Sirius America Travel-Related Accident Insurance

Summary of Travel-Related Accident Insurance Coverage
Underwritten by Sirius America America Insurance Company

This plan provides limited benefits for specific losses from accidents only. It does not pay any benefits for loss caused by sickness.

An Accidental Death Benefit of $20,000 will be paid when a Covered Person’s death results solely from a Covered Accident subject to the Conditions of Coverage described below and within 90 days from the Covered Accident. Benefits for the Covered Person’s loss of life will be paid to Your beneficiary(ies) on file with the Company.

An Inpatient Hospital Confinement Benefit of $200 per day will be paid, up to a maximum of 365 days, when a Covered Person is Hospital Confined as an inpatient: 1. due to a Covered Accident causing a Covered Loss; 2. at the direction and under the care of a Doctor; and 3. within 90 days of the Covered Accident. Separate Hospital Confinements due to injuries from the same Covered Accident will be treated as one Hospital Confinement, unless separated by at least 180 days.

A Recuperation Benefit of $200 per day will be paid for the same number of days that the Covered Person’s Inpatient Hospital Confinement benefit is paid, up to a maximum of 365 days.

An Accident Medical Benefit will be paid if, as a result of a Covered Accident, the Covered Person suffers a Covered Loss subject to a Condition of Coverage that requires treatment that includes any of the services shown as follows: 1) Treatment in an Emergency Room: $150 per visit; 2) Treatment in an Urgent Care Facility: $50 per visit; 3) Follow-up Physician’s Office Visits: $50 per visit. The first treatment for any of the services must occur no later than 24 hours after the date of the Covered Accident. A Covered Person is allowed a maximum number of 6 visits per Covered Accident for any combination of visits to: Treatment in an Emergency Room; Treatment in an Urgent Care Facility; or Follow-up Physician’s Office Visits.

Description of Conditions of Coverage

Private Passenger Automobile Coverage: With this accident plan, you or your covered Spouse/Domestic Partner will be covered while driving or riding as a passenger (including boarding or alighting from) in a Private Passenger Automobile, or as a pedestrian if struck or run down by a motor vehicle (other than as a pedestrian on an Interstate highway). Simple trips to the grocery store or to a friend’s house can lead to accidents that cause Injury - sometimes very serious Injury. With the Travel-Related Accident Plan, you’ll have solid insurance protection for those every day, ‘around town’ trips you make all the time.

Common Carrier Coverage: - The Travel-Related Accident Plan provides coverage while you are riding as a passenger in (including boarding or alighting from, or being struck or run down by) a Common Carrier. It also covers you while you are in an airport, rail station, or bus stop. Unlike some accident plans that only cover you on a regularly scheduled commercial passenger airplane, this plan provides coverage while on any public conveyance by land, water, or air and is Licensed to transport passengers for hire in the state or country in which the conveyance operates. This additional coverage helps protect you when you’re on vacation, on a business trip, visiting the kids, or simply out enjoying yourself.

Eligibility and Effective Date: As a Member in good standing of California School Employees Association (CSEA) you are eligible to enroll regardless of your age or medical history. Your Spouse/Domestic Partner is also eligible if they are a person of the same or opposite sex to whom you are legally married, or they are legally registered as your Domestic Partner.. Your coverage will take effect after your enrollment form and your first premium payment is received by Sirius America Insurance Company.

Premiums: The monthly cost for this plan is $4.50 per person. Premiums may not be changed unless the same change applies to all Members insured under the Group Master Policy. On a monthly basis you have the option of having the cost of the plan to be automatically deducted through either your Credit Card or your checking account. E.J.S. Insurance Services, Inc. is the Insurance Broker that markets the insurance plan, and provides non claim customer service on behalf of Sirius America Insurance Company for the benefit of the Group Policyholder. EJS is compensated for the placement of insurance and for the services it provides to customers on behalf of the insurance company, in addition to other compensation it may receive.

Termination: Your coverage cannot be cancelled as long as you remain a member in good standing, you are not on full time active duty in Any Armed Forces (This does not include Reserve or National Guard duty for training), pay the premium when due and the Group Master Policy remains in effect. Your spouses’/domestic partner’s coverage cannot be cancelled as long as your coverage does not terminate, your Spouse/Domestic Partner is not on full time active duty in Any Armed Forces (This does not include Reserve or National Guard duty for training), premiums are paid, and they remain eligible.

Exclusions: This Insurance does not cover any claim arising out of bodily injury caused or contributed to by any of the following: 1). Intentionally self-inflicted Injury, suicide or any attempt thereat; 2). commission or attempt to commit a felony; 3).commission of or active participation in a riot or insurrection; 4). declared or undeclared war or act of war; 5). flight in, boarding or alighting from an Aircraft: (a). except as a fare-paying passenger on a regularly scheduled commercial airline; (b). being flown by the Covered Person or in which the Covered Person is a member of the crew; (c). being used for: i. crop dusting, spraying or seeding, giving and receiving flying instruction, fire fighting, sky writing, sky diving or hang-gliding, pipeline or power line inspection, aerial photography or exploration, racing, endurance tests, stunt or acrobatic flying; or ii. any operation that requires a special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on); (d). designed for flight above or beyond the earth’s atmosphere; (e). an ultra-light or glider; (f). being used for the purpose of parachuting or skydiving; (g). being used by any military authority, except an Aircraft used by the Air Mobility Command or its foreign equivalent; 6). participation in any motorized race or contest of speed; 7). an accident if the Covered Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator's license, unless: (a) the Covered Person holds a valid learners permit and (b) the Covered Person is receiving instruction from a Driver's Education Instructor; 8). Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, including exposure, whether or not accidental, to viral, bacterial or chemical agents except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food; 9). release, whether or not accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including Sickness or disease resulting from such release; 10). medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice unless it occurs during treatment of injuries sustained in a Covered Accident; 11). travel in any Aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the Policyholder if the Aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year; 12). the Covered Person being legally intoxicated as determined according to the laws of the jurisdiction in which the Covered Accident occurred; 13). voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage; 14). a Covered Accident that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, We will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days; 15). Operating any type of vehicle or conveyance while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Covered Person has been provided a written warning against operating a vehicle or conveyance while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the motor vehicle laws of the state in which the Covered Loss occurred. In addition, benefits will not be paid for services or treatment rendered by any person who is: 1). employed or retained by the Policyholder; 2). living in your household; 3). your parent, sibling, Spouse/Domestic Partner or child; 4). you.

Important Definitions:

Accidental Death means loss of life which results solely from a Covered Accident.

Common Carrier means a public conveyance which is: 1) Licensed to transport passengers for hire by a duly constituted authority having jurisdiction in the state or country in which said conveyance operates; and 2) Provided and operated (a) for regular passenger service by land, water, or air, and (b) on a regular passenger route with regularly published schedules of departures and arrivals between established and recognized points of departure and arrival; and 3) Provided and operated under a valid license or operating specifications for commercial transportation at the time of loss.

Conditions of Coverage means the circumstances under which this insurance is provided.

Covered Accident means a sudden, unforeseeable, event that results solely in a Covered Loss and meets all of the following conditions: 1) occurs while The Covered Person is insured under the Policy; 2) is not contributed to by disease, Sickness, mental or bodily infirmity; 3) is not otherwise excluded under the terms of the Policy.

Covered Loss means an injury which: 1). results solely from a Covered Accident; and 2). for which a Benefit, as shown in this brochure, is payable.

Covered Person means the individuals named in the Eligibility and Effective Date section of this brochure. The term Covered Person also includes, when You have elected coverage, an eligible Spouse or Domestic Partner.

Emergency Room means a facility that is (a) located on the premises of, or physically part of, a Hospital and (b) provides initial Treatment to patients requiring immediate attention. An Emergency Room is specially equipped and staffed to provide emergency care.

Hospital means an institution that: 1) operates as a duly licensed institution, operated lawfully in its area providing for the care, treatment and in-patient services for sick or injured persons; 2) provides 24-hour nursing service by registered nurses on duty or call; 3) has a staff of one or more licensed Physicians available at all times; 4) provides organized facilities for diagnosis, treatment and surgery, either a. on its premises; or b. in facilities available to it, on a pre-arranged basis; 5) is not primarily a nursing care facility, rest home, convalescent home or similar establishment, or any separate ward, wing or section of a Hospital used as such; and 6) is not a facility for the treatment of drug addiction, alcoholism, or treatment of the aged. The Company will not deny a claim for services rendered in a hospital having one or more of the following accreditations solely because the Hospital lacks major surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is specifically for the treatment of a physical disability: 1) the Joint Commission on Accreditation of Hospitals; or 2) the American Osteopathic Association; or 3) the Commission on the Accreditation of Rehabilitative Facilities.

Hospital Confined or Confinement means any period for which a charge for room and board is made by a Hospital.

Private Passenger Automobile means a validly registered four wheel vehicle including private passenger cars, station wagons, jeeps, pick-up trucks, van-type cars, sport utility vehicles, and motor homes that are not licensed commercially.

Urgent Care Facility means a free-standing facility that is engaged primarily in providing minor emergency and episodic medical care. A Physician, a registered nurse and a registered x-ray technician must be in attendance at all times that the facility is open. It must be licensed as an Urgent Care Facility, if required by law.

This brochure explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this brochure and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Insurance is underwritten by Sirius America Insurance Company on Policy Form SAD-13-1000-CA which details exclusions, limitations, reduction of benefits and terms under which the policy may be continued in full or discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Group Master Policy issued to the policyholder by Sirius America Insurance Company.

THIS IS LIMITED ACCIDENT-ONLY COVERAGE

With the coverage, you have the assurance of knowing that you’re covered by a Travel-Related Accident insurance plan. This coverage includes carefully-designed benefits that may be a real help to you ... when help will mean the most! And remember, your benefit checks (which will NOT reduce as you get older) will be made out to YOU, so you can use the money any way you’d like. PLUS, your checks will be paid to you regardless of ANY OTHER insurance you may have, including Medicare, Social Security, and ALL other plans.

If you have any questions about the plan or need assistance with the enrollment website, please call E.J.S. Insurance Services at our toll-free number 1-800-841-6238, Monday - Thursday, 8:30 a.m. – 4:30 p.m. and Friday 8:30 a.m. – 2:30 p.m. Pacific Time. We’ll be glad to help you any way we can!

CSEAACTIVE 2019 Brochure

California School Employees Association (CSEA)
Policy # EXL SA AD 20001
SAD-13-1000-CA