Accident Insurance Protection

Schedule of Benefits

Accidental Death and Dismemberment
Up to $25,000 for Gold, Silver & Bronze Plans

Accident Medical                                                                                                  
Gold Plan Accident Medical: $25,000 with a per occurrence deductible of $500                            
Silver Plan Accident Medical: $10,000 with a per occurrence deductible of $250                        
Bronze Plan Accident Medical: $2,500 with a per occurrence deductible of $100

Air Evacuation / Repatriation*: $4,000 for Gold, Silver & Bronze Plans

Assistance Services*:

*Provided by On-Call International

Accidental Death and Dismemberment

If accidental bodily injury causes the following losses within one year of the date of the accident which are not otherwise excluded, FSG* will pay the following benefits:

If an Insured Person suffers more than one loss under the Schedule of Benefits as the result of one Accident, FSG* will pay only the single largest Benefit Amount applicable.

Additional Benefits

Excess Accident Medical Expense                                                                                                                                                                                               

FSG* will pay up to the Medical Expense Benefit Amount shown above if the Insured Member suffers a Loss, requires medical care and treatment and incurs Medical Expenses.

Medical Expense means the Reasonable and Customary charges for Medical Services that are Medically Necessary for the care and treatment of Accidental Bodily Injuries sustained in a covered Accident.

Medically Necessary means any medical or dental service, supply or course of treatment which

1) is ordered or prescribed by a Physician or a dentist;

2) is appropriate and consistent with the patient’s diagnosis;       

3) is in accord with current accepted medical or dental practice; and

4) could not be eliminated without adversely affecting the patient’s condition or quality of medical or dental care.

Medical Services means the costs for the following Medically Necessary services:

1) medical care and treatment by a Physician or a dentist;

2) hospital room and board and hospital care, both inpatient and outpatient;

3) drugs and medicines prescribed by a Physician or a dentist;

4) diagnostic tests and x-rays;

5) use of a professional ambulance;

6) dental care due to injury of functional, natural teeth.

Other Plan means any: group medical plan; group blanket plan, governmental plan or program; or coverage provided or required by any law or statute, including automobile "fault " and "no-fault" coverage and Workers’ Compensation.

Reasonable and Customary means the lesser of:

1) the usual charge made by Physicians or other health care providers for a given service or supply; or

2) the charge we determine to be the prevailing charge made by Physicians or other health care providers for a given service or supply in the geographical area where it is furnished; or

3) the amount negotiated by the insurer and the health care provider.

The Medical Expense Benefit Amount is payable excess of any valid or collectable insurance. FSG* will determine the Reasonable and Customary charge for the covered Medical Expense. We will then reduce that amount by amounts already paid or payable by any Other Plan from which the Insured Person is entitled to receive benefits. FSG* will pay the resulting amount, plus amounts paid by the Insured Member to satisfy cash deductibles or coinsurance amounts. In no event will FSG* pay more than the benefit amount shown above.

If, as a result of the excess calculation a Benefit Amount is not payable under this Medical Expense coverage, FSG* will reimburse the Insured Person, any amount the Insured Member may have paid to satisfy cash deductibles, or coinsurance amounts. In no event will we pay more than the benefit amount shown above.

Exclusions

The Medical Expense Benefit does not apply to the following charges and services:

1) charges for which the Insured Member has no obligation to pay;

2) eyeglasses, contact lenses and other vision or hearing aids and artificial limbs;

3) any injury for which Worker’s Compensation benefits or occupational injury benefits are payable.

4) Sickness of any kind

5) Travel in or upon:
(a) A snowmobile;
(b) Any two or three wheeled motor vehicle;
(c) Any off‑road motorized vehicle not requiring licensing as a motor vehicle

This Medical Expense coverage applies only to Medically Necessary charges, as defined above.

Emergency Helicopter Rescue - for Gold plan members only

In the event that an eligible member suffers from a life threatening “certified injury” as a result of an accident that requires emergency medical transportation by helicopter in accordance with EMS protocols, the program will reimburse the participant or their provider up to a maximum of $4,000.00 per occurrence. Reimbursement includes expenses incurred from the cost of a “Medically Necessary” or “Life Threatening” situation for helicopter transportation from the scene of an accident to the nearest medical facility capable of treating the injuries, or from one medical facility to another medical facility. Claims for “Medically Necessary” transports from one medical facility to another medical facility are subject to review by Lifeguard’s Medical Officer. This benefit is only available with the gold plan.

Provisions

• One benefit will be paid per occurrence
• Benefit in excess of all other valid collectable insurance
• Coverage is worldwide
• Transportation by helicopter only

How To Use This Benefit
Call 911 or the local equivalent. Local EMS protocols will make the determination for necessity and type of medical transportation that best fits each situation.
To file a claim, please call Lifeguard at 800-446-7142. Certain terms and conditions apply.

THIS BENEFIT IS NOT AVAILABLE IN FLORIDA OR FOR RESIDENTS OF FLORIDA.

On-Call International Assistance Service

Maximum Limit of Insurance/Aggregate

A maximum limit of insurance of 5 lives applies per accident.

Exclusions

Loss caused by or resulting from, directly or indirectly, an Insured Person’s commission or attempted commission of any illegal act including but not limited to any felony.

Loss caused by or resulting from an Insured Person being intoxicated, as defined by laws of  the jurisdiction where the loss occurred, or under the influence of any narcotic unless taken on the advice of a Physician and used in accordance with the prescription.

Please note, that this is a description of coverage only. For a full review of the Plan’s benefits and exclusions, a copy of the full policy will be on file with the Association.

* Products underwritten by: Fairmont Premier Insurance Company & Fairmont Specialty Insurance Company under the management of Fairmont Specialty Group. Fairmont Specialty group is a division owned and operated by Crum and Forster Holding, Inc, a wholly owned, indirect subsidiary of Fairfax Financial Holdings, Limited.

Please note that Fairmont’s “Privacy Policy & Practices” and “Grievance Procedures” apply to the Plan You have purchased. If You would like to receive a copy of this information, please contact Coordinated Benefit Plans

 *Crum and Forster, based in Morristown, New Jersey, is a national commercial property and casualty insurance company in the United States, writing a broad range of commercial coverages.  Since January 1, 2006 the specialty niche property and caualty and accident and health insurance is being carried on as the Fairmont Specialty division of Crumb and Forster. 

Crum and Forster is rated “A- (Excellent)” according to A.M. Best.
Financial size category: XIII (1.25 billion to 1.5 billion)