Expert AuPair

2022-2023 Plan Brochure

PGTAI00523006
Using Your Insurance
If you need to seek medical treatment, please be sure to seek care
appropriately for the condition/situation that you are experiencing, as this will Student Zone
make the billing and payment process much smoother. Here are some The Student Zone is your one-stop
guidelines for choosing appropriate medical care. resource for information, advice
and assistance with your insurance
Non-Emergency Care plan.
For immediate care in non-emergency situations, you SHOULD go
to a Walk-in Clinic, Urgent Care center or local doctor. Urgent Care
and Walk-in Clinics are often the best places to seek medical care Student Zone
as you can walk right in and they require no appointment.

You SHOULD NOT go to the Emergency Room (ER) for this type of
care unless it is a real emergency situation!

24-Hour Assistance
IMG are available 24-hours a day
Emergency Care to assist you with your insurance
needs, including pre-certi cation,
The Emergency Room (ER) is designed for medical emergencies. claims, emergency evacuation and
If you need emergency care for any reason, please get to the much more.
nearest Emergency Room (ER) or call the emergency services
(911 in the USA) for immediate treatment.
You can contact IMG at:
PLEASE NOTE – an additional $250 Deductible will apply for each
Emergency Room visit for an illness which does not result in a
direct Hospital admission. Injuries are not subject to the Toll-free: (855) 731-9445
deductible. Direct Dial: + 1 (317) 927-6806
[email protected]

ID Card
It is extremely important that you carry your insurance ID card with
you at all times and make sure to show it when you seek treatment.
Your ID card will be emailed to you before you travel and should be
kept with you at all times.

Doctor/Hospital Search
You have the freedom of choice to visit any provider you wish,
however you are strongly encouraged to visit medical providers
who are part of the insurance plan network, especially in the USA
This will allow direct billing and can remove the need for you to pay
up front for medical expenses.

• Inside the USA, you can search for a network provider

online.
• Outside the USA, you can seek treatment from any provider
of your choices, pay up front and then le a claim for
reimbursement.
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Bene t Summary
Plan Bene ts Coverage
Period of Coverage limit $100,000
Deductible $0
Coinsurance In-Network: After the deductible, the plan pays 100% of eligible
expenses, up to the maximum limit.

Out-of-Network: After the deductible, the plan pays 80% of eligible

expenses, up to the maximum limit. Out-of-pocket maximum: $1,000
Area of Coverage Worldwide excluding the Insured Person’s Country of Residence
Inpatient and Outpatient Services
NOT Subject to the deductible; Subject to coinsurance - unless stated
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Eligible Medical Expenses In-Network: 100% coverage / Out-of-Network: 80% coverage
Physician Visits / Services In-Network: 100% coverage / Out-of-Network: 80% coverage
Urgent Care / Walk-in-Clinic In-Network: 100% coverage / Out-of-Network: 80% coverage
Hospital Emergency Room In-Network: 100% coverage / Out-of-Network: 80% coverage
(Illness with no direct hospital admission subject to $250 deductible,
injuries not subject to additional deductible)
Hospitalization / Room & Board In-Network: 100% coverage / Out-of-Network: 80% coverage
Average semi-private room rate, includes nursing services, miscellaneous and
ancillary services

Intensive Care In-Network: 100% coverage / Out-of-Network: 80% coverage

Bedside Visit $1,500 maximum limit
Hospitalized in an Intensive Care Unit In-Network: 100% coverage / Out-of-Network: 80% coverage
Outpatient Surgical / Hospital Facility In-Network: 100% coverage / Out-of-Network: 80% coverage
Laboratory In-Network: 100% coverage / Out-of-Network: 80% coverage
Radiology / X-ray In-Network: 100% coverage / Out-of-Network: 80% coverage
Chemotherapy / Radiation Therapy In-Network: 100% coverage / Out-of-Network: 80% coverage
Pre-admission Testing In-Network: 100% coverage / Out-of-Network: 80% coverage
Surgery In-Network: 100% coverage / Out-of-Network: 80% coverage
Reconstructive Surgery In-Network: 100% coverage / Out-of-Network: 80% coverage
Surgery that is incidental to and follows surgery
that was covered under the plan

Assistant Surgeon In-Network: 100% coverage / Out-of-Network: 80% coverage

20% of the primary surgeon’s eligible fees

Anesthesia In-Network: 100% coverage / Out-of-Network: 80% coverage

Durable Medical Equipment In-Network: 100% coverage / Out-of-Network: 80% coverage
Chiropractic Care In-Network: 100% coverage / Out-of-Network: 80% coverage
Medical order or treatment plan required

Physical Therapy In-Network: 100% coverage / Out-of-Network: 80% coverage

Medical order or treatment plan required

Extended Care Facility In-Network: 100% coverage / Out-of-Network: 80% coverage

Upon direct transfer from an acute care facility

Home Nursing Care In-Network: 100% coverage / Out-of-Network: 80% coverage

Provided by a Home Health Care Agency
Upon direct transfer from an acute care facility
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Prescription Drugs and Medication 80% coverage
Dispensing limit per prescription: 90 days

Emergency Services
Not Subject to the deductible and coinsurance - unless stated
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Emergency Local Ambulance In-Network: 100% coverage / Out-of-Network: 80% coverage
Subject to coinsurance Illness resulting in an inpatient hospital admission
Injury

Emergency Medical Evacuation $1,000,000 maximum limit

Approved in advance and coordinated by the
company

Emergency Reunion $100,000 maximum limit

Approved in advance by the company Maximum days: 15
Meal maximum per day: $25
Reasonable and necessary travel costs and accommodations

Interfacility Ambulance Transfer 100% coverage

Transfer must be a result of an inpatient hospital admission

Natural Disaster Evacuation $25,000 maximum limit

Approved in advance by the company

Political Evacuation & Repatriation $100,000 maximum limit

Approved in advance by the company

Return of Minor Children $100,000 maximum limit

Approved in advance by the company

Return of Mortal Remains Up to the Period of Coverage limit

Approved in advance by the company Local Burial/Cremation: $5,000 maximum limit
Return of Insured Person’s Mortal Remains to Country of Residence
Other Services
Not Subject to the deductible and coinsurance - unless stated
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as maximum limit
Accidental Death & Dismemberment $50,000 Principal Sum
Death must occur within 90 days of the Accident
Common Carrier Accidental Death Maximum Limit per adult: $100,000
Dental Treatment 80% coverage
Subject to coinsurance Maximum Limit: $300
Unexpected pain or treatment due to an accident

Traumatic Dental Injury In-Network: 100% coverage / Out-of-Network: 80% coverage

Subject to coinsurance Treatment at a hospital due to an accident

Emergency Eye Examination 80% coverage

Subject to coinsurance Maximum Limit: $150
Deductible per Occurrence: $50
Loss or damage to prescription corrective lenses due to accident

Hospital Indemnity Overnight limit: $250

Maximum Nights: 10
Outside insured person’s country of residence and the United States
Inpatient Hospitalization only
Identity Theft Maximum Limit: $500

Incidental Trip Maximum days: 14

Insured person’s country of residence is not the United States

Lost Luggage Limit $500 / $50 per item

Natural Disaster Limit per day: $250 / Maximum Days: 5

Personal Liability Combined Maximum Limit: $25,000

Secondary to any other insurance Injury to third person deductible: $100 per injury
No coverage for injury to a related third party or
Damage to third person’s property: $100 per damage deductible
damage to related third person’s property
 Pet Return Limit: $1,000
For a pet cat or dog traveling with the insured person

Small Pet Common Air Carrier Limit: $500

Accidental Death Bene t For a pet cat or dog up to 30 pounds traveling with the insured person

Terrorism Maximum Limit: $50,000

Trip Interruption Maximum Limit: $10,000

PRE-CERTIFICATION: The following must always be Pre-certi ed for Medical Necessity by the Company through the
Plan Administrator before admission or receiving the Treatments and/or supplies: (a) Chemotherapy (b) Extended Care
Facility (c) Home Nursing Care (d) Inpatient Hospitalization (e) Interfacility Ambulance Transfer (f) Radiation Therapy (g)
Surgery or Surgical procedure.

Eligibility: If an Insured Person is not eligible, this Certi cate is void ab initio and all Premium paid will be refunded. In
order to be eligible and quali ed for coverage under this insurance, a person must meet all of the following
requirements:

1. complete and sign an Application as the Insured Person (or be listed thereon by proxy as an applicant and
proposed Insured Person), and/or as the Insured Person’s Spouse, Child and/or Grandchild
2. pay the required Premium on or before the Effective Date of Coverage
3. receive written acceptance of his/her Application, renewal or extension from the Company
4. be an individual at least fourteen (14) days old
5. on the Effective Date and on subsequent renewal dates, must have legally departed the Country of
Residence and legally entered the Destination Country
6. not be Pregnant, Hospitalized or Disabled on the Initial Effective Date
7. not be HIV + on the Initial Effective Date
8. not have established a permanent residency in the Destination Country

Claims
Inside the USA Claim Forms
If you sought treatment from an in-network provider, and You can download a copy of the claim form from the
provided your insurance ID card at the time of treatment, Student Zone and submit it with your receipts to:
they should be able to bill the IMG claims team directly Email - [email protected] (recommended)
with no payment up front.
Fax: (+1) 317 655 4505
PLEASE NOTE - After seeking treatment, even if you are
not required to pay up front, please complete a claim International Medical Group
form and email these documents to the claims email for Claims Department
processing. P.O. Box 9162
Farmington Hills, MI 48333-9162 USA

Outside the USA

When outside the USA, please seek treatment from a
Claims Update
provider that is nearest to you, pay for the services Your claims tracking portal, MyIMG, is available in your
upfront and then submit a claim for reimbursement. Student Zone and allows you to view your claims activity
and contact the claims team directly with any questions.

Prescription Medications You can also email the claims team at

You will need to pay for any prescription medication up [email protected] for an update on any
front and then submit the Rx information and receipt from claims that have been submitted.
the pharmacy with your claim to be reimbursed.
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 Exclusions
Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by the
Insured Person, and any claim for death or dismemberment bene ts, and directly or indirectly relating to or arising or
resulting from or in connection with any of the following acts, omissions, events, conditions, Charges, consequences,
claims, Treatment (including diagnoses, consultations, tests, examinations and evaluations related thereto), services
and/or supplies are expressly excluded from coverage under this insurance, and the Company shall provide no bene ts
or reimbursements and shall have no liability or obligation for any coverage thereof or therefor:

1. Economic Sanctions 13. required or recommended as a result of complications

2. War, Military Action or consequences arising from or related to any
3. Terrorism Treatment, Illness, Injury, or supply received prior to
4. Pre-existing conditions: Charges resulting directly or coverage under this insurance or that is excluded from
indirectly from or relating to any Pre-existing Condition are coverage or which is otherwise not covered under this
excluded from coverage under this insurance. insurance
5. Maternity and newborn care : Charges for pre-natal care, 14. for Congenital Disorders and conditions arising out of
delivery, post-natal care, and care of Newborns, including or resulting therefrom
complications of Pregnancy, miscarriage, complications of 9. Charges incurred for failure to keep a scheduled
delivery and/or of Newborns are excluded from this appointment
insurance. 10. Charges incurred for Surgeries, Treatment or supplies
6. Mental or nervous disorders: Charges for Treatment of which are Investigational, Experimental and for research
Mental or Nervous Disorders are excluded from coverage purposes
under this insurance. 11. Charges incurred related to genetic medicine, genetic
7. Preventative Care: Charges for Routine Physical testing, surveillance testing and/or wellness screening
Examinations and immunizations are excluded from procedures for genetically predisposed conditions
coverage under this insurance. indicated by genetic medicine or genetic testing, including,
8. Charges for any Treatment or supplies that are: but not limited to amniocentesis, genetic screening, risk
1. not incurred, obtained or received by an Insured assessment, preventive and prophylactic surgeries
Person during the Period of Coverage recommended by genetic testing, and/or any procedures
2. not presented to the Company for payment by way of a used to determine genetic pre-disposition, provide genetic
completed Proof of Claim within one hundred eighty counseling, or administration of gene therapy
(180) days from the date such Charges are incurred 12. Charges incurred for testing that attempts to measure
3. not administered or ordered by a Physician aspects of an Insured Person’s mental ability, intelligence,
4. not Medically Necessary for the diagnosis, care or aptitude, personality and stress management. Such testing
Treatment of the physical condition involved. This also may include but is not limited to psychometric, behavioral
applies when and if they are prescribed, and educational testing
recommended or approved by the attending Physician 13. Charges incurred for Custodial Care
5. provided at no cost to the Insured Person or for which 14. Charges incurred for Educational or Rehabilitative Care that
the Insured Person is not otherwise liable speci cally relates to training or retraining an Insured
6. in excess of Usual, Reasonable and Customary Person to function in a normal or near-normal manner. Such
7. related to Hospice Care care may include but is not limited to job or vocational
8. incurred by an Insured Person who was HIV + on or training, counseling, occupational therapy and speech
before the Initial Effective Date of this insurance, therapy
whether or not the Insured Person had knowledge of 15. Charges for weight modi cation or any Inpatient,
his/her HIV status prior to the Effective Date, and Outpatient, Surgical or other Treatment of obesity (including
whether or not the Charges are incurred in relation to without limitation morbid obesity), including without
or as a result of said status. This exclusion includes limitation wiring of the teeth and all forms or procedures of
Charges for any Treatment or supplies relating to or bariatric Surgery by whatever name called, or reversal
arising or resulting directly or indirectly from HIV, AIDS thereof, including without limitation intestinal bypass,
virus, AIDS related Illness, ARC Syndrome, AIDS and/ gastric bypass, gastric banding, vertical banded
or any other Illness arising or resulting from any gastroplasty, biliopancreatic diversion, duodenal switch, or
complications or consequences of any of the foregoing stomach reduction or stapling
conditions 16. Charges for modi cation of the physical body in order to
9. provided by or at the direction or recommendation of a change or improve or attempt to change or improve the
chiropractor, unless ordered in advance by a Physician physical appearance or psychological, mental or emotional
10. performed or provided by a Relative of the Insured well-being of the Insured Person (such as but not limited to
Person sex-change Surgery or Surgery relating to sexual
11. not expressly included in the ELIGIBLE MEDICAL performance or enhancement thereof)
EXPENSES provision 17. Charges or Treatment for cosmetic or aesthetic reasons,
12. provided by a person who resides or has resided with except for reconstructive Surgery when such Surgery is
the Insured Person or in the Insured Person's home Medically Necessary and is directly related to and follows a
Surgery which was covered under this insurance
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 18. elective Surgery or Treatment of any kind 31. any Injury or Illness sustained as a result of being under the
19. Charges incurred for any Treatment or supply that either in uence of or due wholly or partly to the effects of alcohol,
promotes or prevents or attempts to promote or prevent liquor, intoxicating substance, narcotics or drugs other than
conception, insemination (natural or otherwise) or birth, drugs taken in accordance with Treatment prescribed and
including but not limited to: arti cial insemination; oral directed by a Physician but not for the Treatment of
contraceptives; Treatment for infertility or impotency; Substance Abuse
vasectomy; reversal of vasectomy; sterilization; reversal of 32. any Injury or Illness sustained while operating a moving
sterilization; surrogacy or abortion vehicle after consumption of intoxicating liquor or drugs in
20. Charges incurred for any Treatment or supply that either excess of the applicable blood/alcohol legal limit, other
promotes, enhances or corrects or attempts to promote, than drugs taken in accordance with Treatment prescribed
enhance or correct impotency or sexual dysfunction and directed by a Physician. For purposes of this
21. any Illness or Injury sustained while taking part in, exclusion, “vehicle” shall include motorized devices
practicing or training for: Amateur Athletics; Professional regardless of whether or not a driver or operator license is
Athletics; or athletic activities that are sponsored by any required (including watercraft and aircraft) and non-
Governing Body or Authority, including but not limited to the motorized bicycles and scooters for which no permit or
National Collegiate Athletic Association, any other license is required
collegiate sanctioning or Governing Body or the 33. any willfully Self-in icted Injury or Illness
International Olympic Committee 34. any sexually transmitted or venereal disease
22. any Illness or Injury sustained while taking part in activities 35. any testing for the following when not Medically Necessary:
designated as Adventure Sports, which are limited to the HIV, seropositivity to the AIDS virus, AIDS-related Illnesses,
following: abseiling; BMX; bobsledding; bungee jumping; ARC Syndrome, AIDS
canyoning; caving; hot air ballooning; jungle zip lining; 36. any Illness or Injury resulting from or occurring during the
parachuting; paragliding; parascending; rappelling; commission of a violation of law by the Insured Person,
skydiving; spelunking; wildlife safaris; and windsur ng including, without limitation, the engaging in an illegal
23. any Illness or Injury sustained while taking part in activities occupation or act, but excluding minor traf c violations
designated as Extreme Sports, which include but are in no 37. any Substance Abuse
way limited to the following (and include any combination 38. biofeedback, acupuncture, music, occupational,
or derivative of the following): BASE jumping; cave diving; recreational, sleep, speech, or vocational therapy
cliff diving; downhill mountain biking and racing; extreme 39. orthoptics, visual therapy or visual eye training
skiing; freediving; free ying; free running; free skiing; 40. any non-surgical Illness or Treatment of the feet, including
freestyle scootering; gliding; heli-skiing; ice canoeing; ice without limitation: orthopedic shoes; orthopedic
climbing; kitesur ng; mixed martial arts; motocross; prescription devices to be attached to or placed in shoes;
motorcycle racing; motor rally; mountaineering above Treatment of weak, strained, at, unstable or unbalanced
elevation of 4500 meters from ground level; parkour; feet; metatarsalgia, bone spurs, hammer toes or bunions;
piloting a commercial or non-commercial aircraft; and any Treatment or supplies for corns, calluses or
powerbocking; scuba diving or sub aqua pursuits below a toenails; except as otherwise expressly set forth
depth of 50 meters; snowmobile racing; truck racing; 41. hair loss, including without limitation wigs, hair transplants
whitewater kayaking or whitewater rafting Class VI and or any drug that promises to promote hair growth, whether
higher dif culty; and wingsuit ying or not prescribed by a Physician
24. any Illness or Injury sustained while taking part in snow 42. any sleep disorder, including without limitation sleep apnea
skiing, snowboarding or snowmobiling where the Insured 43. any exercise and/or tness program or equipment, whether
Person is in violation of applicable laws, rules or regulations or not prescribed or recommended by a Physician
of a ski resort, out of bounds or in unmarked or unpatrolled 44. any exposure to any non-medical nuclear or atomic
areas radiation, and/or radioactive material(s)
25. any Illness or Injury sustained while taking part in 45. any organ or tissue or other transplant or related services,
backcountry skiing Treatment or supplies
26. any Illness or Injury sustained while taking part in skiing off- 46. any arti cial or mechanical devices designed to replace
piste human organs temporarily or permanently after termination
27. any Illness or Injury sustained while taking part in Collision of Inpatient status
Sports 47. any efforts to keep a donor alive for a transplant procedure
28. any Illness or Injury sustained while taking part in athletic or 48. any Illness or Injury incurred in the Destination Country,
recreational activities where the Insured Person is not Affected Area or Country of Residence as a result of a
physically or medically t or does not hold the necessary Public Health Emergency of International Concern,
quali cations to engage in said activities Epidemic, Pandemic, other disease outbreak, or Natural
29. any Illness or Injury sustained while participating in any Disaster, that may affect an Insured Person’s health, unless
sporting, recreational or adventure activity where such coverage is expressly provided under the PUBLIC HEALTH
activity is undertaken against the advice or direction of any EMERGENCY provision of this insurance. This exclusion
local authority or any quali ed instructor or contrary to the DOES NOT apply to Charges resulting from COVID-19/
rules, recommendations and procedures of a recognized SARS-CoV-2
Governing Body for the sport or activity 49. Charges incurred for eyeglasses, contact lenses, hearing
30. any Illness or Injury sustained while participating in any aids or hearing implants and Charges for any Treatment,
activity where such activity is undertaken in disregard of or supply, examination or tting related to these devices, or for
against the recommendations, Treatment programs, or eye refraction for any reason, except as otherwise
medical advice of a Physician or other healthcare provider expressly provided for hereunder
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 50. Charges incurred for eye Surgery, such as but not limited to 58. any infection of the urinary tract (including, without
radial keratotomy when the primary purpose is to correct or limitation, infection of the kidney, ureter, bladder, prostate or
attempt to correct nearsightedness, farsightedness, or urethra) and any complication, medical condition or other
astigmatism Illness directly or indirectly arising therefrom, that occurs
51. Charges incurred for Treatment or supplies for within ninety (90) days of the Effective Date of this
temporomandibular joint (TMJ) including but not limited to Insurance and that requires Treatment of the Insured
TMJ syndrome, craniomandibular syndrome, chronic TMJ Person in a Hospital as an Inpatient
pain, orthognathic Surgery, Le-Fort Surgery or splints 59. Charges and all costs related to or arising from or in
52. Charges incurred in the Insured Person’s Country of connection with all trips to the Destination Country
Residence, except as otherwise expressly provided for in undertaken for the purpose of securing medical Treatment
this insurance or supplies
53. Charges incurred for any travel, meals, transportation and/ 60. Charges incurred for Dental Treatment, except as
or accommodations, except as otherwise expressly speci cally provided for hereunder
provided for in this insurance 61. Wear and tear of teeth due to cavities and chewing or
54. Charges or expenses incurred for nonprescription drugs, biting down on hard objects, such as but not limited to
medicines, vitamins, food extracts, or nutritional pencils, ice cubes, nuts, popcorn, and hard candies
supplements; IV vitamin or herbal therapy; drugs or 62. Dental Injury without associated face, skull, neck and/or
medicines not approved by the United States Food and jaws Injury or that can be evaluated and Treated in a dental
Drug Administration or which are considered “off-label” of ce
drug use; and for drugs or medicines not prescribed by a 63. Dental Treatment for services which provide oral care
Physician maintenance including tooth repair by llings, root canals,
55. any Treatment for an Illness or Injury requiring an tooth removal and x-rays
unapproved U.S. Food and Drug Administration (FDA) 64. Charges for Treatment of an Illness or Injury for which
medical product, services, Surgery, Surgical Procedure, payment is made or available through a workers'
prescription medication, drug, biological product, Durable compensation law or a similar law
Medical Equipment (DME) or device when an Emergency 65. Charges incurred for massage therapy
Use Authorization (EUA) is in place issued by the U.S. Food 66. Charges incurred for Personal Liability legal fees or out-of-
and Drug Administration (FDA) pocket costs associated and/or related to the determination
56. Charges incurred at a Hospital or Facility when the Insured and/or settlement of a legal liability
Person checks himself or herself out Against Medical 67. Accidental Death or Dismemberment when the Insured
Advice of their Physician and leaves before reaching a Person’s death or dismemberment is caused directly or
Medically Necessary speci ed endpoint of Treatment indirectly by, results from, or where there is a contribution
57. Charges incurred for the Worsening of an Illness or Injury from, any of the following:
after the Insured Person left a Hospital or Facility Against 1. bodily or mental in rmity, Illness or disease
Medical Advice or was a Discharge Against Medical 2. infection, other than infection occurring simultaneously
Advice with, and as a direct result of, the accidental Injury.

PLEASE NOTE: This document is being provided for informational purposes only and does not supersede in any way the
terms in the governing documents for your insurance plan. Please visit the Student Zone for a copy of your insurance
certi cate which includes the full plan wording and exclusions.
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