Standard

EMERGENCY ASSISTANCE AND TRANSPORTATION

We will pay this benefit, up to the amount on the Schedule, for the following Covered Expenses incurred by you, subject to the following:

1. Covered Expenses will only be payable at the Usual and Customary level of payment; and

2. Benefits will be payable only for covered expenses listed below resulting from a Sickness that first manifests itself or an Injury that occurs while on a Trip; and

3. Benefits payable as a result of incurred covered expenses will only be paid after benefits have been paid under any Other Valid and Collectible Health Insurance in effect for you. We will pay that portion of covered expenses, which exceeds the amount of benefits payable for such expenses under your Other Valid and Collectible Health Insurance.

FOR CONNECTICUT RESIDENTS
When Emergency Assistance and Transportation is purchased, paragraph 3). is deleted in its entirety.
3) Benefits payable as a result of incurred covered expenses will only be paid after benefits have been paid under any Other Valid and Collectible Health Insurance in effect for you. We will pay that portion of covered expenses, which exceeds the amount of benefits payable for such expenses under your Other Valid and Collectible Health Insurance.
T001AD01.01CT (11/11)

Covered Expenses:

1. Expenses incurred by you for Physician-ordered emergency medical evacuation, including medically appropriate transportation and necessary medical care en route, to the nearest suitable Hospital, when you are critically ill or injured and no suitable local care is available, subject to prior approval by us or our authorized agent;

2. Expenses incurred for non-emergency repatriation, including medically appropriate transportation and medical care en route, to a Hospital or to your place of residence in the United States of America, when deemed medically necessary by the attending physician, subject to prior approval by us or our authorized agent. In lieu of returning to your place of residence, you may opt to be returned to a different city in the United States if proper care for your condition is not available;

3. Expenses for transportation (not to exceed the cost of one round-trip economy-class air fare, to the place of hospitalization), and expenses for reasonable hotel accommodations, meals, telephone calls and local transportation for one person chosen by you up to the amount in the Schedule, provided that you are traveling alone and are hospitalized for more than 7 days;

4. Expenses for transportation, not to exceed the cost of one-way economy-class air fare, to your place of residence in the United States of America, including escort expenses, if you are 17 years of age or younger and left unattended due to the death or hospitalization of an accompanying adult(s), subject to prior approval by us or our authorized agent;

5. Expenses for one-way economy-class air fare (or first class, if your original tickets were first class) to your place of residence in the United States of America, from a medical facility to which you were previously evacuated, less any refunds paid or payable from your unused transportation tickets, if these expenses are not covered elsewhere in the plan;

6. Repatriation expenses for preparation and air transportation of your remains to your place of residence or a funeral home in the United States of America, or up to an equivalent amount for a local burial in the country where death occurred, if you die while outside the United States of America.

T001BR05.01NW (05/11)