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1
International Medical Insurance Plan
Insurance for Participants
CONTENTS
Important Information ......................................................... page 1
Definitions- Meaning of Words ............................................... page 2
Plan term and Conditions ...................................................... page 5
1. Medical, Hospital & Dental Benefits .................................... page 7
2. Medical Transfer Benefits .................................................. page 8
3. Benefits Following Death ................................................... page 10
4. Personal Accident Benefit .................................................. page 11
5. General Conditions Applying to the Whole Plan .................... page 12
6. General Exclusions Applying to Whole Plan .......................... page 13
7. Pre-authorisation and Claims Procedure .............................. page 16
8. Questions and Complaints ................................................. page 17
9. Data Protection Notice, Rights of Third Parties, Sanctions ..... page 18
IMPORTANT INFORMATION
This insurance is underwritten by Catlin Insurance Company (UK) Ltd. whose registered office is 20
Gracechurch Street, London EC3V 0BG, England. (Registered in England No. 5328622). Catlin Insurance
Company (UK) Ltd. is regulated by the Financial Conduct Authority; registration number: 423308.
This International Medical Insurance Plan (“Plan”) was arranged for you and will be administered by Your
Policyholder (Client Organisation detailed on your Certificate) and Global Secutive Limited whose
registered office is at Stenzelbergstr. 10, Meckenheim, 53340, Germany (“Global Secutive”), please do not
use this address for correspondence.
The Claims Administrator shall be LAMP Services Limited of Chester House, Harlands Road, Haywards Heath,
West Sussex RH16 1LR Tel: (01444 451752) Company Number: 4967967 (“LAMP”).
Where certain words start with a capital letter they have been given a special meaning, these defined terms
can be found in the section called ‘Definitions – Meaning of Words’.
This Plan comprises:
1. this Plan document, which contains full details of the benefits, terms, conditions and exclusions of
Your Plan; and
2. a Certificate showing who is covered under the Plan, the Period of Insurance, Your contact and
Country of Residence details (taken from Your application form) and any endorsements; and
2
3. Your Schedule of Benefits, which sets out the benefits and Policy Limits of this Plan.
4. My Insurance Brochure which sets out the details of the insurance which You have purchased and it
contains a full description of Your Health and Accident Insurance Coverage, What is covered, Medical
treatment in the case of Illness, How to file Health and Accident Insurance Claims and frequently
asked questions.
Please read these documents fully and carefully to familiarise yourself with the details of Your cover, the
conditions of cover and what is and is not covered. Please note that there are specific conditions and
exclusions which apply to specific sections of this Plan and there are general conditions and exclusions
which apply to this Plan as a whole. Your Certificate is Your evidence that You have been accepted for
cover. The Plan is effective from the commencement date specified in Your Certificate. If anything is not
correct please return it as soon as practicably possible to Us via the Policyholder.
Cooling Off Period:
If You decide this Plan does not meet Your needs You are entitled to cancel this contract of insurance by
writing to the Policyholder within fourteen (14) days of either the date You receive this Plan; or the
start of the Period of Insurance, whichever is the later.
On condition that a Claim has not already made and it is accepted that one cannot make one later, We
will refund any premium that has been paid. Your Plan will be annulled, which means it will be treated as
if it had never existed.
We will provide the services and benefits described in this Plan during the Period of Insurance, subject
to the Policy Limits and all other terms, conditions and exclusions contained in this Plan, and following
payment of the appropriate premium by the Policyholder.
This Plan is subject to the laws of England and Wales.
DEFINITIONS - MEANING OF WORDS
Wherever the following words and phrases shown below in bold appear in the International Medical
Insurance Plan (and in the Certificate AND Schedule of Benefits attaching to and forming part of the
Insurance) they will always have the meanings defined below.
Accident means a sudden and unforeseen bodily
Injury caused by violent or external means.
Certificate means the document We will issue
to You showing who is covered under the Plan,
the Period of Insurance, Your contact and
Country of Residence details (taken from Your
application form) and any endorsements to You.
Chiropractor means chiropractic Treatment
recommended by a Physician for medical
reasons following an Insured Event and
provided by a licensed Chiropractor
Claim(s) means Your request for payment of
benefit(s) under this Plan.
Close Relative means a spouse, civil partner or
common-law partner, mother, father, mother-in-
law, father-in-law, daughter, son (including
legally adopted daughter or son) brother, sister,
brother-in-law, sister-in-law or fiancé(e),
grandparents of a Participant.
Co-payment means the amount specified in the
Schedule of Benefits payable by You before
any benefit is payable by this Plan for each
Claim.
Country of Residence means a
country/countries for which You hold a passport.
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Day-care means Treatment provided in a
Hospital where You are admitted but is not
required for medical reasons, to stay overnight.
Disability means a state of physical incapacity
resulting from an Accident.
Emergency Dental Treatment means
Treatment necessary for the immediate relief of
pain and suffering as a result of an infection or
Accident by an extra-oral impact, received
within 48 hours from the date and time of the
Accident or emergence of the infection.
Emergency Treatment means Treatment of
an acute Illness or Injury, which occurs during
the Period of Insurance, and causes an
immediate threat to health requiring urgent and
Medically Necessary Treatment, which
cannot, in the opinion of Our Medical Advisor,
be deferred until Your return to Your Country
of Residence.
Emergency Medical Transfer and/or
Repatriation means the emergency
transportation when approved by Our 24-hour
Assistance Centre, and medical care during such
transportation, to move a Participant who
suffers a critical medical condition to a suitable
Hospital where appropriate care and facilities
are available, which may be in Your Country of
Residence.
Hospital means any institution under the
constant supervision of a resident Physician
which is legally licensed as a medical or surgical
Hospital in the country where it is located.
Illness(es) means any acute sickness, disease,
disorder or alteration in the Your medical
condition diagnosed by a Physician which occurs
during the Period of Insurance.
Injury means acute physical damage or harm
caused to the body as a result of an Accident
which occurs during the Period of Insurance.
Inpatient means Treatment provided in a
Hospital where You are admitted and, it is
Medically Necessary to occupy a bed for one or
more nights.
Insured Event means an unforeseen Accident
or Illness requiring Emergency Treatment and
/or Emergency Dental Treatment occurring
during the Period of Insurance and outside the
Country of Residence.
Local Ambulance Services means the
necessary medical transportation to or from a
local Hospital.
Loss of Sight means permanent and total loss
of sight which will be considered as having
occurred when the total loss of sight after
correction is 3/60 or less on the Snellen Scale,
and is considered from medical evidence to be
without hope of improvement and likely to
continue for the remainder of Your life.
Medical Advisor means the medical practitioner
We choose to advise on Claims under this Plan.
Medical Expenses means expenses incurred for
Treatment of an Accident or Illness as a result
of an Insured Event.
Medically Necessary means that a Treatment,
service, supply, drug, or Hospital confinement:
1. is appropriate and essential to diagnose or
treat the patient’s Illness or Injury;
2. does not exceed in scope, duration or
intensity, the level of care which is needed to
provide safe, adequate and appropriate
diagnosis or Treatment;
3. is prescribed by a Physician;
4. is consistent with widely accepted
professional standards of medical practice in
the jurisdiction where Treatment is
rendered;
5. is not primarily for the personal comfort or
convenience of the patient, the family,
Physician, or other provider of care;
6. is not a part of or associated with the
scholastic education or vocational training of
the patient;
7. is not experimental or investigative; and
8. in the case of Inpatient care, cannot be
provided safely on an Outpatient basis.
Outpatient means medical Treatment provided
to the Participant or ordered by a Physician
when it is not Medically Necessary for You to
be admitted as an Inpatient or Day-care
patient in a Hospital or any other facility for
medical care.
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Participant / You / Your means the person
entitled to benefit under this Plan, who is named
or described in the Certificate and for whom the
appropriate premium has been paid, and whom
We have accepted for cover.
Period of Insurance means the period of cover
specified in the Certificate for which the
appropriate premium has been paid.
Permanent Total Disablement means a
condition which, one year after the date of
Accident, is of a permanent, severe and
irreversible nature which is shown by Our
medical evidence to be likely to continue for the
remainder of Your life, and which in Our opinion
prevents You from engaging in gainful
employment of any and every kind for
remuneration or profit.
Physician means a legally licensed medical
practitioner who is a doctor or dentist recognised
by the law of the country where Treatment
covered under this Plan is provided and who, in
rendering such Treatment is practicing within
the scope of his / her license and training.
Physiotherapy means Treatment
recommended by a Physician for medical
reasons following an Insured Event and
provided by a licensed Physiotherapist.
Policy Limit(s) means the maximum benefit per
Insured Event and per Period of Insurance as
specified in the Schedule of Benefits.
Policyholder means the company, corporation,
or organisation who subscribes to the Group
Policy Agreement and pays or undertakes to pay
the appropriate premium on behalf of the
Participant.
Pre-existing Medical Condition means a
known (or You ought to have been aware of)
medical or psychological condition from which
You have suffered or for which You have
received medical Treatment (including
Prescription Drugs) or of which symptoms
have manifested themselves during the 6 month
period prior to Your being first included for cover
under this Plan.
Pre-existing Medical Condition of a Close
Relative means a known (or You ought to have
been aware of) medical or psychological
condition from which a close relative has
suffered or for which they have received medical
Treatment (including Prescription Drugs) or
of which symptoms have manifested themselves
during the 6 month period prior to Your being
first included for cover under this Plan.
Prescription Drugs means medications whose
sale and use are legally restricted to the order of
a Physician.
Schedule of Benefits means the document
attaching to and forming part of this Plan, stating
(amongst other things), the benefits provided
under each Section of this Plan, and the
maximum amounts payable in respect of those
benefits (Policy Limits).
Total and Permanent Loss means the
permanent physical severance or loss of use of a
limb or part thereof which is of a permanent and
irreversible nature which is shown by medical
evidence to be likely to continue for the
remainder of Your life.
Treatment means any Medically Necessary
surgical procedure or medical intervention which
is required to cure an Injury or Illness.
Usual, Reasonable and Customary means the
lower of:
1. the provider’s usual charge for furnishing the
Treatment, service, or supply; or
2. the charge which We determine to be the
general rate charged by others who render or
furnish such Treatments, services or
supplies to persons:
a) who reside in the same area; and
b) whose Injury or Illness is comparable in
nature and severity.
We will consider such factors as:
1. complexity;
2. degree of skill needed;
3. type of specialist required;
4. range of services of supplies provided by a
facility; and
5. the prevailing charge in other areas.
We or Us / Our means Catlin Plan Company
(UK) Ltd.
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PLAN TERMS AND CONDITIONS
INFORMATION YOU HAVE PROVIDED
We have relied on the information provided by You to the Policyholder. You must take
care when answering any questions asked by ensuring that any information provided is
true, accurate and complete.
If We establish that You deliberately or recklessly provided untrue or misleading
information, We will have the right to:
(a) treat this Plan as if it never existed;
(b) decline all Claims;
If We establish that You carelessly provided untrue or misleading information, We will
have the right to:
(i) treat this Plan as if it never existed, decline to pay any Claim and return
the premium, if We would not have provided You with cover;
(ii) treat this Plan as if it had been entered into on different terms from those
agreed, if We would have provided You with cover on different terms;
(iii) reduce the amount We pay on any Claim in the proportion that the
premium paid bears to the premium We would have charged, if We would
have charged more.
We will notify You in writing if (i), (ii) and/or (iii) apply.
If there is no outstanding Claim and (ii) and/or (iii) apply, We will have the right to:
(1) give You thirty (30) days’ notice that We are terminating this Plan; or
(2) give You notice that We will treat this Policy and any future Claim in
accordance with (ii) and/or (iii),
(3) in which case You may then give Us thirty (30) days’ notice that You are
terminating this Plan.
If this Plan is terminated in accordance with (1) or (2), We will refund any premium due
to You in respect of the balance of the Period of Insurance.
FRAUD
If You, or anyone acting for You, makes a Claim which is fraudulent and/or intentionally
exaggerated and/or supported by a fraudulent document, We will not pay any part of
Your Claim or any other subsequent Claim. In addition, We will have the right to:
(a) treat this Plan as if it never existed, or at Our option terminate this Plan, without
returning any premium that You have paid;
(b) refuse any other benefit under this Plan.
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CHANGE IN CIRCUMSTANCES
You must tell the Policyholder within fourteen (14) days of Your becoming aware of
any changes in the information You have provided which happen before or during any
Period of Insurance. If You become aware that the information You have given is
inaccurate or untrue, You should inform the Policyholder as soon as practicably
possible.
When We are notified of a change We will tell You if this affects this Plan. For example
We may not be able to continue to provide cover and reserve the right to cancel the
Cover immediately and provide You with a proportional daily rate refund for the
unexpired portion of the Plan. Alternatively We may choose to amend the terms and
conditions of this Plan or require the Policyholder to pay an additional premium. If
You do not inform Us about a change it may affect any Claim You make or could result
in this Plan being invalid.
BENEFITS AND SERVICES
Following payment of the premium, subject to the terms, conditions and exclusions of this Plan,
We will arrange and / or pay for the benefits and services shown in this Plan for Emergency
Treatment, Emergency Dental Treatment and ancillary benefits, which are Medically
Necessary, resulting from an Insured Event occurring outside Your Country of Residence.
We will pay the necessary costs, up to the Policy Limits for each Participant, in each Period of
Insurance.
Our liability for any Claim will cease on the date of Your return to Your Country of Residence
or when this Plan expires, whichever is the sooner.
Benefits are payable on Your behalf to the licensed providers of the services insured under this
Plan, or alternatively at Our discretion are reimbursable directly to You (e.g. where You have
made a payment for Emergency Return Home under section 2.4 of this Plan).
Benefit payments shall be processed by the Claims Administrators, specialised in the handling of
medical Claims, who are appointed by Us.
PLEASE NOTE: You MUST obtain our pre-authorisation before incurring ANY costs for the
following Treatments otherwise Your Claim may be invalidated:
1. Inpatient Treatment and/or supplies of any kind;
2. any other surgery or surgical procedure;
3. Major Diagnostic Testing, including but not limited to Computerised Axial Tomography
(CAT) Scan, Magnetic Resonance Imaging (MRI) Scan or Positon Mission Tomography
(PET) Scan;
4. or where costs are anticipated to exceed $5,000.
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SECTION 1 - MEDICAL, HOSPITAL & DENTAL BENEFITS
We will pay the following costs if You suffer an Insured Event.
1.1 Hospitalisation Costs
We will arrange and pay up to the amount specified in the Schedule of Benefits for Your
Emergency Treatment for Inpatient or Day-care admission to Hospital in a semi-private
room, and for all Medically Necessary Treatment and services ordered by a Physician and
approved by Our Medical Advisor.
1.2 Outpatient Care
We will pay Medically Necessary costs agreed by Us for Emergency Treatment up to the
amount specified in the Schedule of Benefits for Outpatient services, including:
1.2.1. Physicians fees, and Prescription Drugs;
1.2.2. laboratory and X-Ray fees, medical scanning, imagery services, and
1.2.3. Physiotherapy and Chiropractors fees when referred and recommended by a
Physician and for immediate pain relief only.
1.3 Emergency Dental Treatment
1.3.1 We will arrange and pay up to the amount specified in the Schedule of Benefits
for Outpatient Emergency Dental Treatment.
1.3.2 Emergency Dental Treatment shall not include restorative or remedial work, the
use of any precious metals, and orthodontic Treatment of any kind or tooth
traction performed in a Hospital, unless tooth extraction is the only Treatment
available to alleviate the pain.
SPECIFIC EXCLUSIONS APPLYING TO SECTION 1
We will not pay any costs:
1. which need to be pre-authorised (as shown above) and which have not been authorised by
Us in advance;
2. for Treatment which the Physician treating You or Our Medical Advisor, can
reasonably be delayed until Your return to Your Country of Residence;
3. where prior to the commencement of the Period of Insurance, You have not received
the required vaccinations as recommended by the World Health Organisation for travel to
Your Country of placement;
4. incurred in Your Country of Residence other than in connection with transportation of
You or Your remains to Your home from abroad;
5. for Root Canal Treatment or Periodontics;
6. incurred after one year of the date that the need Treatment first arises;
7. for Durable Medical Equipment (DME) unless deemed Medically Necessary by Our
Medical Advisor and in any case not exceeding $250 (limit applies to external DME use
only).
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SECTION 2 - MEDICAL TRANSFER BENEFITS
We will pay the following costs for Emergency Treatment if You suffer an Insured Event
covered under Section 1:
2.1 Local Ambulance Services
We will arrange and pay up to the amount specified in the Schedule of Benefits for Your
transport to the nearest suitable Hospital by the most appropriate means available, comprising
road / off-road ambulance, train, helicopter or fixed-wing aircraft, with a medical escort if Our
Medical Advisor considers Medically Necessary.
2.2 Emergency Medical Transfer and/or Repatriation
2.2.1 If an Insured Event occurs which, in Our Medical Advisor's opinion requires
Your Emergency Medical Transfer and/or Repatriation We will arrange and
pay all costs up to the amount specified in the Schedule of Benefits for Your
medical transportation.
The most appropriate means of transport available locally will be used. If by air
We will employ a regular scheduled or charter airline, or, if Medically Necessary
in the opinion of Our Medical Advisor, a specially chartered air ambulance. If
You had been travelling by plane, transport will be in the same class as the
original airline ticket (unless Medically Necessary), but if You were not,
transport will be by the airline's economy / tourist class (unless Medically
Necessary).
2.2.3 When Our Medical Advisor considers Medically Necessary, We will arrange
and pay for a medical escort to accompany You.
2.2.4 Where We have arranged and paid for Your Emergency Medical Transfer
and/or Repatriation We will pay travel expenses by first class rail or by
economy/tourist class air travel to return You to Your location at the time of the
Insured Event.
Medical Emergency Helpline
For 24 hour Emergency Evacuation, and/or Repatriation assistance:
Providers and Participants in the USA/Canada call: +1 877 455 3542
Participants in Other Countries call: +1 647 288 7830
email: LAMP@intrepid247.com
The medical emergency helpline is operated by Intrepid 24/7.
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2.3 Companion
Where You are (or in the opinion of Our Medical Advisor likely to be) hospitalised for a period of
in excess of 5 days We will provide the following benefits:
2.3.1 We will arrange and pay for one return trip by first class rail or by economy/tourist
class air travel for a nominated relative or friend to travel to the location where
You are hospitalised.
2.3.2 We will arrange and pay for additional transportation costs by first class rail or by
economy/tourist class air travel incurred for a nominated relative or friend to
accompany You if We arrange an Emergency Medical Transfer and / or
Repatriation
2.3.3 We will pay for overnight accommodation and subsistence for Your nominated
relative or friend while You remain hospitalised outside Your Country of
Residence, up to USD300 each night for a maximum of 10 nights.
2.4 Emergency Return Home
Where it is necessary for You to return to Your Country of Residence due to the death or
imminent demise of a Close Relative We will pay Your return travel expenses by first class rail
or by economy/tourist class air travel for You to return to Your Country of Residence. Expenses
will be processed on a reimbursement basis on provision of a valid death certificate.
A Claim under Section 2.4 is not subject to a valid Claim under Section 1.
SPECIFIC CONDITIONS APPLYING TO SECTION 2.1 and 2.2
1. Our Medical Advisor's decision is final and We are entitled to refuse any request which is
incompatible with their opinion of Your medical condition and safety.
2. Our Medical Advisor will set up the medical team and resources to be used as and when
appropriate, to ensure Your safety during the Emergency Medical Transfer or
evacuation.
3. If You reject the assistance procedures We propose then We shall be released from Our
obligations under Section 2.1 and 2.2.
SPECIFIC EXCLUSIONS APPLYING TO SECTION 2
We will not pay any costs:
1. not arising from a valid Claim under Section 1 other than in respect of Section 2.4.;
2. not arranged and approved by Us in advance (other than emergency ambulance transfer).
3. for You to return to Your Country of Residence due to the death or imminent demise of
a Close Relative where there was a Pre-Existing Medical Condition of a Close
Relative, or where You ought to have reasonably been aware at the start of the Period
of Insurance of the need to return to Your Country of Residence;
4. for more than one Emergency Return Home Claim in any one Period of Insurance;
5. any costs incurred in Your Country of Residence other than in connection with
transportation of You or Your remains to Your Country of Residence from abroad;
6. any subsequent Emergency Medical Transfer costs arising out of the same Insured
Event once We have returned You to Your Country of Residence.
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SECTION 3 - BENEFITS FOLLOWING DEATH
If You die outside Your Country of Residence during the Period of Insurance as the result of
an Insured Event, We will provide one of the three following benefits according to Your wishes
expressed prior to death or those of the next-of-kin. We will arrange and pay for:
3.1 Repatriation of Remains
3.1.1 up to the amount specified in the Schedule of Benefits for preparation and
repatriation of Your mortal remains from the country where death occurs to the
place of the funeral in the Country of Residence. We will make all arrangements
as required under international regulations and will pay up to USD300 towards the
cost of the coffin.
3.1.2 the additional travel costs of one other person (who was accompanying the
deceased at the time of death) to return by first class train or economy / tourist
class air travel to attend the funeral.
OR
3.2 Cremation
3.2.1 up to USD300 towards the cost of cremation in the country where death occurs;
and
3.2.2 for transportation of the funeral urn to the Country of Residence.
OR
3.3 Local Burial
3.3.1 up to USD1,000 for burial in the country where death occurs.
We will pay any additional costs necessary to comply with statutory requirements.
SPECIFIC EXCLUSIONS APPLYING TO SECTION 3
We will not pay any costs not arranged and approved by Us in advance.
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4 PERSONAL ACCIDENT BENEFIT
We will pay the following percentages of the benefit specified in the Schedule of Benefits should
You sustain Injury resulting from an Accident:
Percentage of benefit payable
1. Death 100%
2. Permanent Total Disablement 100%
3. Loss of Sight in
3.1. Both eyes 100%
3.2. One eye 50%
4. Total and Permanent Loss of
4.1. Two or more limbs 100%
4.2. One limb 50%
4.3. Four fingers and thumb of one hand 50%
4.4. Four fingers of one hand 40%
4.5. A thumb 25%
4.6. One index finger 15%
4.7. Any one other finger 10%
4.8. All toes of one foot 15%
4.9. Big toe 7.5%
4.10. Any one other toe 5%
Subject to the following terms and conditions
1. the maximum benefit payable in respect of any one Participant in respect of any one
Accident shall not exceed the personal accident sum insured specified in the Schedule of
Benefits in respect of that Participant;
2. for forms of Total and Permanent Loss not specified the degree of Disability will be
assessed by comparison with the percentages shown in the above scale without taking into
account Your occupation at Our absolute discretion;
3. the maximum death benefit payable in respect of a Participant aged 17 years or younger
will not exceed USD5,000.
SPECIFIC EXTENSION APPLYING TO SECTION 4
1. Death or Injury caused by the effects of:
1.1 drowning;
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1.2 unavoidable exposure to natural elements; or
1.3 suffocation by smoke, poisonous fumes or gas
must have resulted from accidental Injury provided that such events do not arise from an
Your intentional, wilful or reckless acts.
2. In the event of Your disappearance after 12 months it is reasonable to believe that Death
has occurred as a result of an Accident, the Death Benefit shall become payable subject
to the beneficiary of the Death Benefit signing an undertaking that if the belief is
subsequently found to be wrong such amount shall be refunded to Us.
SPECIFIC EXCLUSIONS APPLYING TO SECTION 4
We will not pay any Claim directly or indirectly resulting from:
1.1 sickness or disease, bacterial or viral infections even if contracted by an Accident;
1.2 existing defect or chronic or recurring disease, disorder or other condition unless
We have accepted it in writing and specifically stated it as covered under this
Section of this Plan;
1.3 Post-Traumatic Stress Disorder, psychiatric, mental or nervous disorder, anxiety
and or depression;
1.4 pregnancy, childbirth, abortion, miscarriage or any complications arising from such.
5. GENERAL CONDITIONS APPLYING TO WHOLE PLAN
The following conditions apply to all parts of this Plan.
5.1. All Pre-Existing Medical Conditions are excluded from cover under this Plan.
5.2. Full compliance with the terms and conditions of this Plan is necessary before a Claim will
be paid.
5.3. In all cases, We require a completed Claim form, together with full original supporting
evidence to substantiate the expense, such as receipts and reports. These must be
provided at Your own expense. This does not apply for Claims through Our direct billing
network in the United States.
5.4. You must take all steps to avoid or minimise any Claim. You must act as if not insured.
5.5. The provision of benefits and services under this Plan is subject to local availability,
national and international law, regulation and authorisations.
5.6. If You have a right of action against any third party in respect of the Accident giving rise
to a Claim under this Plan We are entitled to take over Your rights in the defence or
settlement of such Claim or to take proceedings in Your name for Our own benefit
against another party and We shall have full discretion in such matters.
5.7. We may, at any time, pay to You Our full liability under this Plan after which, We shall
have no further liability in any respect.
5.8. If another insurance company or a state scheme pays part of Your Claim You must send
Us the original bill which clearly shows the amount paid by the insurer or scheme and We
shall only be responsible for Our fair proportion of Your Claim.
13
5.9. We reserve the right to arrange and pay for Your early Repatriation if, in the opinion of
Our Medical Advisor, You are medically fit to travel, and Your Treatment can be
postponed until Your return to Your Country of Residence.
5.10. Our obligations under contracts of insurance to which We subscribe are several and not
joint and are limited solely to the extent of Our individual subscriptions. We are not
responsible for the subscriptions of any co-subscribing insurer who for any reason does not
satisfy all or part of its obligations.
5.11. This Plan is not available for citizens of the USA and is not subject to, and does not provide
certain insurance benefits required by the United States Patient Protection and Affordable
Care Act ("PPACA"). The insurance benefits provided by this Plan are stated in Your Plan
documents and do not include any additional benefits required by the PPACA. The PPACA
requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage.
In certain circumstances penalties may be imposed on U.S. residents and citizens who do
not maintain PPACA compliant insurance coverage. You should consult Your attorney,
insurance agent, or tax professional to determine if the PPACA's requirements are
applicable to You.
6 GENERAL EXCLUSIONS APPLYING TO WHOLE PLAN
You are not covered and We will not pay under any part of this Plan for:
6.1.1 any expenses, Treatment, medical or dental condition or procedures relating
thereto not specifically stated in this Plan as being insured;
6.1.2 sums in excess of the Policy Limits;
6.1.3 any expense which We and / or Our Medical Advisor considers to be
unreasonable, unnecessary or excessive;
6.1.4 any Treatment where We require pre-authorisation and this has not been
provided;
6.1.5 costs which would have been incurred if the Insured Event had not occurred;
6.1.6 the Co-payment (where applicable) specified in this Plan.
6.2 any Claim:
6.2.1 arising from a Pre-Existing Medical Condition;
6.2.2 arising from Treatment of a chronic, or recurrent condition;
6.2.3 for routine medical check-ups, vaccinations, and other preventive Treatment;
6.2.4 for any Treatment and examinations which can reasonably await Your return to
Your Country of Residence.
6.2.5 which is not for Emergency Treatment, or which is not Medically Necessary;
6.2.6 for elective surgery, or Treatment, of any kind; 6.2.7 for Medical Expenses which are in excess of Usual, Reasonable and
Customary charges;
6.2.8 arising from pregnancy after the 26th week of pregnancy;
6.2.9 arising from any sexually transmitted diseases;
14
6.2.10 arising from Human Immunodeficiency Virus or HIV related Illness, including
Acquired Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC) and
any similar infections, Illnesses, injuries or medical conditions arising there from.
6.2.11 involving fraud, misrepresentation or concealment or their consequences.
6.2.12 from self-inflicted Injury (including suicide or attempted suicide);
6.2.13 from needless self-exposure to peril (except in an attempt to save human life); or
6.2.14 from travel undertaken against medical advice, or for the purpose of obtaining
Treatment.
6.2.15 being intoxicated (meaning affected temporarily with diminished physical and
mental control by means of alcoholic liquor, a drug, or another substance) other
than under the direction of a registered Physician provided that such direction is
not for Treatment for drug addiction or dependence and You follow such
direction.
6.2.16 Your own criminal act including but not limited to road traffic offences and guns
laws. We reserve the right to withhold any payment under this Plan until such time
as You are found to be not guilty of any charges or proceedings taken against
You.
6.3 Treatment for drug and substance abuse (including alcohol) or dependency or other
addictive condition and any condition arising directly or indirectly there from.
6.4 any costs arising after expiry of the Period of Insurance. If at the time of the expiry of
the Period of Insurance You are receiving Inpatient Treatment covered under this
Plan the Period of Insurance will be extended by up to 30 days or until such time as
You are discharged from Hospital, whichever occurs first.
6.5 any Injury or Illness sustained while taking part in:
6.5.1 mountaineering, climbing or trekking activities where specialized climbing
equipment, ropes or guides are normally or reasonably should have been used;
professional sports (for the purposes of this exclusion a professional sport is any
sporting event where a monetary prize is awarded or any Participants receive a
monetary inducement to participate and shall include any Olympic sport);
6.5.2 aviation (except when travelling solely as a passenger in a commercial aircraft),
hang gliding, parachuting, paragliding, parascending or skydiving;
6.5.3 snow skiing and snowboarding (except for recreational downhill and/or cross
country snow skiing or snowboarding (no cover provided while skiing / boarding in
violation of applicable laws, rules or regulations; away from prepared and marked
in-bound territories; and/or against the advice of the local ski school or local
authoritative body)), heli-skiing, ski jumping, in-line skating without the use of
proper helmet and pads equipment, bobsledding, luge, skeleton or snowmobiling;
6.5.4 riding on a motorcycle or quad bike (or derivative) unless You hold a full licence,
or riding as a passenger where the person in control of the motorcycle does not
hold the relevant licence;
6.5.5 motocross or BMX;
6.5.6 BASE jumping, bungee jumping, abseiling or rappelling;
6.5.7 hunting contrary to local regulations, license requirements and/or without the
necessary permits;
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6.5.8 canyoning or white-water rafting;
6.5.8 caving or spelunking;
6.5.9 high diving;
6.5.10 jet skiing;
6.5.11 rodeo or polo;
6.5.12 racing of any kind, including by horse or motor vehicle (of any type);
6.5.13 cave diving, scuba diving, snorkelling or other sub aqua pursuits in depths of more
6.5.14 than 10 meters involving underwater breathing apparatus;
6.5.15 sports or activities involving the use of the use of weapons (unless at a recognised
shooting gallery and under professional supervision) or physical combat (unless as
part of a school activity and under professional/teacher supervision);
6.5.16 Extreme Sports;
6.5.17 any similar activities listed within 6.5 which are not referred to Us for acceptance
Practice or training in preparation for any excluded activity which results in Injury will be
considered as taking part in such activity.
6.6 any Claim arising when the Participant is under military authority or is engaged in
activities involving the use of firearms or physical combat or in an area of military conflict.
6.7 any expenses relating to search and rescue operations to find a Participant in mountains,
at sea, in the desert, in the jungle and similar remote locations, including air/sea rescue
charges for evacuation to shore from a vessel or from the sea.
6.8 any expense where We are not satisfied with the documents submitted and / or where We
do not receive the Claim documents within 90 days of the date that expenses were
incurred, and in any event within 28 days after the expiry of Your Plan, unless We agree
otherwise.
6.9 Treatment for mental or nervous disorders, psychiatric Treatment and / or the costs of a
psychotherapist, psychologist, family therapist or bereavement counsellor. The cost of
initial diagnosis would be covered up to maximum Policy Limit of USD500.
6.10 any Claim arising from the radioactive, toxic, explosive or other hazardous or
contaminating properties of any nuclear installation, reactor or other nuclear assembly or
nuclear component thereof.
6.11 any Claim in any way caused or contributed to by the use or release or the threat thereof
of any nuclear weapon or device or chemical or biological agent.
6.12 any Claim(s) whatsoever resulting from war, invasion, act of foreign enemy, hostilities
(whether war be declared or not), act of terrorism, civil war, rebellion, revolution,
insurrection, military or usurped power or taking part in civil commotion or riot of any
kind.
(For the purpose of this exclusion, an act of terrorism means an act, including but not
limited to the use of force or violence and/or the threat thereof, of any person or group(s)
of persons, whether acting alone or on behalf of or in connection with any organisation(s)
or government(s), committed for political, religious, ideological or similar purposes or
reasons including the intention to influence any government and/or to put the public, or
any section of the public, in fear).
6.13 any expense which at the time of happening is covered by, or would, but for the existence
of this Plan, be covered by any other existing insurance certificate, policy, Worker’s
Compensation or other similar programme, or state scheme. If there is any other cover in
16
force which may pay in respect of the event for which You are claiming, You must tell Us
at the time You first contact Us.
6.14 any losses which are not directly covered by the terms and conditions of this Plan
(examples of losses We will not pay for include loss of earnings due to being unable to
work as a result of Illness or Injury).
7 PRE-AUTHORISATION AND CLAIMS PROCEDURES
The following explains what to do if You need to make a Claim under this Plan.
7.1 To ensure the most appropriate care possible You should contact the relevant organisation
as shown on the Membership card.
7.2 You must bear in mind that to comply with the terms and conditions of this Plan, Our
service provider must be contacted for Our pre-authorisation before You incur costs for
the following Treatments:
7.2.1 Inpatient Treatment and/or supplies of any kind;
7.2.2 any other surgery or surgical procedure;
7.2.3 Major Diagnostic Testing, including but not limited to Computerised Axial
Tomography (CAT) Scan, Magnetic Resonance Imaging (MRI) Scan or Positron
Mission Tomography (PET) Scan.
7.2.4 Or where costs are anticipated to exceed $5,000.
7.3 If the Treatment scheduled is eligible for cover, We can confirm the level of benefit
applicable to the medical provider/s and authorise Treatment, subject to the terms and
conditions of the Plan. When the Claim is subsequently fully validated, We will arrange for
costs to be settled direct to the medical provider/s. Payments will not include any co-
payments that are to be paid by You.
7.4 It is important to note that if We authorise Treatment which ultimately transpires to have
been related to a condition excluded by the Plan, for example, Treatment for a Pre-
Existing Medical Condition, You will be responsible for all costs, including those settled
by Us. In such cases, You must repay Us within one month of Our request to you, any
costs or expenses We have paid out on Your behalf of which are not covered under the
terms of this Plan.
7.5 In case of an emergency, if You are physically prevented from contacting Us as soon as
practicably possible, You or someone designated by You must contact Us within 48 hours.
You must make no admission of liability, offer, promise or payment without Our prior
consent. We must be telephoned first.
7.6 You must give Us written details of any Claim within 28 days of Our request. As often as
We require, You shall submit to medical examination at Our expense. In the event of the
death of a Participant We shall be entitled to have an autopsy carried out at Our
expense (where this is not forbidden by local law or religious beliefs).
7.7 You must supply Us with a written statement substantiating Your Claim, together with
(at Your expense) all original invoices, certificates, information, evidence and receipts that
We require.
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8 QUESTIONS AND COMPLAINTS
We aim to provide a first class service at all times. However, if You have any questions or
concerns regarding the standard of service received under this Plan, the following procedure is
available to resolve the situation:
In the first instance You should write to:
Operations Team
LAMP Services Limited
Chester House
Harlands Road
Haywards Heath
West Sussex
RH16 1LR
If We cannot give you a final decision within 4 weeks from the date We receive your complaint,
We will explain why and tell you when We hope to reach a decision.
You also have the right to refer Your complaint directly to the:
Complaints Manager
Catlin Insurance Company (UK) Ltd.
20 Gracechurch Street
London
EC3V 0BG
England
If You remain dissatisfied after the Complaints Manager has considered Your complaint, or You
have not received a final decision within eight (8) weeks, you can refer Your complaint to the
Financial Ombudsman Service at:
Financial Ombudsman Service
Exchange Tower
London
E14 9SR
United Kingdom
Email: complaint.info@financial-ombudsman.org.uk
From outside the United Kingdom
Telephone Number: +44 (0) 20 7964 1000
Fax: +44 (0) 20 7964 1001
The United Kingdom Financial Services Compensation Scheme Catlin Insurance Company (UK) Ltd. is covered by the United Kingdom Financial Services Compensation Scheme. The Insured may be entitled to compensation from the Scheme if an Insurer is unable to meet their obligations under this contract of insurance. If the Insured were entitled to compensation under the Scheme, the level and extent of the compensation would depend on the nature of this contract of insurance. Further Information about the Scheme is available from the Financial Services Compensation Scheme (10th Floor, Beaufort House, 15 St. Botolph Street, London EC3A 7QU) and on their website: www.fscs.org.uk
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9 DATA PROTECTION
9.1 We collect and maintain Your personal information in order to:
9.1.1 underwrite and administer the Polices of insurance that We issue;
9.1.2 provide You with information, products or services which We feel may interest You;
9.1.3 verify Your identity;
9.1.4 carry out Our obligations rising from the Policy; and
9.1.5 notify You about changes to this Policy.
9.2 All personal information is treated with the utmost confidentiality and with appropriate
levels of security in accordance with the Data Protection Act 1998. We will not keep Your
information longer than is necessary. Your information will be protected from accidental or
unauthorised disclosure. We will only reveal Your information if it is allowed by law,
authorised by You, to prevent fraud or in order that We can liaise with Our agents in the
administration of this Policy. You have the right to ask for a copy of any information We hold
on You upon payment of an administrative fee and to require a correction of any incorrect
information held. Any inaccurate or misleading data will be corrected as soon as possible.
9.3 We shall not transfer your personal information outside the European Economic Area (EEA)
but We may transfer it to Our agents and subcontractors within the EEA who help Us
administer Your Policy. We may disclose Your personal information to any member of Our
group, which means our subsidiaries and parent company. In the event that We buy or sell
any business or assets, We may disclose your personal information to the prospective buyer
or seller of such business assets.
9.4 The above principles apply whether We hold Your information on paper or in electronic
form. We will notify You of any changes to this section 9 of this Policy.
9.5 Enquiries in relation to data held by the data controller should be addressed to Group
Compliance Officer, Catlin Insurance Company (UK) Ltd., 20 Gracechurch Street, London
EC3V 0BG
RIGHTS OF THIRD PARTIES
You, the Policyholder and the Insurer are parties to this Plan, a person who is not a party to this Plan
has no right under the Contracts (Rights of Third Parties) Act 1999 to enforce any term of this Plan
but this does not affect any right or remedy of a third party which exists or is available apart from
that Act.
SANCTIONS
We shall not provide any benefit under this Plan to the extent of providing cover, payment of any
Claim or the provision of any benefit where doing so would breach any sanction, prohibition or
restriction imposed by law or regulation.
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