United States Fire Insurance Company
Administrative Office: 5 Christopher Way,
Eatontown, NJ 07724
(Hereinafter referred to as “the Company”)
TRAVEL PROTECTION INSURANCE
Certificate of Insurance
This Certificate of Insurance describes all of the travel
insurance benefits underwritten by United States Fire
Insurance Company, herein referred to as the Company. The
insurance benefits vary from program to program. Please
refer to the accompanying Confirmation of Benefits. It
provides the Insured with specific information about the
program he or she purchased. The Insured should contact
the Company immediately if he or she believes that the
Confirmation of Benefits is incorrect.
Signed for the Company,
Chairman and CEO,
Marc J. Adee
Insurance provided by this Certificate is subject to all of the
terms and conditions of the Group Policy. If there is a conflict
between the Policy and Certificate, the Policy will govern.
SCHEDULE OF BENEFITS
TABLE OF CONTENTS
I. COVERAGES
II. DEFINITIONS
III. INSURING PROVISIONS
IV. GENERAL LIMITATIONS AND EXCLUSIONS
V. GENERAL PROVISIONS
SECTION I. COVERAGES
EMERGENCY MEDICAL EVACUATION, MEDICAL
REPATRIATION AND RETURN OF REMAINS
When You suffer loss of life for any reason or incurs a
Sickness or Injury during the course of a Covered Trip, the
following benefits are payable, up to the Maximum Benefit
Amount.
- For Emergency Medical Evacuation: If the local
attending Legally Qualified Physician and the authorized
travel assistance company determine that transportation
to a Hospital or medical facility is Medically Necessary to
treat an unforeseen Sickness or Injury which is acute or
life threatening and adequate Medical Treatment is not
available in the immediate area, the Transportation
Expense incurred will be paid for the Usual and
Customary Charges for transportation to the closest
Hospital or medical facility capable of providing that
treatment.
If You are in the Hospital for more than seven
consecutive days and Your dependent children who are
under 18 years of age and accompanying You on the
Covered Trip, are left unattended, Economy
Transportation will be paid to return the dependents to
their home (with an attendant, if considered necessary
by the travel assistance company).”
If You are traveling alone and is in the Hospital for more
than seven consecutive days and Emergency
Evacuation is not imminent, upon Your or of Your next
of kin if You are incapacitated, benefits will be paid to
transport one person, chosen by You, by Economy
Transportation, for a single visit to and from Your
bedside.
- For Medical Repatriation:
- If the local attending Legally Qualified Physician
and the authorized travel assistance company determine that it is Medically Necessary for You to
return to Your place of permanent residence
because of an unforeseen Sickness or Injury which
is acute or life-threatening, the Transportation
Expense incurred will be paid for Your return to his
or her permanent residence via:
- one-way Economy Transportation; or
- commercial upgrade, based on an Insured’s
condition as recommended by the local
attending Legally Qualified Physician and
verified in writing.
Transportation must be via the most direct and
economical route.
- If the local attending Legally Qualified Physician
and the authorized travel assistance company
determine that it is Medically Necessary for You to
return to his or her place of permanent residence
for continued treatment of an unforeseen Sickness
or Injury which is acute or life-threatening, the
Transportation Expense incurred will be paid for
transportation to the Hospital or medical facility
closest to Your permanent place of residence
capable of providing that treatment. Transportation
must be by the most direct and economical route.
Covered land or air transportation includes, but is
not limited to, commercial stretcher, medical escort,
or the Usual and Customary Charges for air
ambulance, provided such transportation has been
pre-approved and arranged by the authorized travel
assistance company.
- For Return of Remains: In the event of Your death, the
expense incurred will be paid for minimally necessary
casket or air tray, preparation and transportation of Your
remains to his or her place of residence or to the place of
burial.
Benefits are paid less the value of Your original unused
return travel ticket.
If benefits are payable under this Coverage and You have
other insurance that may provide benefits for this same loss,
the Company reserves the right to recover from such other
insurance. You shall:
- notify the Company of any other insurance;
- help the Company exercise the Company’s rights in
any reasonable way that the Company may
request, including the filing and assignment of other
insurance benefits;
- not do anything after the loss to prejudice the
Company’s rights; and
- reimburse to the Company, to the extent of any
payment the Company has made, for benefits
received from such other insurance.
The Maximum Benefit Amount is shown in the Confirmation of
Benefits.
COLLISION DAMAGE WAIVER
The Insured is eligible for benefits up to the Maximum Benefit Amount per person if the Insured rents a car while on the
Trip, and the car is damaged due to collision, theft, vandalism,
windstorm, fire, hail, flood or any cause not in the Insured’s
control while in the Insured’s possession, or the car is stolen
while in the Insured’s possession and is not recovered. The
Company will pay the lesser of:
- The cost of repairs and rental charges imposed by
the rental company while the car is being repaired; or
- The Actual Cash Value of the car, meaning purchase
price less depreciation; or
- The amount shown on the Schedule.
Coverage is provided to the Insured, provided the Insured
and Traveling Companions are licensed drivers, and are listed
on the rental agreement.
DEFINITIONS
“Exotic Vehicles” includes Alfa Romeo, Aston Martin, Auburn,
Avanti, Bentley, Bertone, BMC/Leyland, BMW M Series,
Bradley, Bricklin, Clenet, Corvette, Cosworth, De Lorean,
Excalibre, Ferrari, Iso, Jaguar, Jensen Healy, Lamborghini,
Lancia, Lotus, Maserati, MG, Morgan,
Pantera, Panther, Pininfarina, Porsche, Rolls Royce, Rover,
Stutz, Sterling, Triumph, and TVR.
WHAT IS NOT PAYABLE UNDER COLLISION DAMAGE
WAIVER:
Unless otherwise stated, benefits are not payable for:
- Any obligation of the Insured, a Traveling Companion or
Family Member traveling with the Insured assumed
under any agreement (except insurance collision
deductible);
- Rentals of trucks, campers, trailers, off-road or four
wheel drive vehicles, motor bikes, motorcycles,
recreational vehicles or Exotic Vehicles;
- Any loss which occurs if the Insured or anyone traveling
with the Insured are in violation of the rental agreement;
- Failure to report the loss to the proper local authorities
and the rental car company;
- Damage to any other vehicle, structure or person as a
result of a covered loss;
- Any loss as the result of or attributed to driving the rental
vehicle: while under the influence of alcohol or any illegal substance or the abuse of a legal substance; while using
any medication which recommends abstinence from driving; in a speed competition; for compensation for
hire; for illegal trade purposes, or transporting
contraband;
- Any loss as the result of physical damage or loss
attributed to: mechanical failure or breakdown of the
rental vehicle; wear and tear, gradual deterioration,
corrosion, rust or freezing; any neglect or abuse of the
vehicle; any dishonest act or conversion; any
consequence of war (declared or otherwise); or
contamination by a radioactive material.
ADDITIONAL CLAIMS PROVISIONS SPECIFIC TO
COLLISION DAMAGE WAIVER:
The following outlines the Insured’s Duties in the event of any
damage to the vehicle. The Insured must:
- Take all necessary and reasonable steps to protect the
vehicle and prevent further damage to it;
- Report the loss to the appropriate local authorities and
the rental company as soon as possible;
- Obtain all information on any other party involved in the
Accident, such as name, address, insurance information
and driver’s license number;
- Provide the Company all documentation such as rental
agreement, police report and damage estimate.
SECTION II. DEFINITIONS
“Additional Transportation Cost” means the actual cost
incurred for one-way Economy Transportation by Common
Carrier reduced by the value of an unused travel ticket.
“Common Carrier” means any land, sea, and/or air
conveyance operating under a valid license for the transportation of passengers for hire.
“Confirmation of Benefits” means the coverage confirmation
provided to You following enrollment and payment of the
applicable premium.
“Covered Trip” means scheduled trips, tours or cruises for
which (a) coverage is requested: and (b) the required
premium is submitted prior to the Scheduled Departure Date.
“Economy Transportation” means the lowest published
available transportation rate for a ticket on a Common Carrier
matching the original class of transportation that the Insured
purchased for the Covered Trip.
“Family Member” means Your or a Traveling Companion’s:
legal spouse or common-law spouse where legal; legal
guardian; son or daughter (adopted, foster or step); son-inlaw;
daughter-in-law; grandmother; grandmother-in-law;
grandfather; grandfather-in-law; grandchild; aunt; uncle;
niece; or nephew; brother, step-brother; sister; step-sister;
brother-in-law; sister-in-law; mother; father; step-parent.
“Hospital” means (a) a place which is licensed or recognized
as a general hospital by the proper authority of the state in
which it is located: (b) a place operated for the care and
treatment of resident inpatients with a registered graduate
nurse (RN) always on duty and with a laboratory and X-ray
facility: (c) a place recognized as a general hospital by the
Joint Commission on the Accreditation of Hospitals. Not
included is a hospital or institution licensed or used
principally: (1) for the treatment or care of drug addicts or
alcoholics: or (2) as a clinic continued or extended care
facility, skilled nursing facility, convalescent home, rest home,
nursing home or home for the aged.
“Injury” or “Injuries” means accidental bodily injuries: (a)
received while insured under the Policy and any attached
coverages: (b) resulting in loss independently of sickness and
all other causes: and (c) not excluded from coverage.
“Insured” means the person(s) named on the enrollment form
or Roster as the Principal Participant, participant’s spouse or
participant’s child.
“Intoxicated” mean a blood alcohol level that equals or
exceeds the legal limit for operating a motor vehicle in the
state or jurisdiction where You are located at the time of an
incident.
“Legally Qualified Physician” means a physician or a Christian
Science Practitioner (a) other than You, a Traveling
Companion or a Family Member: (b) practicing within the
scope of Your license: and (c) recognized as a physician in
the place where the services are rendered.
“Maximum Benefit Amount” means the maximum amount
payable for coverage provided to an Insured as shown in the
Confirmation of Benefits.
“Medical Treatment” means treatment advice or consultation
by a Legally Qualified Physician.
“Medically Necessary” means a service or supply which: (a) is
recommended by the attending Legally Qualified Physician: (b) is appropriate and consistent with the diagnosis in accord
with accepted standards of community practice: (c) could not
have been omitted without adversely affecting Your condition
or quality of medical care: (d) is delivered at the most
appropriate level of care and not primarily for the sake of
convenience: and (e) is not considered experimental unless
coverage for experimental services or supplies is required by
law.
“Scheduled Departure Date” means the date on which You
are originally scheduled to leave on the Covered Trip.
“Scheduled Return Date” means the date on which You are
originally scheduled to return to the point of origin or the
original final destination.
“Sickness” means an illness or disease that is diagnosed or
treated by a Legally Qualified Physician after the effective
date of insurance and while You are covered under the
Policy.
“Third Party” means a person or entity other than You or the
Company.
“Transportation Expense” means: (a) the cost of conveyance
of You and any medical personnel (if Medically Necessary):
and (b) Medically Necessary services or supplies.
“Travel Arrangements” means: (a) transportation: (b)
accommodations: and (c) other specified services arranged
by the Travel Supplier for the covered trip.
“Traveling Companion” means a person or persons with
whom a covered person has coordinated travel arrangements
and intends to travel with during the trip.
“Travel Supplier” means any entity or organization that
coordinates or supplies travel services for You.
“Usual and Customary Charges” means those comparable
charges for similar treatment, services and supplies in the
geographic area where treatment is performed.
SECTION III. INSURING PROVISIONS
Insured’s Term of Coverage:
For all coverages: Coverage begins at the point and time of
departure on the Scheduled Departure Date. Coverage ends
at the point and time of return on Your Scheduled Return
Date.
In the event the Scheduled Departure Date and/or the
Schedule Return Date are delayed, or the point and time of
departure and/or point and time of return are changed
because of circumstances over which neither the Travel
Supplier nor You have control Your term of coverage shall be
automatically adjusted accordance with the Travel Supplier’s
notice to the Company of the delay or change.
SECTION IV. GENERAL LIMITATIONS AND EXCLUSIONS
Benefits are not payable for Sickness, Injuries or losses of
You, Your Traveling Companion or Your Traveling
Companion’s Family Member, or Your Business Partner:
- resulting from suicide, attempted suicide or any
intentionally self-inflicted injury while sane or insane;
- resulting from an act of declared or undeclared war;
- while participating in maneuvers or training exercises of
an armed service;
- while riding, driving or participating in races, or speed or
endurance contests;
- while mountaineering (engaging in the sport of scaling
mountains generally requiring the use of picks, ropes, or
other special equipment);
- while participating as a member of a team in an
organized sporting competition;
- while participating in skydiving, hang gliding, bungee
cord jumping, scuba diving or deep sea diving;
- while piloting or learning to pilot or acting as a member
of the crew of any aircraft;
- received as a result or consequence of being
Intoxicated, as specifically defined in the policy, or under
the influence of any controlled substance unless
administered on the advise of a Legally Qualified
Physician;
- to which a contributory cause was the commission of or
attempt to commit a felony or being engaged in an illegal
occupation;
- due to normal childbirth, normal pregnancy through the
first 6 months of pregnancy or voluntarily induced abortion;
- which exceed the Maximum Benefit Amount for each
attached coverage as shown in the Confirmation of Benefits.
SECTION V. GENERAL PROVISIONS
Notice of Claim: Notice of claim must be reported within 20
days after a loss occurs or as soon as is reasonably possible.
You or someone on Your behalf may give the notice. The
notice should be given to the Company or designated
representative and should include sufficient information to
identify the Insured.
Claim Forms: When notice of claim is received by the
Company or designated representative, forms for filing proof of loss will be furnished. If these forms are not sent within 15
days, the proof of loss requirements can be met by sending a
written statement of what happened. This statement must be
received within the time given for filing proof of loss.
Proof of Loss: Proof of loss must be provided within 90 days
after the date of the loss or as soon as is reasonably possible.
Proof must, however, be furnished no later than 12 months
from the time it is otherwise required, except in the absence
of legal capacity.
Time of Payment of Claims: The Company or its
designated representative will pay the claim after receipt of
acceptable proof of loss.
Payment of Claims: Benefits for loss of life are payable to
the Principal Insured, who is the beneficiary for all other Insureds. If: (a) the Principal Insured predeceases You: and
(b) a beneficiary is not otherwise designated by the Principal
Insured benefits for loss of life will be paid to the first of the
following surviving preference beneficiaries:
- the Principal Insured’s spouse;
- the Principal Insured’s child or children jointly;
- Your parents jointly if both are living or the surviving
parent if only one survives;
- Your brothers and sisters jointly; or
- the Principal Insured’s estate.
All or a portion of all other benefits provided by the Policy
may, at the option of the Company, be paid directly to the
provider of the service(s). All benefits not paid to the provider
will be paid to the Principal Insured.
Other than for loss of life, if any benefit is payable to: (a) You
or the Principal Insured’s beneficiary who is minor or
otherwise not able to give a valid release: or (b) the Principal
Insured’s estate: the Company may pay up to $1,000.00 to
the Principal Insured’s beneficiary or any relative to whom the
Company finds entitled to the payment. Any payment made in good faith shall fully discharge the Company to the extent
of such payment.
Legal Actions: No legal action for a claim can be brought
against us until 60 days after we receive proof of loss. No legal action for a claim can be brought against us more than 3
years after the time required for giving proof of loss. This 3-
year time period is extended from the date proof of loss is
filed and the date the claim is denied in whole or in part.
Concealment and Misrepresentation: The entire coverage
will be void, if before, during or after a loss, any material fact
or circumstance relating to this insurance has been concealed
or misrepresented.
Other Insurance with the Company: You may be covered
under only one travel policy with the Company for each Covered Trip. If You are covered under more than one such
policy, You may select the coverage that is to remain in effect.
In the event of death, the selection will be made by the
beneficiary or estate. Premiums paid (less claims paid) will
be refunded for the duplicate coverage that does not remain
in effect.
Subrogation: If the Company has made a payment for a
loss under this coverage, and the person to or for whom payment was made has a right to recover damages from the
Third Party responsible for the loss, the Company will be
subrogated to that right. You shall help the Company
exercise the Company’s rights in any reasonable way that the
Company may request: nor do anything after the loss to
prejudice the Company’s rights: and in the event You recover
damages from the Third Party responsible for the loss, the
Insured will hold the proceeds of the recover for the Company
in trust and reimburse the Company to the extent of the
Company’s previous payment for the loss.
Reductions in the Amount of Insurance: The applicable
benefit amount will be reduced by the amount of benefits, if any, previously paid for any loss or damage under this
coverage for this Covered Trip.
STATE EXCEPTIONS
NEW HAMPSHIRE: The definition of “Family Member” is
amended to read:
“Family Member” means an Insured’s or a Traveling
Companion’s: legal spouse or common-law spouse where
legal; legal guardian; son or daughter (adopted, foster or step); child placed for adoption with the Insured or Traveling Companion; son-in-law; daughter-in-law; grandmother;
grandmother-in-law; grandfather; grandfather-in-law; grandchild; aunt; uncle; niece; or nephew; brother, stepbrother;
sister; step-sister; brother-in-law; sister-in-law; mother; father; step-parent.
The definition of “Hospital” is amended to read:
“Hospital” means (a) a place that operates according to law in
the state where it is located; and b) a place operated for the
care and treatment of resident inpatients with a registered
graduate nurse (RN) always on duty and with a laboratory
and X-ray facility: Not included is a hospital or institution
licensed or used principally: (1) for the treatment or care of
drug addicts or alcoholics: or (2) as a clinic continued or
extended care facility, skilled nursing facility, convalescent
home, rest home, nursing home or home for the aged.
“Proof of Loss” is amended to read:
Proof of Loss: Proof of loss must be provided within 90 days
after the date of the loss or as soon as is reasonably possible.
TP-401-CRT
When used throughout this document “The Company”, “Our”, “We”, or “Us” means:
United States Fire Insurance Company
PRIVACY POLICY AND PRACTICES
The Company values your business and your trust. In order to administer insurance policies and provide you with effective customer service, we
must collect certain information about our customers. We want you to know that we are committed to protecting your private information and we
will comply with all federal and state privacy laws. Below is a Privacy Notice describing our policy regarding the collection and disclosure of
personal information. Please review this Notice and keep a copy of it with your records.
Your Privacy is Our Concern
When you apply to The Company for insurance or make a claim against a policy written by The Company, you disclose information about
yourself to us. There are legal requirements governing the collection, use, and disclosure of such information. The Company maintains physical,
electronic, and procedural safeguards that comply with state and federal regulations to guard your personal information. We also limit employee
access to personally identifiable information to those with a business reason for knowing such information. The Company instructs our
employees as to the importance of the confidentiality of personal information, and takes measures to enforce employee privacy responsibilities.
What kind of information do we collect about you and from whom?
We obtain most of our information from you. The application or claim form you complete, as well as any additional information you provide,
generally gives us most of the information we need to know. Sometimes we may contact you by phone or mail to obtain additional information.
We may use information about you from other transactions with us, our affiliates, or others. Depending on the nature of your insurance
transaction, we may need additional information about you or other individuals proposed for coverage. We may obtain the additional information
we need from third parties, such as other insurance companies or agents, government agencies, medical personnel, the state motor vehicle
department, information clearinghouses, credit reporting agencies, courts, or public records. A report from a consumer reporting agency may
contain information as to creditworthiness, credit standing, credit capacity, character, general reputation, hobbies, occupation, personal
characteristics, or mode of living.
What do we do with the information collected about you?
If coverage is declined or the charge for coverage is increased because of information contained in a consumer report we obtained, we will
inform you, as required by state law or the federal Fair Credit Reporting Act. We will also give you the name and address of the consumer
reporting agency making the report. We may retain information about our former customers and may disclose that information to affiliates and
non-affiliates only as described in this notice.
To whom do we disclose information about you?
We may disclose all the information that we collect about you, as described above. We may disclose such information about you to our affiliated
companies, such as:
- Insurance companies;
- Insurance agencies;
- Third party administrators;
- Medical bill review companies; and
- Reinsurance companies.
We may also disclose nonpublic personal information about you to affiliated and nonaffiliated third parties as permitted by law. You have a right
to access and correct the personal information we collect, maintain, and disclose about you.
How to contact Us
You may obtain a more detailed description of the information practices prescribed by law by contacting us at the address below. Remember to
include your name, address, policy number, and daytime phone number.
Privacy Policy Coordinator
Fairmont Specialty
5 Christopher Way, 3rd Floor
Eatontown, New Jersey 07724 Privacy-USF
When used throughout this document “Company”, “Our”, “We”, or “Us” means:
United States Fire Insurance Company
GRIEVANCE PROCEDURES
When you submit a claim and that claim is denied, we will provide a written statement containing the reasons for the Adverse Determination.
You have the right to request a review of any Company decision or action pertaining to our contractual relationship and to appeal any adverse
claim determination we’ve made by filing a Grievance. These procedures have been developed to ensure a full investigation of a Grievance
through a formal process.
DEFINITIONS
A “Grievance” is a written complaint requesting a change to a previous claim decision, claims payment, the handling or reimbursement of health
care services, or other matters pertaining to your coverage and our contractual relationship.
An “Adverse Determination” is a determination by the Company or its designated utilization review organization that (i) a service, treatment,
drug, or device, is experimental, investigational, specifically limited or excluded by your coverage; or (ii) a facility admission, the availability of
care, continued stay or other health care services proposed or furnished have been reviewed and, based upon the information provided, does
not meet the contractual requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness and therefore,
the benefit coverage is denied, reduced or terminated in whole or in part.
INFORMAL GRIEVANCE PROCEDURE
You, your authorized representative, or a provider acting on your behalf may submit an oral complaint to us within 60-days after an event that
causes a dispute. Telephoning allows you to discuss your complaint or concerns and gives us the opportunity to immediately resolve the
problem.
If we don’t have all the information necessary to review your complaint, we will request any additional information within 5 business days of
receiving your complaint. After we receive all the necessary information, we will provide you, your authorized representative, or a provider acting
on your behalf with our written decision within 30-days after receiving the complaint and all necessary information.
If the problem cannot be resolved in this manner, you still have the right to submit a written request for the complaint to be reviewed through the
Formal Grievance Procedure, as outlined below.
FORMAL GRIEVANCE PROCEDURE
A formal Grievance may be submitted by you, your authorized representative, or in the event of an Adverse etermination, by a provider acting
on your behalf.
If you file a formal Grievance, you will have the opportunity to submit written comments, documents, records and other information you feel are
relevant to the Grievance, regardless of whether those materials were considered in the initial Adverse Determination.
First Level Review
Within 3 working business days after receiving the Grievance, we must acknowledge the Grievance and provide you, your authorized
representative or a provider with the name, address, and telephone number of the coordinator handling the Grievance and information on how to
submit written material. The person(s) who reviews the Grievance will not be the same person(s) who made the initial Adverse Determination.
During the review, all information, documents, and other materials submitted relating to the claim will be considered, regardless of whether they
were considered in making the previous claim decision. The Insured will not be allowed to attend, or have a representative attend, a First Level
Review. The Insured may, however, submit written material for consideration by the reviewer(s).
When the Grievance is based in whole or in part on a medical judgment, the review will be conducted by, or in consultation with, a medical doctor
with appropriate training and expertise to evaluate the matter.
Following our review of your Grievance, we must issue a written decision to you and, if applicable, to your representative or provider, within 20-
days after receiving the Grievance. The written decision must include:
- The name(s), title(s) and professional qualifications of any person(s) participating in the First Level Review process.
- A statement of the reviewer’s understanding of the Grievance.
- The specific reason(s) for the reviewer’s decision in clear terms and the contractual basis or medical rationale used as the basis for the decision in sufficient detail for the Insured to respond further to our position.
- A reference to the evidence or documentation used as the basis for the decision.
- If the claim denial is based on medical necessity, experimental treatment or similar exclusion, instructions for requesting an
explanation of the scientific or clinical rationale used to make the determination.
- A statement advising you of your right to request a Second Level Review, if applicable, and a description of the procedure and
timeframes for requesting a Second Level Review.
Second Level Review
The Second Level Review process is available if you are not satisfied with the outcome of the First level Review for an Adverse Determination.
Within ten business days after receiving a request for a Second Level Review, we will advise you of the following:
- the name, address, and telephone number of a person designated to coordinate the Grievance review for the Company;
- a statement of your rights, including the right to:
- attend the Second Level Review
- present his/her case to the review panel;
- submit supporting materials before and at the review meeting;
- ask questions of any member of the review panel;
- be assisted or represented by a person of his/her choice, including a provider, family member, employer representative, or
attorney.
- request and receive from us free of charge, copies of all relevant documents, records and other information that is not
confidential or privileged that were considered in making the Adverse Determination.
We must convene a review panel and hold a review meeting within 45-days after receiving a request for a Second Level Review. We will notify
you in writing of the meeting date at least 15-days prior to the date. The review meeting will be held during regular business hours at a location
reasonable accessible to you. In cases where a face-to-face meeting is not practical for geographic reasons, we will offer you the opportunity to
communicate with the review panel at our expense by conference call or other appropriate technology. Your right to a full review may not be
conditioned on whether or not you appear at the meeting.
If you choose to be represented by an attorney, we may also be represented by an attorney. If we choose to have an attorney present to
represent our interests, we will notify you at least 15 working days in advance of the review that an attorney will be present and that you may
wish to obtain legal representation of your own.
The panel must be comprised of persons who:
- were not previously involved in any matter giving rise to the Second Level Review;
- are not employees of the Company or Utilization Review Organization; and
- do not have a financial interest in the outcome of the review.
A person previously involved in the Grievance may appear before the panel to present information or answer questions.
All persons reviewing a Second Level Grievance involving a Utilization Review non-certification or a clinical issue will be providers who have
appropriate expertise, including at least one clinical peer. If we use a clinical peer on an appeal of a Utilization Review non-certification or on a
First Level Review, we may use one of our employees on the Second Level Review panel if the panel is comprised of 3 or more persons.
We must issue a written decision to you and, if applicable, to your representative or provider, within 10 business days after completing the review
meeting. The decision must include:
- the name(s), title(s) and qualifying credentials of the members of the review panel;
- a statement of the review panel’s understanding of the nature of the Grievance and all pertinent facts;
- the review panel’s recommendation to the Company and the rationale behind the recommendation;
- a description of, or reference to, the evidence or documentation considered by the review panel in making the recommendation;
- in the review of a Utilization Review non-certification or other clinical matter, a written statement of the clinical rationale, including
the clinical review criteria, that was used by the review panel to make the determination;
- the rationale for the Company’s decision if it differs from the review panel’s recommendation;
- a statement that the decision is the Company’s final determination in the matter;
- notice of the availability of the Commissioner’s office for assistance, including the telephone number and address of the
Commissioner’s office.
EXPEDITED REVIEW
You are eligible for an expedited review when the timeframes for an Informal, formal First Level review or Second Level review would reasonably
appear to seriously jeopardize your life or health, or your ability to regain maximum function. An expedited review is also available for all
Grievances concerning an admission, availability of care, continued stay or health care service for a person who has received emergency
services, but who has not been discharged from a facility.
A request for an expedited review may be submitted orally or in writing. An expedited review must be evaluated by an appropriate clinical peer in
the same or similar specialty as would typically manage the case being reviewed. If we don’t have the information necessary to decide an
appeal, we will send you notification of precisely what is required within 24-hours of our receipt of your Grievance. All necessary information,
including our decision, will be transmitted by telephone, facsimile, or the most expeditious method available. Provided we have enough
information to make a decision, you, your authorized representative, or a provider acting on your behalf will be notified of the determination as
expeditiously as the medical condition requires, but in no event more than 72-hours after the review has commenced. Written confirmation of our
decision will be provided within 2 working business days of the decision and will contain the same items described in the written decision
requirements for First Level reviews.
If the expedited review does not resolve the situation, you, your representative or a provider acting on your behalf may submit a written
Grievance.
We will not provide an expedited review for retrospective reviews of Adverse Determinations.
Grievance-USF IMPORTANT: This benefit does not apply to cars rented in Jamaica, Republic of Ireland, Northern Ireland and Israel.
NON-INSURANCE WORLDWIDE ASSISTANCE
SERVICES
On Call International
Not a care in the world…when you have our 24/7 global
network to assist you on your travels.
- CareFreeTM Travel Assistance
- Medical Assistance
- Emergency Services
CareFreeTM Travel Assistance
Travel Arrangements
- Arrangements for last-minute flight and hotel
changes
- Luggage Locator (reporting/tracking of lost, stolen
or delayed baggage)
- Hotel finder and reservations
- Airport transportation
- Rental car reservations and automobile return
- Coordination of travel for visitors to bedside
- Return travel for dependent/minor children
- Assistance locating the nearest embassy or
consulate
- Cash transfers
- Assistance with bail bonds
Pre-Trip Information
- Destination guides (hotels, restaurants, etc.)
- Weather updates and advisories
- Passport requirements
- Currency exchange
- Health and safety advisories
Documents and Communication
- Assistance with lost travel documents or passports
- Live email and phone messaging to family and friends
- Emergency message relay service
- Multilingual translation and interpretation services
Medical Assistance Services
- Medical case management, consultation and monitoring
- Medical Transportation
- Dispatch of a doctor or specialist
- Referrals to local medical and dental service providers
- Worldwide medical information, up-to-the-minute travel medical advisories, and immunization requirements
- Prescription drug replacement
- Replacement of eyeglasses, contact lenses and dental appliances
Emergency Services
- Emergency evacuation
- Repatriation of mortal remains
- Emergency medical and dental assistance
- Emergency legal assistance
- Emergency medical payment assistance
- Emergency family travel arrangements
CareFreeTM Travel Assistance, Medical Assistance and
Emergency Services can be accessed by calling On Call
International at 1-800-618-0692 or, from outside the U.S. or
Canada, call collect: 1-603-898-2679.
CLAIMS PROCEDURE
- EMERGENCIES ARISING DURING YOUR COVERED
TRIP: Please contact On Call International (as above).
- ALL CLAIMS: Report your claim as soon as possible to
Aon Affinity (below). Provide the policy number, Your travel
dates, and details describing the nature of Your loss. Upon
receipt of this information, Aon Affinity will promptly forward You
the appropriate claim form to complete.
Online |
www.travelclaim.com |
Phone |
1-(877) 892-7951 or 1-(516) 342-2720 |
Mail |
Aon Affinity
300 Jericho Quadrangle, P.O. Box 9022
Jericho, NY 11753 |
By E-mail: |
tripprotect@aon.com |
Office Hours |
8:00 AM - 10:00 PM ET, Monday - Friday;
9:00 AM - 5:00 PM ET, Saturday |
|