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VISIT® Travel & Medical Insurance Program
for International Students, Scholars, Spouses, Families and Visitors
 
 
 
Incoming to USA Schedule of Coverage

Please review the Plans carefully!  Coverage and Plan options have been Updated.
Coverage Economy 100 Economy 250 Standard 100 Standard 250 Super 
100
 Super 
250
 Plan E-Plus
 Plan "S"
Accident & Sickness Medical  Maximums - Per Injury or Illness

 Student
$100,000
 Age 12-49

$50,000 
 Age 50-64
Spouse/Child
$50,000
Spouse
$25,000
 Age 50-64		 Student
$250,000
 Age 12-49

$100,000
 Age 50-64
Spouse/Child
$50,000
Spouse
$25,000
 Age 50-64		 Student
$100,000
 Age 12-49

$50,000 
 Age 50-64

 Spouse/Child
 $50,000
Spouse
$25,000
 Age 50-64		 Student
$250,000
 Age 12-49

$100,000
 Age 50-64

 Spouse/Child
 $50,000
Spouse
$25,000
 Age 50-64		 Student
$100,000
 Age 12-49

$50,000 
 Age 50-64
Spouse/Child
$50,000
Spouse
$25,000
 Age 50-64		 Student
$250,000
 Age 12-49

$100,000
 Age 50-64
Spouse/Child
$50,000
Spouse
$25,000
 Age 50-64		 Student, Scholar, Family, Visitor
$100,000
Age 0-69

$50,000
 Age 70-79		 Student only
$100,000
17-26, inclusive
Lifetime Maximum $1,000,000 per Student
$100,000 Spouse/Child		 $1,000,000 per Student
$100,000 Spouse/Child		 $1,000,000 per Student
$100,000 Spouse/Child		 $100,000 Age 0-69
$50,000 Age 70-79		 $100,000
Deductible -  Per Injury or Illness $50 
Student Health
$100 Non-Student Health 		 $50 
Student Health
$100 Non-Student Health 		 $50 
Student Health
$100 Non-Student Health 		 $50 
Student Health
$100 Non-Student Health 		 $50 Student Health
$100 Non-Student Health 		 $50 Student Health
$100 Non-Student Health 		 $100 per policy period $100 Annual
Prescription Drugs: Covered as any other covered Injury or Illness Covered as any other covered Injury or Illness Covered as any other covered Injury or Illness Covered as any other covered Injury or Illness Covered as any other covered Injury or Illness Covered as any other covered Injury or Illness Covered as any other covered Injury or Illness

Prescription Deductible per script:

Prescription Coinsurance per script:

$0 per script

100% up to policy maximum per script

$0 per script

100% up to policy maximum per script

$0 per script

100% up to policy maximum per script

$0 per script

100% up to policy maximum per script

$0 per script

100% up to policy maximum per script

 

$0 per script

100% up to policy maximum per script

  
Coinsurance 80% to $10,000, then 100% to Plan Maximum 80% to $10,000, then 100% to Plan Maximum 80% to $5,000, then 100% to Plan Maximum 80% to $5,000, then 100% to Plan Maximum 80% to $5,000, then 100% to Plan Maximum 80% to $5,000, then 100% to Plan Maximum 80% to $5,000, then 100% to Plan Maximum
Benefit Period Covered Expenses incurred during the benefit period Covered Expenses incurred during the benefit period Covered Expenses incurred during the benefit period Covered Expenses incurred during the benefit period Covered Expenses incurred during the benefit period Covered Expenses incurred during the benefit period Covered Expenses incurred during the benefit period
Maternity Up to $10,000 per Policy Year Up to $10,000 per Policy Year Up to $10,000 per Policy Year Up to $10,000 per Policy Year Covered as any other illness Covered as any other illness NO COVERAGE
Mental Illness per Lifetime
Inpatient:		 Payable at 50% to $10,000, to a max. of 40 days Payable at 50% to $10,000, to a max. of 40 days Payable at 50% to $10,000, to a max. of 40 days Payable at 50% to $10,000, to a max. of 40 days Payable at 50% to $10,000, to a max. of 40 days Payable at 50% to $10,000, to a max. of 40 days NO COVERAGE
Mental Illness per Lifetime
Outpatient:		 Payable at 80% up to max. of $500 Payable at 80% up to max. of $500 Payable at 80% up to max. of $500 Payable at 80% up to max. of $500 Payable at 80% up to max. of $500 Payable at 80% up to max. of $500 NO COVERAGE
Alcohol & Drug Abuse per Lifetime
Inpatient/Outpatient		 Payable at 50% up to $1000 Payable at 50% up to $1000 Payable at 50% up to $1000 Payable at 50% up to $1000 Payable at 50% up to $1000 Payable at 50% up to $1000 NO COVERAGE
Injuries from a Motor Vehicle Accident $10,000 per policy period $10,000 per policy period $10,000 per policy period $10,000 per policy period Up to Policy Maximum Up to Policy Maximum Up to Policy Maximum
Sports-related Injuries (non-interscholastic sports) $10,000 per policy period $10,000 per policy period $10,000 per policy period $10,000 per policy period $10,000 per policy period $10,000 per policy period Up to Policy Maximum
Hazardous Sports Coverage as listed $10,000 per policy period $10,000 per policy period $10,000 per policy period $10,000 per policy period $10,000 per policy period $10,000 per policy period Must Choose Hazardous Sports Option
Dental (Emergency) $250 per tooth to a max. of $500 per policy period $250 per tooth to a max. of $500 per policy period $250 per tooth to a max. of $500 per policy period $250 per tooth to a max. of $500 per policy period $250 per tooth to a max. of $500 per policy period $250 per tooth to a max. of $500 per policy period $100 per tooth to a max. of $500
Emergency Medical Evacuation $100,000 per policy period $100,000 per policy period $100,000 per policy period $100,000 per policy period $100,000 per policy period $100,000 per policy period Up to $100,000
Repatriation of Mortal Remains $25,000 per policy period $25,000 per policy period $25,000 per policy period $25,000 per policy period $25,000 per policy period $25,000 per policy period Up to $25,000
Emergency Reunion $5000 per policy period $5000 per policy period $5000 per policy period $5000 per policy period $5000 per policy period $5000 per policy period Up to $25,000
Accident, Death & Dismemberment $10,000 per Student
$5000 per Spouse/Child		 $10,000 per Student
$5000 per Spouse/Child		 $10,000 per Student
$5000 per Spouse/Child		 $10,000 per Student
$5000 per Spouse/Child		 $10,000 per Student
$5000 per Spouse/Child		 $10,000 per Student
$5000 per Spouse/Child		 $25,000 per Insured/Spouse
$5000 per Dependent Child
Home Country Coverage -Incidental Trips to the Insured's Home Country 30 days of coverage up to a max. of $25,000 per policy period 30 days of coverage up to a max. of $25,000 per policy period 30 days of coverage up to a max. of $25,000 per policy period 30 days of coverage up to a max. of $25,000 per policy period 30 days of coverage up to a max. of $25,000 per policy period 30 days of coverage up to a max. of $25,000 per policy period 60 days per 12 months of coverage up to $50,000
Home Country Coverage Extension of Benefits Up to $5000, expenses must be incurred within 30 days of returning to your Home Country Up to $5000, expenses must be incurred within 30 days of returning to your Home Country Up to $5000, expenses must be incurred within 30 days of returning to your Home Country Up to $5000, expenses must be incurred within 30 days of returning to your Home Country Up to $5000, expenses must be incurred within 30 days of returning to your Home Country Up to $5000, expenses must be incurred within 30 days of returning to your Home Country Up to $5000, expenses must be incurred within 30 days of returning of Your Home Country
Pre-existing Conditions
12 months prior to Effective Date, waived after 12 consecutive months of coverage		 Yes Yes Yes Yes Yes Yes NO COVERAGE no coverage
Return of Minor Children NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE Up to $10,000
Interruption of Trip NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE Up to $5000
Loss Baggage NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE NO COVERAGE Up to $250
Assistance 24-Hour - Worldwide 24-Hour - Worldwide 24-Hour - Worldwide 24-Hour - Worldwide 24-Hour - Worldwide 24-Hour - Worldwide 24-Hour -
Worldwide

Eligibility

Student- The Student rate is open to International Students, visiting Faculty, Scholars, or other persons over the age of twelve (12) up to and including age sixty-four (64), who are temporarily residing outside their Home Country. The Insured must remain engaged in educational or research activities outside their Home Country during the Period of Coverage.

Spouse-An eligible spouse shall be defined as the Primary Insured’s legal spouse up to and including age sixty-four (64). 

Child-An Eligible Dependent Child shall mean the Primary Insured Person’s unmarried children over thirty (30) days and under nineteen (19) years of age or under twenty-five (25) years of age if they are attending an accredited institution of higher learning on a regular full-time basis and/or wholly dependent upon the Insured Person for maintenance and support.

A Student must be the primary insured in order for the Spouse and Child to be eligible for PLANS E100, E250, STD100, STD250, SPR100 and SPR250.

What is Covered?

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 Illness which occurred during the Period of Coverage outside your Home Country (except as provided under the Home Country Coverage).  The initial Treatment of an Injury or Illness must occur within thirty (30) days of the date of Injury or onset of Illness.

Only such expenses which are specifically enumerated in the following list of charges that are incurred within the Benefit Period, 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 semiprivate 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, to a maximum of $500, if recommended by a Physician for the Treatment of a specific Disablement following hospitalization and administered by a licensed physiotherapist.

  9. Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or Surgeon.

  10. 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 ground ambulance only to a limit of $350, within the metropolitan area in which you are located at that time the service is used.  If you are in a rural area, then licensed air ambulance transportation to the nearest metropolitan area shall be considered a Covered Expense.

Pre-notification: For each scheduled hospital admission, emergency hospital confinement, or Outpatient Treatment, you or someone on your behalf must contact the Assistance Company for pre-notification as soon as possible, but no later than forty-eight (48) hours prior to the admission to the hospital, the hospital confinement or Outpatient Treatment.  For emergency hospital confinement, you or someone on your behalf must notify the Assistance Company as soon as possible, but not later than forty-eight (48) hours after the date of admission.  Pre-notification does not guarantee or confirm benefits or the payment of said benefits.

Maternity: When covered maternity expenses are incurred by you or your eligible dependents, the Company will pay Reasonable Charges for medical expenses in excess of the Deductible and Coinsurance.  In no event shall the Company’s maximum liability exceed the maximum stated in the Schedule of Benefits, as to Covered Expenses during any one period of individual coverage.

You or your representative must notify the Company of a Pregnancy within the first trimester.   

As stated in the Schedule of Benefits, benefits will be payable for Covered Expenses you incur before, during, and after delivery of a child, including physician, hospital, laboratory, and ultrasound services.  Coverage for the Inpatient postpartum stay for you and your newborn child in a hospital, will, at a minimum, be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their guidelines for perinatal care.  

Coverage for a length of stay shorter than the minimum period mentioned above may be permitted if your attending physician determines further Inpatient postpartum care is not necessary for you or your newborn child provided the following are met:

1.       In the opinion of your attending physician, the newborn child meets the criteria for medical stability in the guidelines for perinatal care prepared by the Academy of Pediatrics and the American College of Obstetricians and Gynecologists that determine the appropriate length of stay based upon the evaluation of:

a.       The antepartum, intrapartum, postpartum course of the mother and infant;

b.       The gestational stage, birth weight, and clinical condition of the infant;

c.        The demonstrated ability of the mother to care for the infant after discharge; and

d.       The availability of post discharge follow-up to verify the condition of the infant after discharge; and

2.       One (1) at-home post delivery care visit is provided to you at your residence by a physician or nurse performed no later than forty-eight (48) hours following discharge for you and your newborn child from the hospital.  Coverage for this visit includes, but is not limited to:

a.       Parent education;

b.       Assistance and training in breast or bottle feeding; and

Performance of any maternal or neonatal tests routinely performed during the usual course of Inpatient care for you or your newborn child, including the collection of an adequate sample for the hereditary and metabolic newborn screening.  (At your discretion, this visit may occur at the physician’s office.)  

Mental Illness:  Benefits are paid for Treatment or medication for Mental Illness, which are not excluded and covered under this policy, and shall be considered a Covered Expense:

Inpatient Care – Shall be payable at 50% to $10,000, subject to a maximum of forty (40) days of Inpatient care.

Outpatient – Shall be payable at 80% up to a maximum of $500.  

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, and shall be considered a Covered Expense.  Benefits shall be payable at 50% up to $1,000.

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.

Emergency Medical Evacuation and Repatriation

Benefits are paid for Covered Expenses incurred up to the maximum as stated in the Schedule of Benefits, for any covered Injury or Illness 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 the Assistance Company in consultation with your local attending Physician.  

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 the Assistance Company 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 the Assistance Company.
Emergency Medical Reunion
When the Assistance Company and your attending Physician determine that it is necessary and prudent for you to have an Emergency Medical Evacuation or Repatriation, this Plan will arrange to bring an individual of your choice, from your current Home Country, to be at your side while you are hospitalized and then accompany you during your return to your current Home Country.  Benefits will be paid up to the maximum as stated in the Schedule of Benefits for a round-trip economy airfare ticket as well as for reasonable travel and accommodation expenses up to a maximum of ten (10) days, as pre-approved and arranged by the Assistance Company.
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%
Hazardous Sports Coverage

This Plan shall pay up to the maximum as stated in the Schedule of Benefits for Injury which occurs while You are participating in one of the following hazardous sports: snow skiing or snowboarding.

Underwritten by Virginia Surety Company, Inc. (VSC), rated A- “Excellent” by A.M. Best.  The VSC Master Policies are filed under form numbers IN/OUT-EOC (01/2004) and Liability AIFS LIAB (IL 09/98R).

Incoming to the USA Forms and Applications:

Apply Online or by Phone or Fax

Incoming Application -  (.pdf format)

 Click Here for Premium Information

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VISIT Travel & Medical Insurance Program, an Insurance program of PENTECO, LLC
www.visitinsurance.com
Correspondence: P.O. Box 210, Mount Vernon, VA  22121 (703) 660-9062/ (800) 247-5575/ (703) 991-9164 fax
email:  info@visitinsurance.com

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