Patriot America Lite

G. ELIGIBLE MEDICAL EXPENSES: Subject to the Terms of this insurance, and the insurance plan shown in the Declaration, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the following costs, Charges and expenses incurred by the Insured Person during the Period of Coverage with respect to an Illness or Injury suffered or sustained by the Insured Person during the Period of Coverage and while this Certificate is in effect, so long as the Illness or Injury is covered under this Certificate, Charges are Usual, Reasonable and Customary, and Charges are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”):

(1) Charges incurred at a Hospital for:

(a) daily room and board, nursing services, and Ancillary Services not to exceed the average semi-private room rate. A private room will be considered when no semi-private room is available or if medical necessity warrants this type of room. The private room rate is not to exceed the average private room rate.
(b) daily room and board, nursing services and Ancillary Services in an Intensive Care Unit
(c) use of operating, Treatment or recovery room
(d) services and supplies that are routinely provided by the Hospital to persons for use while an Inpatient
(e) Emergency Treatment of an Injury, even if Hospital confinement is not required
(f) Emergency Treatment of an Illness; however, an additional Deductible (as shown in the BENEFIT SUMMARY) will be required unless the Insured Person is directly admitted to the Hospital as Inpatient for further Treatment of that Illness

(2) Charges incurred for Surgery at an Outpatient Surgical Facility, including services and supplies
(3) Charges by a Physician for professional services rendered, including Surgery; provided, however, that Charges by or for an assistant surgeon will be limited and covered at the rate of up to twenty percent (20%) of the Usual, Reasonable and Customary charge of the primary surgeon; and provided, further, that the standby availability of a Physician or surgeon will not be deemed to be a professional service and is not eligible for coverage

(4) Charges incurred for:

(a) dressings, sutures, casts or other supplies that are Medically Necessary
(b) diagnostic testing using Radiology, ultrasonography or laboratory services. Laboratory services billed for professional component fees are covered if the pathologist has direct involvement in providing a written report or verbal consultation for specimen-specific pathology services
(c) Implant devices that are Medically Necessary; however, any Implants provided outside the PPO network are limited to a payment of no more than one hundred fifty percent (150%) of the established invoice price and/or list price for that item
(d) basic functional artificial limbs, eye or larynx or breast prostheses, but not the replacement or repair thereof
(e) reconstructive Surgery when the Surgery is incidental to and follows Surgery that was covered hereunder
(f) radiation therapy or Treatment, and chemotherapy
(g) hemodialysis for the Treatment of acute renal failure only and the Charges by a Hospital for processing and administration of blood or blood components
(h) oxygen and other gases and their administration
(i) anesthetics and their administration by a Physician
(j) drugs that require prescription by a Physician for Treatment of Illness or Injury, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of ninety (90) days of any one (1) prescription
(k) care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital
(l) Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from an acute care Hospital
(m) Emergency Local Ambulance Transport necessarily incurred in connection with:

(i) an Injury
(ii) an Illness resulting in Hospital confinement as an Inpatient

(n) Interfacility Ambulance Transfer must be a result of an Inpatient Hospital Admission, Medically Necessary and from one licensed health care Facility to another licensed health care Facility via air or land ambulance
(o) chiropractic services prescribed by a Physician and performed by a professional chiropractor and necessarily incurred to continue recovery from a covered Injury or covered Illness; services include manipulations, x-rays and laboratory tests ordered by the chiropractor
(p) physical therapy prescribed by a Physician and performed by a professional physical therapist and necessarily incurred to continue recovery from a covered Injury or covered Illness
(q) Durable Medical Equipment, as defined herein, deemed to be Medically Necessary
(r) a Telehealth, Teleconsultation or Virtual Physician Visit

(5) Charges incurred for Treatment at an Urgent Care Clinic
(6) Charges incurred for Treatment at a Walk-in Clinic
(7) Charges for Treatment of an Injury to the foot due to an Accident covered hereunder
(8) Charges for Treatment of an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment
(9) Charges for Dental Treatment as follows up to the amount shown in the BENEFIT SUMMARY:

(a) Charges for Treatment following Traumatic Dental Injury from a covered Accident that resulted in physical Injury to the Insured Person
(b) Charges for necessary Dental Treatment of Unexpected pain to sound natural teeth
(c) Charges incurred for non-emergency Dental Treatment necessary due to an Accident covered hereunder

(10) Charges for an Emergency eye examination performed by a licensed optometrist or ophthalmologist to obtain a Medically Necessary prescription for corrective lenses that were lost or damaged due to an Accident covered hereunder, but not for the replacement of prescription corrective lenses or contact lenses
(11) Charges for value-added tax (VAT) or like tax incurred on Eligible Medical Expenses.

V. PUBLIC HEALTH EMERGENCY: Subject to all other Terms of this insurance, in the event of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, the Company will cover an Illness or Injury incurred during the Period of Coverage and caused by the Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster when, prior to the issuance of a Travel Warning for the Destination Country or a Global Travel Warning:

(1) the Effective Date of Coverage has occurred; and
(2) the Insured Person has arrived in the Destination Country or Affected Area.

In the event that the applicable Travel Warning is removed for the Destination Country or Affected Area, coverage for an Illness or Injury incurred during the Period of Coverage after the Travel Warning is removed, which was caused by the Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster will be considered by the Company the same as any other Illness or Injury, subject to all other Terms and conditions of this insurance.