental Illness, Alcohol and Drug Abuse, Dental, Emergency Medical Evacuation/Repatriation, Return of Mortal Remains, and Emergency Medical Reunion, as the result of: 1. Any Pre-existing Condition as defined hereunder, except as provided under the Unexpected Recurrence of a Pre-Existing Condition. This exclusion does not apply to Emergency Evacuation/Repatriation or Return of Mortal Remains. 2. Charges provided at no cost to you; 3. Charges for Treatment which exceeds Reasonable and Customary charges; 4. Charges incurred for Surgery or Treatments which are, Experimental/Investigational, or for research purposes; 5. Services, supplies or Treatment, including any period of hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician; 6. Suicide or any attempts thereof, while sane or self-destruction or any attempt thereof, while insane; 7. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with: a) War, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war. b) Mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power. c) Acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence. d) Martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the Occurrences ). Any consequence happening or arising during the existence of such conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, arising in connection with, any of the said Occurrences shall be deemed to be consequences for which the Plan shall not be liable for except to the extent that you prove that such consequence happened independently of the existence of such conditions. 8. Injury sustained while participating in professional athletics; 9. Routine physicals, immunizations or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a Disablement established by a prior call or attendance of a Physician. Unless otherwise covered under this plan. 10. Treatment of the Temporomandibular joint; 11. Vocational, speech, recreational or music therapy; 12. Services or supplies performed or provided by a Relative of yours, or anyone who lives with you; 13. Cosmetic or plastic Surgery, except as the result of a covered Accident; for the purposes of this Plan, Treatment of a deviated nasal septum shall be considered a cosmetic condition; 14. Elective Surgery which can be postponed until you return to your Home Country, where the objective of the trip is to seek medical advice, Treatment or Surgery; 15. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids; 16. Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eyeglasses or for the fitting thereof, unless caused by Accidental bodily Injury incurred while covered hereunder; 12

13 17. Treatment in connection with alcoholism and drug addiction, or use of any drug or narcotic agent, unless otherwise covered under this Plan; 18. Injury sustained while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician for a condition which is covered hereunder, but not for the Treatment of drug addiction; 19. Any Mental and Nervous disorders or rest cures, unless otherwise covered under this Plan; 20. Congenital abnormalities and conditions arising out of or resulting there from; 21. Expenses which are non-medical in nature; 22. Expenses as a result of, or in connection with, intentionally self-inflicted Injury or Sickness; 23. Expenses as a result of, or in connection with, the commission of a felony offense; 24. Injury sustained while taking part in mountaineering where ropes or guides are normally used; hang gliding, parachuting, bungee jumping, racing by horse, motor vehicle or motorcycle, snowmobiling, motorcycle/motor scooter riding, scuba diving involving underwater breathing apparatus, unless PADI or NAUI certified, and parasailing; 25. Treatment paid for or furnished under any other individual or group policy or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for Treatment without any cost to you; 26. Dental care, except as the result of Injury to natural teeth caused by Accident, unless otherwise covered under this Plan; 27. Routine Dental Treatment; 28. For Pregnancy or Illness resulting from Pregnancy, childbirth, or miscarriage, unless otherwise covered under this Plan; 29. Drug, Treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, Treatment for infertility or impotency, sterilization or reversal thereof; 30. Treatment for human organ tissue transplants and their related Treatment; 31. Expenses incurred while in your Home Country, except as provided under the Home Country Coverage and Home Country Extension of Benefits Coverage; 32. Covered Expenses incurred for which the Trip to the Host Country was undertaken to seek medical Treatment for a condition; 33. Covered Expenses incurred during a Trip after your Physician has limited or restricted travel; 34. Sex change operations, or for Treatment of sexual dysfunction or sexual inadequacy; 35. Weight reduction programs or the surgical Treatment of obesity. No Benefit shall be payable for Accidental Death and Dismemberment as the result of: 1. Suicide, or attempt thereof, while sane; or self-destruction, or any attempt thereof, while insane; 2. Disease of any kind; Bacterial infections, except pyogenic infection, which shall occur through an accidental cut or wound; 3. Hernia of any kind; 4. Injury sustained while you are riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting from, any type of aircraft; 5. Injury sustained while you are riding as a passenger in any aircraft (a) not having a current and valid Airworthy Certificate and (b) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft; 6. Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with: a) War, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war. 13

14 b) Mutiny, riot, strike, military or popular uprising insurrection, rebellion, revolution, military or usurped power. c) Acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by terrorism or violence. d) Martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege (hereinafter for the purposes of this Exclusion called the Occurrences ). Any consequence happening or arising during the existence of such conditions (whether physical or otherwise), whether directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed to be consequences for which the Plan shall not be liable, except to the extent that you can prove that such consequence happened independently of the existence of such conditions. 7. Service in the military, naval or air service of any country; 8. Flying in any aircraft being used for, or in connection with, acrobatic or stunt flying, racing or endurance tests; 9. Flying in any rocket-propelled aircraft; 10. Flying in any aircraft being used for, or in connection with, crop dusting or seeding or spraying, firefighting, exploration, pipe or power line inspection, any form of hunting or herding, aerial photography, banner towing or any experimental purpose; 11. Flying in any aircraft which is engaged in any flight which requires a special permit or waiver from the authority having jurisdiction over civil aviation, even though granted; 12. Sickness of any kind; 13. Being under the influence of alcohol or having taken drugs or narcotics unless prescribed by a legally qualified Physician or surgeon; 14. Injury occasioned or occurring while you are committing or attempting to commit a felony or to which a contributing cause was your being engaged in an illegal occupation; 15. While riding or driving in any kind of competition; 16. This Plan does not insure against loss or damage (including death or Injury) and any associated cost or expense resulting directly or indirectly from the discharge, explosion or use of any device, weapon or material employing or involving nuclear fission, nuclear fusion or radioactive force, or chemical, biological, radiological or similar agents, whether in time of peace or war, and regardless of who commits the act, regardless or any other cause or event contributing concurrently or in any other sequence thereto. 14

15 PLAN PROVISIONS Important Information: In the event of Injury or Sickness, you should: In an emergency: Go directly to the hospital. Call Europ Assistance USA 24 hours a day at (toll-free) or (collect) or ops@europassistance-usa.com to alert the plan of your situation. If not an emergency: Call Europ Assistance USA 24 hours a day at (toll-free) or (collect) or ops@europassistance-usa.com for assistance in locating English-speaking or appropriate providers, facilities, medical or medical transport advice. Notice of Claim: Written notice of claim(s) should be given to the Claims Administrator, Consolidated Health Plans (CHP), within thirty (30) days after the occurrence or commencement of any Disablement, or as soon thereafter as is reasonably possible. Notice given by someone on your behalf to CHP, with information sufficient to identify you shall be deemed sufficient notice to CHP. Excess Benefits: All coverages, except Accidental Death and Dismemberment, shall be in excess of all other valid and collectible Insurance Indemnity, and shall apply only when such benefits are exhausted. Other valid and collectable Insurance Indemnity, for which benefits may be payable, are Insurance programs provided by: a) Individual, group or blanket Insurance or coverage; b) Other pre-payment coverage provided on a group or individual basis; c) Any coverage under labor management trusted plans, union welfare plans, employer organization plans, employee benefit organization plans, or other arrangement of benefits for individuals of a group; d) Any coverage required or provided by any state or socialized Insurance program; e) Any no-fault automobile Insurance; or f) Any third-party liability Insurance. Monetary Limits: The monetary limits stated in this Plan and the Plan Cost shall be in U.S. dollars. For service outside of the territorial limits of the United States, the exchange rate date used to determine the amount of U.S. dollars to be paid is the exchange rate effective for the date the claim expense was incurred. 15

16 Subrogation: To the extent the Plan pays for a loss suffered by you, the Plan will take over the rights and remedies you had relating to the loss. This is known as subrogation. You must help the Plan to preserve its rights against those responsible for the loss. This may involve signing any papers and taking any other steps the Plan may reasonably require. If this Plan takes over your rights, you must sign an appropriate subrogation form supplied to you. Renewal: Coverage under this Plan is not renewable. If additional coverage time is needed, a new application must be completed and correct Premium submitted to Plan Administrator. A new Deductible, Coinsurance, and Pre-existing Condition Exclusion will apply at each succeeding or subsequent Period of Coverage. Underwriter: Products underwritten by Nationwide Mutual Insurance Company. Notice for Florida Residents: Products underwritten by Allied Property and Casualty Insurance Company. Important Notice: Please keep this document as a general summary of the Insurance. This Evidence of Benefits is a brief summary of filed form number NHPINTRVL which contains complete details of the coverage. A copy of the Travel Protection Policy is available for inspection at the Plan Administrator's office. The Evidence of Benefits shall control in the event of any conflict between this Evidence of Benefits and the Travel Protection Policy. 16

17 Nationwide Privacy Statement Thank you for choosing Nationwide Our privacy statement explains how we collect, use, share, and protect your personal information. So just how do we protect your privacy? In a nutshell, we respect your right to privacy and promise to treat your personal information responsibly. It s as simple as that. Here s how. Confidentiality and security We follow all data security laws. We protect your information by using physical, technical, and procedural safeguards. We limit access to your information to those who need it to do their jobs. Our business partners are legally bound to use your information for permissible purposes. Collecting and using your personal information We collect personal information about you when you ask about or buy one of our products or services. The information comes from your application, business transactions with us, consumer reports, medical providers, and publicly available sources. Please know that we only use that information to sell, service, or market products to you. We may collect and use the following types of information: Name, address, and Social Security number Assets and income Account and policy information Credit reports and other consumer report information Family member and beneficiary information Public information Sharing your information for business purposes We share your information with other Nationwide companies and business partners. When you buy a product, we share your personal information for everyday purposes. Some examples include mailing your statements or processing transactions that you request. You cannot opt out of these. We also share your information where federal and state law requires. Sharing your information for marketing purposes We don t sell your information for marketing purposes. We have chosen not to share your personal information with anyone except to service your product. So there s no reason for you to opt out. If we change our policy, we ll tell you and give you the opportunity to opt out before we send your information. Using your medical information We sometimes collect medical information. We may use this medical information for a product or service you re interested in, to pay a claim, or to provide a service. We may share this medical information for these business purposes if required or permitted by law. But we won t use it for marketing purposes unless you give us permission. Accessing your information You can ask us for a copy of your personal information. Please call the number on your insurance ID card if applicable, contact your customer service representative, or send a letter to the address below and have your signature notarized. This is for your protection so we may prove your identity. We don t charge a fee for giving you a copy of your information now, but we may charge a small fee in the future. We can t update information that other companies, like credit agencies and third parties, provide to us. So you ll need to contact these other companies to change and correct your information. Send your privacy inquiries to the address below. Please include your name, address, and policy number. If you know it, include your agent s name and number. Consolidated Health Plans On behalf of Nationwide Mutual Insurance Company and Affiliated Companies 2077 Roosevelt Avenue Springfield, MA A parting word These are our privacy practices. They apply to all current and former clients of Nationwide health plans. They also apply to joint policy or contract holders. This includes the following companies: Nationwide Better Health, Inc. Nationwide Life Insurance Company Nationwide Mutual Insurance Company National Casualty Company Allied Property and Casualty Insurance Company 17

18 The following plan is not affiliated with Nationwide. PERSONAL LIABILITY INSURANCE (GENERALI VERSICHERUNGEN) The private liability insurance provided by Generali Versicherungen is summarized here for local representatives, students, and natural/host families for illustrative purposes only and is not meant to replace the complete terms and conditions. Amount in Euros General Coverage 1,000,000 Deductible/Excess Property Damage 150 Personal Damage 150 Rental Property Damages 250,000 Gradual Damage 1,000,000 Bail Bond 25,000 Loss of Keys 15,000 Damage of Assets 200,000 3rd Party Damage to your property 2,500 Coverage of Losses 2,500 Covered Benefits 1. Generali guarantees the policyholder insurance coverage in the case a third party requests compensation due to personal damage (during period of coverage) to another individual (human) which results in death, injury or damage to their health as well as property damage or demolition (unintentional). 2. The insurance coverage applies to legal liability a. from the given benefits in the insurance policy, legal relationships or activities of the policy holder (insured risk); b. from risks that emerge for the policy holder after signing of the contract. Insurance commencement, plan benefits and payment terms I. 1. The insurance coverage starts on the given date of the insurance policy. II. 1. If a claim has been made, Generali duties involve: a. investigate whether the claim is rightful, b. deny any unjustified claims c. reimbursement for payments the insured had to make on grounds of an approved recognition by Generali, an approved compromise or a legal court decision. d. If the obligation of Generali for a payment is certain, compensation has to be made within two weeks, however this can be delayed when it concerns international payments. 2. Generali s plan benefits and coverage amount given in the insurance policy form the maximum limit of each claim situation. It is agreed that the insurance policy holder takes part in every event of damage and fulfils their deductible. 3. In the case of the insured event going to court, the law suit between the insurance policy holder and the injured party or his legal successor will be held in Germany and the insurance policy holder will be represented by Generali. 18

19 III. 1. In the case of legal proceedings, Generali will only pay the insured amount that is written in the insurance policy. Exclusions and Limitations If the insurance policy does not clearly state otherwise, the insurance coverage does not include: 1. Liability claims that, based on the contract or special agreements, exceed the legal liability of the insurance policy holder. 2. Claims for earnings, pensions, salary and other settled payments/benefits, medical treatment as a result of participation in any kind of demonstrations, movements as well as claims from tumult and political unrest. 3. The insurance policy is only valid in the participant s host country listed on their enrollment form and will not provide coverage in the participant s home country or any other country visited at the time of policy duration. 4. Liability claims for injuries resulting from the participation in horse, bike or motorized vehicle races, boxing or ring fights as well as during the training for those events. 5. Liability claims on property damage that emerge/originate from gradual exposure through temperature, gases, fumes, humidity, precipitation (smoke, soot, dust and similar substances), sewage, fungus development, ground lowering on properties, landslides, ground motion due to ground works flooding from still standing or flowing waters as well as damages by cattle or wild animals. 6. Claims due to damages on third-party belongings if: a. the insurance policy holder has rented, leased, borrowed or has stolen the object of concern. b. the damages are job or work related or damages resulting from those action. 7. Liability claims on properties that are connected with ionised radiation (such as radioactive substances that emit alpha-, beta- and gamma radiation as well as neutrons) as well as laser radiation. 8. Liability claims on property due to environmental influences and all other damages resulting from it, as well as fire and/or explosion. 9. Claims because of damages that result from handling asbestos, asbestos-containing substances or products. 10. Work related or claims whilst the insured is at work. Remaining insurance exclusions are: 1. Any insurance claims for damages that have been caused deliberately. 2. Liability claims: a. for damages within the family of the insurance policy holder. The following people listed are considered family members and relatives: spouses, partners in the sense of lawful partnership, parents and children, adoptive parents and adoptive children, parents-in-law and children-in-law, stepparents and stepchildren, grandparents and grandchildren, siblings as well as foster parents and foster children. b. that involve other participants that are insured under the same group insurance policy as the insurance policy holder. c. from legal representatives of people that are incapable of contracting or that have limited contracting abilities. d. from liquidators. 19

20 3. Liability claims which can be traced back to the insurance policy holder s negligence, where they have ignored or underestimated potentially dangerous circumstances that they were aware of and did not rectify. 4. Liability claims for personal damage, resulting from the insurance policy holder transmitting a disease/illness to a third-party, as well as property damages that originates from disease infected animals which have been kept and held by the insurance policy holder, unless the insurance policy holder has not acted deliberately or grossly negligent. Insured Event/ Occurrence of Event Insured Obligations of the insurance policyholder, procedures 1. The insured case according to the insurance policy is the event of damage, which could result in liability claims against the insurance policy holder. 2. In the case of an event that could result in liability claims, Generali has to be informed about the details immediately in writing and within one week of the event. In case of any legal actions taken against the insurance policy holder by the state or the third-party involved, after informing Generali about the event the insurance policy holder has the obligation to report this or any other changes to Generali. If the third-party involved claims compensation against the insurance policy holder, Generali has to be informed about this claim within one week by the insurance policy holder. 3. The insurance policy holder is obliged to act in the interest and to follow the instructions of Generali to possibly prevent or minimize the damage and to do everything that helps to clarify the case of damage. The insurance policy holder has to support Generali to defend any damage as well as help the ascertainment and regulation of damages. This includes giving complete and true statements, describing the circumstances in detail and handing in relevant papers and documents that are needed by Generali. 4. In case a lawsuit has been filed over the liability claim, the insurance policy holder has to fully/completely hand over the leadership/conduct of the case to Generali. 5. The insurance policy holder has no right to fully or partly accept/approve/acknowledge a liability claim, neither to make any kind payment to the third party claiming, without the approval of Generali. By violating these terms, Generali is free from any obligations to provide indemnification. 6. Generali is authorized to give appropriate statements in the name of the insurance policy holder in order to settle or defend the claim. Legal consequences of violating given obligations If any of the mentioned obligations have been violated, the insurance policy holder will lose his full insurance coverage, unless the policy holder can prove that the obligations have not been violated deliberately or grossly negligent. Insurance policy content Limitation of claim, period for filing suit 1. Claims based on the insurance policy become time-barred in two years. The deadline starts on the end of the year where the benefit can be claimed. 2. If Generali denies insurance coverage, the insurance policy holder has the right to seek a judicial decision in that case within six months to gain back insurance coverage. The deadline begins with the receipt of the written denial from Generali. 20

21 Conditions precedent to the policy for the insurance policyholder I. 1. The insurance policy holder or its authorized representative are obliged to give written, complete, truthful notice and answer all questions asked in the enrolment form about any known potentially dangerous circumstances that may affect the policy, before signing the contract with Generali. 2. If the contract has been signed by an authorised or unauthorised representative of the insurance policyholder, knowing about any potential dangerous circumstance, the insurance policy holder has to be treated as if he had known and in that case will be considered as fraudulent concealment. II. 1. Incomplete and faulty information given about any potential dangerous circumstances gives Generali the right to withdraw from the contract. This will also be valid if the insurance policy holder fully withholds the information about those circumstances. 2. In the case of Generali s withdrawal, insurance coverage will end. III. 1. In the case of fraudulent concealment, Generali s right to withdraw from the contract with the insurance policyholder or its representative remains untouched. Applicable law 1. For this contract German law is applicable. Court of jurisdiction 1. For complaints/lawsuits that result from the insurance policy against Generali, the judicial authority will be decided/defined according to the location of the registered office or the branch of Generali responsible for this insurance policy. Notifications/reports and declaration/statement of intent. All notifications/reports and information addressed to Generali have to be given in writing. Coverage Underwritten by: Generali Versicherung AG Generali Policy Number: 615FKH Liability Claims Procedure: In the event of a claim, YFU students or their host family must notify CHP in writing within seven (7) days using the Liability Claim Form found on the next page. CHP will inform YFU USA of the claim. Always make copies of the form and all documents and receipts for your own records. Please submit claims in English or German only. Claims submitted in other languages may not be processed. If you need assistance writing your claim information in English or German, we suggest using Google Translate. To submit liability claim form by customerservice@consolidatedhealthplan.com To submit liability claim form by fax: Attention: CHP Claims Dept To submit liability claim form by mail: CHP Claims Dept Roosevelt Avenue Springfield, MA