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You have dreamed of this trip for years. At last, your relatives or international business associates are coming to visit you in the United States! You’ll introduce them to your friends and colleagues, show them your town, and maybe vacation together. But what if they have an accident or an illness strikes them? Will they have the health and financial protection they need?

When visiting the U.S., foreign nationals are often unaware that health services are not provided by the government but by private companies. Payment in full is required at time of treatment, and the price of health care in the U.S. is very expensive. However, for less than the cost of dinner for two at a good restaurant, your visitors from abroad can have the health care insurance they need. And you can have peace of mind.

What you should know about HealthCare America:

Medical insurance provides up to $250,000 for each covered personal injury and sickness that occurs after visitors arrive in the United States. Expenses for pre-existing medical conditions are not covered. Medical evacuation, if warranted, to a more suitable hospital or their home is included, as are the costs of hospitalization, visits to doctors’ offices, prescriptions, lab fees, x-rays, local ambulance, and emergency dentistry arising from an accident. After the deductible, 100% of all covered expenses are paid. In the very unlikely event of accidental death, the return of their remains to their home is covered.
 

  On-Line Brochure Download PDF of Brochure & Application
 

International assistance is not insurance. Rather it is the service (24 hours per day, 7 days a week) of a personal assistant, professionally trained and fluent in their language and culture, who will arrange doctors’ appointments and other appropriate medical care as soon as your guest needs it. These pros act as their advocate in communicating with doctors and hospitals in the U.S. These assistants can help them arrange a second medical opinion if they want it, revise travel plans, facilitate emergency communications with their personal physician and family at home. They’ll assist you in getting knowledgeable legal advice for your guest if needed. It’s as if you both have a good friend—no further away than a toll free phone call—who knows what to do if an emergency strikes.

Here in the United States, setting of a broken leg or arm from a nasty fall could require an immediate payment of $10,000 in a city like New York or Los Angeles. Should air transportation back home be required, costs can range from $15,000 on a commercial air carrier to more than of $100,000 for use of an international air ambulance with a medically trained crew.
 

What you should do:

Review the travel plans of your associates or relatives to determine how long they will be in the United States.
Read the detailed description of coverages below.
Call Wallach & Company (800-237-6615) with questions and concerns about emergency medical and related assistance.

 

Medical Expense Benefits

$250,000 Accident and Sickness Expense Benefit
After the $100 deductible, the Company will pay up to the benefit limit for those medical expenses incurred within the USA during the Period of Insurance which are the direct result of each covered injury or sickness which first manifests itself during the Period of Insurance. Covered expenses include, but are not limited to; the necessary medical or surgical treatment, services and supplies, hospital services, local ambulance, x-rays, laboratory fees, and visits to a physician’s office.

Benefits for claims resulting from: (1) downhill (alpine) skiing; and (2) cardiovascular/circulatory related conditions are limited to $10,000.

If medical expenses are expected to exceed $500, the Assistance Center must be notified immediately.

Medical Evacuation
If a covered injury or sickness occurs during the Period of Insurance and requires your medical evacuation, the Company with your concurrence and that of the attending physician, may evacuate you to a more suitable hospital or to your home location in the event you are hospitalized more than five consecutive days. An evacuation to your home location will terminate coverage under the policy.

Repatriation of Remains Benefit
If a covered injury or sickness results in the loss of your life during the Period of Insurance, the Company will pay the expenses for the preparation and transportation of the body back to your home.

All medical evacuations and repatriations of remains must be approved (in advance) and coordinated by the Assistance Center.

Dental Expense Benefit
This benefit covers the expenses incurred for dental treatment resulting from a covered accident. The limitation is $200 per natural tooth with a maximum benefit of $1,000.

 
This is a descriptive brochure containing a summary of the coverages provided by the Master Policy. Once insured you will receive a Certificate of Insurance which contains details of the coverage. This Insurance is underwritten by Pan-American Life Insurance Company, 601 Poydras Street, New Orleans, Louisiana 70130.

 $25,000 Accidental Death & Dismemberment Benefit
The principal sum benefit is $25,000. If a covered injury occurs to you during the Period of Insurance, which is independent of all other causes and results in one of the following losses within 180 days of the covered injury, the Company will pay the sum indicated below.
 
Loss Benefit
Life Principal Sum
Any two limbs (above the elbow/knee) Principal Sum
Sight in both eyes (irrecoverable) Principal Sum
One limb and the sight in one eye Principal Sum
One limb or the sight in one eye One-half Principal Sum

Period of Insurance
Coverage begins: (a) at 12:01 a.m. on the date requested on the Application; (b) 12:01 a.m. on the day your mailed Application is received by the Administrator; (c) 12:01 a.m. on the day after your electronically submitted Application is received by the Administrator; or (d) when you arrive in the USA, whichever occurs last. Coverage terminates: (a) at 11:59 p.m. on the last day of coverage requested on the Application; or (b) when you leave the USA, whichever occurs first.

HealthCare America Travelers Assistance Services

  1. Multilingual professional staff to help in locating the nearest, most appropriate medical care.
  2. Available Medical Advisors consultative and advisory services including second opinion and review of appropriateness/quality of medical care, plus progress monitoring during treatment.
  3. Assistance in establishing contact with family, personal physician and employer as necessary; emergency message transmittal.
  4. Special assistance to facilitate direct claims payment or transfer of funds.
  5. Arrange and coordinate medical evacuation with the appropriate medical escort or in case of death, repatriation of remains.
  6. Knowledgeable legal referral assistance

Exclusions & Limitations
This insurance does not cover, nor has premium been charged for losses resulting from:
 
A.

A Pre-existing Condition defined as: Any injury or sickness, or complications arising therefrom, for which symptoms were manifested during the 12 months immediately prior to the Period of Insurance; or for which a physician was consulted, treatment was received or medicines/drugs were taken in the 12 months immediately prior to the Period of Insurance. Since this is short-term travel insurance, no claim for cancers or tumors (malignant or benign), tuberculosis or organ transplants are eligible to be covered.
 

B.

Any claim in respect of:

  1. Congenital conditions; suicide, self-inflicted injury or any attempt thereat; cosmetic surgery, including treatment for a deviated nasal septum and dental care, except if required by a covered injury;
  2. Expenses incurred after the Period of Insurance or in your home country;
  3. Expenses not recommended and approved as necessary by an attending physician; examinations or treatment where there is no objective impairment of normal health;
  4. Eyeglasses, contact lenses or hearing aids;
  5. Sexually transmittable diseases (this exclusion does not apply to HIV, AIDS, ARC or any derivative thereof);
  6. Alcohol, drug or intoxicant related treatment;
  7. Birth control, fertility or infertility treatment, or pregnancy including miscarriage or abortion;
  8. Emotional or mental disorders of any kind;
  9. “Off-Road”, All-Terrain Vehicle accidents; mountaineering (where ropes or guide persons are customarily used); or
  10. Other vehicle accident, if such expenses are recoverable under any other valid and collectible insurance, regardless of whether you assert your rights to obtain benefits from these sources. Nor will this insurance cover you while operating the vehicle unless you are properly licensed to operate the vehicle at the place and time of the accident.
C.

Any claim arising from war, declared or undeclared, or any act of war or while in the military service. An act of terrorism shall not be considered an act of war.
 

D.

Participation in professional sports, scuba diving; or aviation other than as a passenger in powered aircraft currently licensed for the carrying of passengers.
 

E. Amounts covered under any occupational or other benefit plan, or any other insurance or public assistance program.
 
F.

A claim or loss that occurs:

  1. Anywhere in the world except in the USA, Canada and the Caribbean Islands;
  2. While traveling against the advice of a physician;
  3. While on a waiting list for a specific treatment; or
  4. When traveling for the purpose of obtaining medical treatment

Understandings

  1. HealthCare America provides insurance for foreign nationals visiting the United States and will also cover incidental travel from the United States to Canada or the Caribbean Islands. Foreign nationals who are permanent residents of the United States or intend to live in the United States are not eligible for this insurance. The Administrator may require the Applicant to provide proof of entry (copy of the I-94 Arrival/Departure Record) into the United States.
  2. HealthCare America is temporary insurance for protection against unanticipated injuries and sicknesses. Therefore, it does not provide coverage for medical expenses which are the result of a pre-existing medical condition. Nor will HealthCare America provide coverage for cancer, tumors, organ transplants or tuberculosis related conditions.
  3. Eligible Applicants must be between the ages of 3 and 60 years of age with a premium of $7.00 per day. For Applicants from age 61 to 70, the premium is $14.00 per day. For applicants over age 70, please contact Wallach & Company, Inc.
  4. The HealthCare America policy cannot be renewed or extended. If additional insurance is required, one more policy may be purchased if requested before the expiration of the first policy. Any injury or sickness incurred during the first policy will be considered a Pre-existing Condition under the new policy and therefore not covered.
  5. Refund policy: If the Administrator receives a written request to cancel the insurance prior to the beginning of the Period of Insurance, the premium (less the $15 enrollment fee and any applicable credit card processing fees) will be refunded. After the Period of Insurance has begun, the premium is considered fully earned and will not be refunded.
  6. Right of Subrogation: If you are injured or become sick as a result of another person's negligence, the Insurer has the right to seek reimbursement on your behalf against the negligent party for any claims paid under this insurance.
  7. HealthCare America covers injuries resulting from random acts of terrorism. However, if it is your intention to travel to an area where a state of war exists, that is faced with the threat of war, or is in a state of civil unrest, that information must be included on the Application. Additional premium may be required.

 

HealthCare America Application
INT 6/03 - AgentID=

Eligibility: You must be between the ages of 3 and 70 years of age to enroll in HealthCare America. Persons over 70 years of age should contact Wallach & Company, Inc. (800-237-6615).

You may complete and submit your Application online and you will receive a receipt of your Application by email; or you may print your completed Application, mail it or fax it to:

Wallach & Company, Inc.
Post Office Box 480
107 West Federal Street
Middleburg, Virginia 20118 USA

Fax: (540) 687-3172

Please call (800) 237-6615 or (540) 687-3166 between 9:00 a.m. - 5:00 p.m. EST, Monday–Friday for telephone assistance.

 

This plan is not available to residents of the State of Washington, USA.
 

Required Information:

Applicant Name (as it appears on your passport)  
 First Name 
 Last Name 
c/o Contact in U.S.
Street Address in the U.S.
 
City
State
Zip or Postal Code
Email Address - Required
Your Telephone Number
Contact's Telephone Number
Relationship of Contact in U.S. to Applicant
Nationality Of Insured
Passport No.
Applicant's Date of Birth (Must be age 3 to 70)
Is Applicant currently under medical care?  No  Yes: If yes, please describe:
Desired Effective Date
Date Of Arrival In U.S.

Premium: 
 Please indicate the number of days coverage you require.
The premium calculated is determined by your age on the Desired Effective Date.
Minimum premium is for 10 days. Maximum premium is for 90 days. Persons over the age of 70 should contact Wallach & Company, Inc.
Ages 3-60
$7.00/day = $0.00
+ $15.00 enrollment fee
Ages 61-70
$14.00/day = $0.00
+ $15.00 enrollment fee
Total Premium = $0.00

The effective date of the insurance cannot be prior to the date of the Application and premium are received and approved by the Administrator.

Payment:
Check payable in U.S. funds, drawn on a U.S. bank, and made payable to Wallach & Company, Inc.
Visa MasterCard American Express
Card Number
Security Code
Expiration Date  / 
Name on Credit Card
The Security Code provides an additional security measure to prevent card misuse within online transactions. For the majority of credit cards, the security code is the last three digits of the number shown above the signature strip on the reverse side of the credit card. For American Express Cards, the security code is the four digit number shown above the credit card number, on the right-hand side of the front of the card.


Declaration of Applicant:
I hereby apply to purchase the insurance. I declare to the best of my knowledge and belief that the information given in this Application is true and complete. I acknowledge (on behalf of the person(s) to be insured) that benefits will not apply to treatment arising from pre-existing medical conditions. It is agreed that this declaration and the information given herein shall form the basis of the contract between the Insured Person and the Company. Further, I hereby subscribe to the International Sojourners Insurance Trust and acknowledge enrolling in this group coverage for which I am eligible under the contract issued by the Company.
 
  Signature Date

Please sign and date this Application if you elect to print and mail it to Wallach & Company.
 

By submitting this Application you agree to the terms of the Applicant Declaration.

Your insurance documents will be sent to the email address supplied with this enrollment form.


Administered by Wallach & Company, Inc.
© Wallach & Company, Inc., 2017.