Swarthmore College

Policy Number

GLM N06566212

Questions

24/7 Emergency Assistance – Team Assist

Phone:
(inside the U.S.) 1-855-327-1411
(call collect from outside the U.S.)+001-312-935-1703

Benefit or Claim Questions?
Contact CISI
(9AM-5PM EST Mon-Fri)
Phone:
1-203-399-5130
(toll-free)
1-800-303-8120
Email:
Claimhelp@mycisi.com

World Class Coverage Designed for Swarthmore College Programs Abroad

This plan is provided by Cultural Insurance Services International
and underwritten by Ace American Insurance Company

Coverage Summary for Policy #

GLM N06566212

SCHEDULE OF BENEFITS

Coverages and Services	Maximum Limits
TRAVEL ACCIDENT INDEMNITY INSURANCE
Accidental Death and Dismemberment Per Insured Person	$10,000
ACCIDENT AND SICKNESS INSURANCE
Medical expenses (per Covered Accident or Sickness):
Deductible	Zero
Benefit Maximum	$150,000 at 100%
Extension of Benefits	30 days
TRAVEL ASSISTANCE INSURANCE
Emergency Medical Reunion	(incl. hotel/meals, max $150/day) $5,000
Quarantine	$2,000
EVACUATION AND REPATRIATION INSURANCE
Emergency Medical Evacuation	$300,000
Repatriation/Return of Mortal Remains	$100,000
Security Evacuation (Comprehensive)	$100,000 ($1M Aggregate)
NON-INSURANCE SERVICES
Team Assist Plan (TAP): 24/7 medical, travel, technical assistance

Policy terms and conditions are briefly outlined in this Description of Coverage. Complete provisions pertaining to this insurance are contained in the Master Policy on file with Swarthmore College under form number AH-15090. In the event of any conflict between this Description of Coverage and the Master Policy, the Policy will govern.

In Case of Emergency

Please contact Team Assist run by AXA Assistance by phone at 312-935-1703.
Non-Emergency questions may be directed to CISI at 203-399-5132 (toll free 800-303-8120).

Schedule of Benefits
Benefits	Limits
Medical Expenses Limits:
Lifetime/Annual Maximum	Unlimited
Per Accident or Sickness	$250,000
Per Occurrence Deductibles:
Emergency Room Deductible (waived if admitted)	$250
Call-A-Doc	$0
Physician/Outpatient/Dr. Visit	$100
Urgent Care	$50
Walk in Clinic	$25
MRI/CAT Scan	$0
Rx Copay	$0
Pre-Existing Conditions-12 Month Look Back; thereafter up to policy max	Up to $500
Coinsurance Percentage (%)	100% Coinsurance
Prescription Drugs (inpatient/outpatient)	Inpatient: 100% of Covered Expenses Outpatient: 100% of Covered Expenses
Mental Health	Inpatient up to 30 days/Outpatient 30 visits
Pregnancy (conception must occur while covered under this plan)	Treated as any other illness
Physiotherapy	Covered
Chiropractic Care & Therapeutic Services	Up to $500 max, $50 per visit
Emergency Reunion	$15,000 (hospitalized 3 days)
Home Country (Incidental Trips)	$1,000
Trip Delay (applies mid trip as well) 24-hour time	Up $1,500/daily limit $100
Political Evacuation	$10,000
Dental Injury Only	Up to policy max
Palliative Dental	$1,000max/$200 per tooth
24/7 Assistant Services & In-house Crisis Team	Included
Medical Evacuation	$50,000
Repatriation of Remains	$25,000
Accidental Death & Dismemberment	$15,000 ($1M aggregate limit)

Schedule of Benefits
Benefits	Limits
Medical Expenses Limits:
Lifetime/Annual Maximum	Unlimited
Per Accident or Sickness	$2,000,000
Per Occurrence Deductibles:
Emergency Room (waived if admitted)	$250
Call-A-Doc	$0
Physician/Outpatient/Dr. Visit	$50
Urgent Care	$50
Walk in Clinic	$25
MRI/CAT Scan	$0
Rx Copay	$0
Pre-Existing Conditions-12 Month Look Back; thereafter up to policy max	Up to $500
Coinsurance Percentage (%)	100% Coinsurance
Prescription Drugs (inpatient/outpatient)	Inpatient: 100% of Covered Expenses Outpatient: 100% of Covered Expenses
Mental Health	Inpatient up to 30 days/Outpatient 30 visits
Pregnancy (conception must occur while covered under this plan)	Treated as any other illness
Emergency Reunion	$15,000 (hospitalized 3 days)
Physiotherapy	Covered
Chiropractic Care & Therapeutic Services	Up to $500 max, $50 per visit
Home Country (Incidental Trips)	$1,000
Trip Delay (applies mid trip as well) 24-hour time	Up $1,500/daily limit $100
Political Evacuation	$10,000
Dental Injury Only	Up to policy max
Palliative Dental	$1,000max/$200 per tooth
24/7 Assistant Services & In-house Crisis Team	Included
Medical Evacuation	$50,000
Repatriation of Remains	$25,000
Accidental Death & Dismemberment	$15,000 ($1M aggregate limit)
Trip Interruption	$1,000
Personal Liability
Personal Liability Limit	$2,000,000
Liability deductible	$100
Medical Payments to Others	$25,000
Additional Living Expenses	$10,000
Payment of Homeowners Deductible	$1,000
Personal Property	$1,500