Your Guide to Benefit describes the benefit in effect as of 2/1/21. Benefit information in this guide replaces any prior benefit information You may have received. Please read and retain for Your records. Your eligibility is determined by Your financial institution.
Needing emergency medical or dental treatment during Your travel is something You don’t want to have to worry about, but when it happens, it is good to know that there is help with some of Your covered expenses.
It can be an overwhelming and expensive experience when You are dealing with an emergency away from Your home. To try and help ease some of the financial burden, You can receive coverage if You, Your spouse or dependent children require Emergency Treatment while on a Covered Trip.
Emergency Medical/Dental provides reimbursement for Emergency Treatment if You become sick or accidentally injured while traveling on a Covered Trip purchased with Your eligible Account and/or rewards program associated with Your covered Account. To be eligible for this coverage, You need to purchase either a portion or the entire cost of the Covered Trip using Your covered Account and/or rewards program associated with Your covered Account.
You, Your spouse and Your dependent children are eligible for coverage if You purchase a Covered Trip with Your eligible card issued in the United States and/or rewards program associated with Your covered Account.
Emergency Medical/Dental benefit limit: up to two thousand five hundred dollars ($2,500.00); subject to a fifty-dollar ($50.00) deductible.
What is Emergency Medical/Dental and when does it apply?
The Emergency Medical/Dental benefit applies if You suffer an injury or illness and require Emergency Treatment during Your Covered Trip. The Covered Trip must take place via a Common Carrier, be no less than five (5) days and no more than sixty (60) days and at least one hundred* (100) miles from Your Residence.
*Note: Under New York laws, when a cardholder’s mailing address is in the State of New York, the requirement that You must be one hundred (100) or more miles from Your Residence does not apply.
Your covered medical expenses are necessary services and supplies that are recommended by Your attending physician and take place during the course of Your Covered Trip. They include:
- The services of a legally qualified physician, surgeon, graduate nurse, dentist, or osteopath
- Charges for hospital confinement and use of operating rooms
- Charges for anesthetics (including administration), x-ray examinations or treatments, and laboratory tests
- Ambulance services
- Drugs, medicines, and therapeutic services and supplies
Please Note: This benefit is supplemental to and excess of any valid and collectible insurance or other reimbursement.
What if I need to recuperate after my hospital stay?
If You are hospitalized as a result of a covered accident or sickness during Your Covered Trip and Your attending physician determines that You should recover in a hotel immediately after Your release from the hospital and before returning home, You may be eligible for an additional benefit of seventy-five dollars ($75.00) per day for up to a maximum of five (5) days towards the cost of a hotel room.
What is not covered?
Benefits will not be paid in excess of the Reasonable and Customary charges. These benefits do not cover any expense resulting from the following:
- Travel for the purpose of obtaining medical treatment
- Non-emergency services, supplies or charges
- Services, supplies, or charges rendered by You, Your spouse, dependent children or family member.
- Care not prescribed by or performed by or upon the direction of a physician or dentist
- Care not medically necessary as determined by the Benefit Administrator
- Care rendered by a provider other than a hospital, physician, or dentist
- Care which is experimental/investigative in nature
- Care for any illness or bodily injury that occurs in the course of employment if You are eligible for benefits or compensation in whole or in part, under the provisions of any legislation of any governmental unit (for example – workers compensation coverage). This applies whether or not You claim or recover any benefits or compensation and whether or not You recover losses from a third party.
- Payments to the extent benefits are provided by any governmental agency or unit (except Medicare)
- Care received for which You would have no legal obligation to pay in the absence of this or any similar benefit
- Care received in Afghanistan, Burma, El Salvador, Iran, Iraq, Kampuchea, Laos, Lebanon, Nicaragua, North Korea, Vietnam, Yemen, and any other country which may be determined by the U.S. Government from time to time to be unsafe for travel.
- Care for any illness or injury suffered due to:
- Self-inflicted harm
- Attempted suicide
- Mental health issues
- Alcoholism or substance abuse
- War; military duty; civil disorder
- Air travel except as a passenger on a licensed aircraft operated by an airline or air charter company
- Routine physical examinations
- Hearing aids; eyeglasses or contact lenses
- Routine dental care, including dentures and false teeth
- Hernia, unless it results from a covered accident
- Elective abortion
- Participation in or attempt at a felonious act
- Skydiving, scuba, skin, or deep sea diving
- Hang gliding, parachuting, rock climbing and contests of speed
How to file an Emergency Medical/Dental claim
- Within ninety (90) days of receiving medical care while on an eligible Covered Trip notify the Benefits Administrator at 1-800-434-1280, or call collect outside the U.S. at 1-804-673-6499. The Benefits Administrator will answer Your questions and send You a claim form.
- Return the claim form and the requested documentation below within one-hundred and eighty (180) days of the date of the event to the address below:
Card Benefit Services
P.O. Box 72034
Richmond, VA 23255
Please submit the following documents:
- The completed signed claim form
- A copy of Your monthly billing statement or the travel itinerary (showing the last four [4] digits of the Account number) confirming the Common Carrier ticket was charged to Your covered Account and/or rewards program associated with Your covered Account
- If more than one method of payment was used, please provide documentation as to additional currency, voucher, points or any other payment method utilized
- A statement from Your insurance carrier (and/or Your employer, or Your employer’s insurance carrier) or other reimbursement showing any amounts they may have paid towards the costs claimed Or, if You have no other applicable insurance or reimbursement, please provide a statement to that effect
- A copy of any other valid and collectible insurance or reimbursement available to You if applicable
- Receipts for the eligible medical/dental expenses
- Any other documentation deemed necessary by the Benefit Administrator to substantiate the claim
Definitions
Account means Your credit or debit card Accounts.
Common Carrier means any mode of transportation by land, water or air operating for hire under a license to carry passengers for which a ticket must be purchased prior to travel. Does not include taxi, limousine service, commuter rail or commuter bus lines.
Covered Trip means arrangements that are made by a commercial licensed travel establishment consisting of travel agencies and/or Common Carrier organizations, for which the expense has been charged to Your eligible Account and/or rewards program associated with Your covered Account, and which is not less than five (5) consecutive days but does not exceed sixty (60) consecutive days in duration.
Eligible Person means a cardholder, his/her spouse or legally dependent children under age eighteen (18) [twenty-five (25) if enrolled as a full-time student at an accredited university whose Covered Trip was paid for by using their eligible card and/or rewards program associated with their covered Account.
Emergency Treatment means the services or supplies provided by a dentist, hospital, physician or other provider which are medically necessary to treat any injury, sickness or other covered condition where the onset is sudden and unexpected, considered life-threatening, and if left untreated, could deteriorate resulting in serious and irreparable harm.
Reasonable and Customary Charges means charges commonly used by providers of medical care in the locality in which care is furnished.
Residence means Your home address as listed in Your card issuer’s file or address reflected on Your billing statement. The home address from the card issuer’s records will take precedence over billing statement address in determining the eligibility of coverage.
You or Your means an Eligible Person or Your spouse or dependent children who charged their Covered Trip to Your eligible Account and/or rewards program associated with Your covered Account.
Additional provisions for Emergency Medical/Dental Coverage
- Signed or pinned transactions are covered as long as You use Your eligible card to secure the transaction.
- You shall do all things reasonable to avoid or diminish any loss covered by this benefit. This provision will not be unreasonably applied to avoid claims.
- If You make any claim knowing it to be false or fraudulent in any respect, no coverage shall exist for such claim, and Your benefit may be cancelled. Each cardholder agrees that representations regarding claims will be accurate and complete. Any and all relevant provisions shall be void in any case of fraud, intentional concealment, or misrepresentation of material fact.
- No legal action for a claim may be brought against the Provider until sixty (60) days after the Provider receives Proof of Loss. No legal action against the Provider may be brought more than two (2) years after the time for giving Proof of Loss. Further, no legal action may be brought against the Provider unless all the terms of the Guide to Benefits have been complied with fully.
- This benefit is provided to eligible cardholders at no additional cost. The terms and conditions contained in this Guide to Benefits may be modified by subsequent endorsements. Modifications to the terms and conditions may be provided via additional Guide to Benefits mailings, statement inserts, statement messages or electronic notification. The benefits described in this Guide will not apply to cardholders whose Accounts have been suspended or cancelled.
- Termination dates may vary by financial institutions. Your financial institution can cancel or non-renew the benefits for cardholders, and if they do, they will notify You at least thirty (30) days in advance. Indemnity Insurance Company of North America (“Provider”) is the underwriter of these benefits and is solely responsible for its administration and claims. The Benefit Administrator provides services on behalf of the Provider.
- After the Benefit Administrator has paid Your claim, all Your rights and remedies against any party in respect of this claim will be transferred to the Benefit Administrator to the extent of the payment made to You. You must give the Benefit Administrator all assistance as may reasonably be required to secure all rights and remedies.
- This benefit does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit the provision of insurance, including, but not limited to, the payment of claims.
FORM #OPTMEDDENT – 2017 (04/17) EM-O
For more information about the benefit described in this guide, call the Benefit Administrator at 1-800-434-1280, or call collect outside the U.S. at 1-804-673-6499.
