You will become an Insured Person when You have enrolled for Coverage under the Group Policy, paid the premium for the Coverage Period shown in the Certificate Schedule, and been accepted by United States Life. Eligible Persons who satisfy the criteria for eligibility described in the Certificate Schedule on the Policy Effective Date will have Coverage on that date.
For a person who becomes an Eligible Person after the Policy Effective Date, You will become an Insured Person at 12:01 a.m. on the date following the date United States Life or its agent approves his or her enrollment form and receives the premium due.
An Eligible Dependent’s insurance will become effective on the Insured Person’s effective date unless added at a later date as described in the “Additional Insured Persons” provision.
Your Coverage and that of Your covered dependents remains in effect for the Coverage Period.
Additional Insured Persons: You may add other Eligible Dependents who become eligible after the Coverage effective date by enrolling such dependent and paying the premium due. The premium due will be the single premium pro-rated to the end of the Coverage Period. The Coverage will be effective on the date United States Life or its agent approves the enrollment. Your Coverage will terminate at midnight at the end of the Coverage Period.
For a person who becomes an Eligible Person after the Policy Effective Date, You will become an Insured Person at 12:01 a.m. on the date following the date United States Life or its agent approves his or her enrollment form and receives the premium due.
An Eligible Dependent’s insurance will become effective on the Insured Person’s effective date unless added at a later date as described in the “Additional Insured Persons” provision.
Your Coverage and that of Your covered dependents remains in effect for the Coverage Period.
Additional Insured Persons: You may add other Eligible Dependents who become eligible after the Coverage effective date by enrolling such dependent and paying the premium due. The premium due will be the single premium pro-rated to the end of the Coverage Period. The Coverage will be effective on the date United States Life or its agent approves the enrollment. Your Coverage will terminate at midnight at the end of the Coverage Period.
BENEFITS
BENEFIT A
ACCIDENT MEDICAL INSURANCE BENEFIT
Benefits for Covered Diving Accidents
Covered Medical Charges
United States Life will pay the benefits described below subject to the terms and limitations. Covered charges means eligible charges that are for Medically Necessary services, supplies, care, or treatment for a Covered Diving Accident. The accident must occur during the Coverage Period. The expense incurred as a result of the accident must be incurred within 365 days of the Covered Diving Accident. Such services, supplies, care or treatment must be prescribed, performed or ordered by a Physician. Charges for such services, supplies, care or treatment must be Reasonable and Customary. United States Life will not pay for charges in excess of the Lifetime Maximum shown in the Certificate Schedule.
Eligible charges include:
1. Hyperbaric Chamber Treatment Charges for up to seven treatments per Covered Diving Accident.
Any treatment after the seventh must be pre-certified by National Baromedical Services at (800) 292- 8381;
2. Physician’s charges for Hyperbaric Chamber Treatment, medical care and surgical operations;
3. Ambulance charges for transportation by a professional ground, air or marine ambulance service to the nearest Hospital or Hyperbaric Chamber where appropriate care or treatment can be given. All transportation involving air or marine ambulance service must be approved in advance by DAN TravelAssist to be eligible for reimbursement;
4. Hospital charges for:
a. room and board;
b. general nursing care, including Hyperbaric Chamber treatment;
c . other Inpatient and Outpatient services and supplies. These do not include charges for professional services;
d. confinement in an Intensive Care Unit as long as such confinement is ordered by a Physician and due to an Injury that requires special medical and nursing treatment not generally provided to other Inpatients in the Hospital.
5. Medical supply charges for oxygen;
6. Other eligible charges including:
a. ambulatory surgical charges for necessary services and supplies if:
1. the charges are due to surgery;
2. benefits for these charges would have been payable if the surgery had been done in a Hospital; and
3. such surgery is performed in an ambulatory surgical center that is operating within the scope of its license to perform such surgery.
b. surgeon’s charges for the performance of surgical procedures;
c. anesthesia charges and its administration when these are not covered as Hospital charges;
d. nursing, physiotherapy, and occupational therapy charges for:
1. private duty nursing care by a Nurse; and
2. treatment by a licensed physiotherapist; and
3. treatment by a licensed occupational therapist.
e. radiological and laboratory charges for X-rays, radiological treatment, and diagnostic laboratory
tests;
f. chiropractic services payable at $35 per visit by an Insured Person for up to 10 visits in a Coverage Period to a maximum of $350 per Insured Person per such Coverage Period.
g. medical supply charges for:
1. casts, splints, trusses, braces, crutches, and surgical dressing; and
2. artificial eyes and limbs for the initial replacement of natural eyes and limbs severed while an Insured Person; and
3. rental of manually operated wheelchairs and hospital beds, oxygen equipment and other durable medical equipment that is used solely by the Insured Person for the treatment of the Injury. United States Life may, at its discretion, approve purchase of such items.
Benefits for Accident Medical Expense
Covered Medical Charges
If an Insured Person incurs charges for treatment of Injury due to a non-Diving Accident that occurs outside his or her Home Country, United States Life will pay the benefits described below subject to the terms and limitations.
Covered charges means eligible charges that are for Medically Necessary services, supplies, care, or treatment for such Injury. The accident must occur while Coverage is in force and while the Insured Person is on a trip that is more than fifty miles from his or her primary residence and for recreational purposes only. The charge incurred as a result of the accident must be incurred within 365 days of the accident.
Such services, supplies, care or treatment must be prescribed, performed or ordered by a Physician and include medical, surgical, and emergency dental care, professional nursing, hospital, x-ray, ground ambulance services and prosthetic devices. Charges for such services, supplies, care or treatment must be Reasonable and Customary. United States Life will not pay for charges in excess of the maximum shown in the Certificate Schedule.
Exclusions for Covered Diving Accidents and Accident Medical Expense Benefits No benefits are payable for charges for:
1. services or supplies for which an Insured Person is not required to pay or charges made only because insurance exists (subject to the right, if any, of the United States government to recover Reasonable and Customary Charges for care provided in a military or veteran’s hospital);
2. a diving accident or Injury for which benefits are paid or payable under Workers’ Compensation or any Occupational Disease or similar law whether such benefits are insured or self-insured;
3. any act due to war, declared or not;
4. Custodial Care;
5. drugs and medicine that may be obtained without written prescription and/or not furnished by and administered during a Hospital confinement as an Inpatient;
6. charges that are more than the Reasonable and Customary Charges for the services and supplies furnished;
7. Hospital services and supplies when confinement is solely for diagnostic testing purposes;
8. nervous, emotional, or mental disorders;
9. a diving accident or Injury that occurs after drug or alcohol use unless such drug was prescribed by a Physician;
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