Coverage Information Medical Insurance

This document provides a brief summary of your insurance plan.

To access your complete insurance information, including the general insurance conditions, all important contact
information and a VISA letter, please login to your personal MyInsurance area at:
www.esecutive.com/MyInsurance

To create your personal account, you will need:

- Your Last Name: PORTILLA SOTO

- Your First Name: JOSE HUMBERTO
- Certificate Number: 2024/171/1/34/0
- Your Date of Birth: 01/25/2004

Insurance ID-Card

Health Insurance ID Card

INFORMATION FOR MEMBERS
International Exchange of North America Please find all important Insurance Information online at: eSecutive.com/MyInsurance
(IENA) Please call the Claims Administrator, OTH, prior to receiving any medical services,
unless you are having a life-threatening emergency.
Group #: Aetna PPO/NAP Claims Administrator: One Team Health (OTH) (844) 805-9444
863995-018-00100 oneteamhealth@dhig.net
MEMBERS: SEE BACK OF CARD FOR ADDITIONAL INFORMATION PPO Network: Aetna Passport to Healthcare Primary (844) 805-9444
PPO https://aet.na/2wx9Enx
Member Name JOSE HUMBERTO PORTILLA SOTO
Aetna PPO Member ID # 0000189694 Coverage While Traveling/ One Team Health (OTH) (844) 805-9444
Emergency After-Hours Collect
Plan Name Aetna Passport to Healthcare Primary PPO Care: 905-907-0074
Medical Policy ID # 2024/171/1/34/0 Claims Mailing Address (for One Team Health (OTH) (844) 805-9444
Effective Dates 06/16/2024 - 09/06/2024 non-Aetna, outsite U.S. or PMB 309-266 Elmwood Ave.
prescription claims): Buffalo, NY, 14222
dhig ID # (dhig use only) 3299108206935
Submit Claims Via Email: othclaims@dhig.net
Deductible: $50 per injury or sickness ER Copay: $350 (waived if admitted) Prescriptions: Paid at 100% of reasonable charges; however, you must pay for
prescriptions in full, then submit a claim for reimbursement to
the address above.
Aetna Network Provider Services: (800) 414-0596 Payer ID: 60054
Provider Claims Mailing Address: Aetna Claims Administrator: Managing General Underwriter:
P.O. Box 981543 One Team Health (OTH) Daily Health Insurance Group
El Paso, TX 79998-1543
AETNA NETWORK PROVIDERS: For questions about benefits or eligibility, call One Team
Health (OTH) at (844) 805-9444. Coverage for medical treatment subject to patient’s eligibility
on the date of service, terms, limitations and exclusions of the policy. File claims electronically
to Payer ID above, or mail claims to address indicated above.

Pre-Authorization required for Inpatient Hospitalization, Outpatient Surgery, CT/ MRI/PET One Team Health (OTH) must be contacted prior to seeking medical services unless
scans, Physical Therapy & Rehabilitation Services, Specialty Treatment and Highly Specialized you are having a life-threatening emergency. You must contact OTH within 48 hours
Drugs. Call OTH at (844) 805-9444 or send an email to: oneteamhealth@dhig.net prior to of such as emergency. Failure to do so may result in a reduction in benefits.
obtaining treatment.

NOTICE: Possession of this card does not guarantee coverage or payment for a service or
procedure

Medical Provider guidelines for filing claims with Aetna Passport PPO
Dear Aetna Passport PPO Network Provider,
Here are the following steps to check enrollment eligibility and claim submission:

Please search the member by the exact name spelling on their ID card.
Please submit the claims via EDI to Aetna Passport to Healthcare PPO provider, if needed there is a mail option identified below:

Member ID: As provided on ID card

Group number: 863995-018-00100

Claims address: P.O. Box 981543 El Paso, TX 79998-1543

Payor ID: 60054

Aetna Network Provider Services: 800-414-0596

*IMPORTANT: Medical providers name the applicable Aetna PPO to be used in their systems - it is not consistent across providers. As you search your
system, the following are the likely naming conventions, “Aetna International PPO”, “Aetna Global PPO,” or “Aetna Global Patient Services PPO”
Submit Claim to Aetna PPO/NAP via Mail : P.O. Box 981543, El Paso, TX 79998-1543
PLEASE NOTE: If you do not have the above Aetna Address in your system, please mail the claim under “Commercial PPO” and request “Aetna
International PPO” to be added to your system.
Submit Claim to Aetna PPO/NAP via EDI : Payor ID/EDI:60054
Thank you for your assistance
Insured Member Guidelines for using your health insurance policy
Please download and print or save on your mobile: Or click here to open the pdf

Schedule of Benefits

The following benefits are per person per Injury or Sickness (unless otherwise stated) and subject to the Insured Person’s per Injury or
Sickness Policy Deductible. After satisfaction of the Policy Deductible, the Underwriter will pay the eligible benefits set forth in this
Schedule at the Allowable Charge, which is defined as the Negotiated Rate or the Usual, Customary, and Reasonable (UCR). This is
the lower of: a) the Provider’s usual charge for furnishing the treatment, service or supply; or b) the charge determined by the
Underwriter to be the general rate charged by the others who render or furnish such treatments, services or supplies to persons who
reside in the same country and whose Injury or Illness is comparable in nature and severity, or the rate that has been negotiated.

Benefits will be paid on a Usual, Customary, and Reasonable basis or a negotiated basis with the contracted providers. Subject to
Policy exclusions, limitations and conditions, for the charges listed, if they are:

• Incurred as a result of sickness or accidental bodily injury, under the care of a Physician; and
• Medically Necessary; and
• Ordered by a Physician; and
• Delivered in an appropriate medical setting.
All benefits shown are in USD
PART 1A: ACCIDENT & SICKNESS MEDICAL EXPENSE BENEFITS
Insured Amount per Person per Injury or Sickness: 500.000 USD
Deductible per Injury or Sickness: 50 USD
Benefit Coverage Covered Benefit
Hospital Room & Board Benefit: 100% of the Semi-private room rate
Intensive Care/Cardiac Care Unit Benefit: 100%
Hospital Miscellaneous Expense Benefit: 100%
Surgeon (In or Outpatient) Benefits: 100%
Assistant Surgeon Benefit: 100%
Pre-Admission Testing Benefit: 100%
Anesthesia Benefit: 100%
Day Surgery Miscellaneous Benefit: 100%
Diagnostic X-Ray and Lab Benefit: 100%
Ambulance Benefit: 100%
Physician Visit Benefit (Inpatient): 100%
Physician Visit Benefit (Outpatient): 100%
Consultant Physician Benefit: 100%
Radiation/Chemotherapy Benefit: 100%
Emergency Room Benefit: 100% subject to a $350 copay. The Co-Payment, waived if admitted.

Triage is mandatory
Co-Payment only applies to services rendered in the USA
Emergency Dental Expense Benefit: 100%
Palliative Dental: 100% up to a $200 maximum benefit per tooth
Physiotherapy Expense Benefit – Inpatient: 100%
Physiotherapy Expense Benefit – Outpatient: 100% up to a $2,500 maximum
Durable Medical Equipment Expense Benefit: 100%
Out-Patient Prescription Drug Benefit: 100%
Mental & Nervous Conditions Expense Benefit Inpatient: Payable at 80% URC up to $10,000, up to the maximum of 40 days;
Outpatient: Payable at 80% URC, up to $5,000
Home Country Accident Sickness Medical Benefit (not available for the US-citizens) 30 days of coverage up to a maximum of $1,000 per Policy Period
Continuation of Treatment by return to the Home Country Benefit (not available for Up to $1,000, expenses must be incurred within 30 days of returning to your Home
the US-citizens) Country
(5,000) Emergency Treatment of a Pre-Existing Condition 100% URC, up to a maximum of $5,000 per Policy Period

PART 1B: MEDICAL TRANSPORTATION BENEFITS

Benefits will be provided only for the coverages listed below and will be paid only up to the amounts shown.

Sum Insured per insured Person: 250,000 USD

Emergency Medical Evacuation, Medical Repatriation: Up to $250,000 Maximum

Returns of Remains Benefit: Up to $25,000 Maximum
Emergency Reunion: As further specified in this policy
 Return Ticket Benefit: 100% URC, up to $5,000 per Policy Period
Trip Interruption Benefit: As further specified in this policy

PART 1C: ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

Principal Sum: $15,000.00

Personal accident/body injury leading to Benefit: (Percentage of Principal Sum)

Loss of Life 100%
Loss of Both Hands 100%
Loss of Both Feet 100%
Loss of Entire Sight of Both Eyes 100%
Loss of One Hand and One Foot 100%
Loss of One Hand 50%
Loss of One Foot 50%
Loss of Entire Sight of One Eye 50%
Loss of Thumb and Index Finger of the Same Hand 25%
Aggregate Limit per all persons insured under this Policy: $500,000

Pre-Authorization Requirements
Pre-Authorization is required for the following services to maximize the benefits covered under the plan and to arrange for direct billing
with the medical provider:
• Interfaculty Ambulance Transfer: No coverage if Pre-Authorization requirements are not met.
• Medical Evacuation/Medical Repatriation; Preparation & Return of Mortal Remains; Emergency Reunion; Return Ticket Benefit: No
coverage if not approved by the company.

Treatments and supplies listed below: Fifty percent (50%) reduction of eligible medical expenses if Pre-authorization requirements are
not met. Maximum Penalty: $1,000. The penalty amount is not applied towards the deductible.
• In-Patient Hospitalization
• Outpatient Surgery
• All CAT scans, PET scans, and MRIs
• Air Ambulance (Air Ambulance service will be coordinated by the Assistance Service)
• Specialty Treatments and Highly Specialized Drugs
• Physical Therapy and Rehabilitation Services

COVID-19 Tests & Treatment Benefit

The following is paid at locally reasonable and customary costs within the relevant limits and subject to co-payments / deductibles
established in other sections of Schedule of Benefits:

PCR virus detecting test for COVID-19, if prescribed by the doctor in case of confirmed symptoms;
treatment of COVID-19 infection, including hospitalization, medication and local transportation costs if allowed by the local
authorities and if specialized transportation facilities available; and
treatment of any resulting complications.

COVID-19 Tests & Treatment Benefit does not cover:

evacuation to another country;
rapid antibody testing (e.g. population screening tests for use by health authorities to monitor herd immunity);
tests undergone by the insured person without doctor’s prescription;
COVID-19 vaccination.

THIS PLAN IS UNDERWRITTEN BY: KOOPERATIVA poistovna, a. s., Vienna Insurance Group
The insurance companies of the Vienna Insurance Group offer high-quality insurance services in both the life and non-life segments. With a Standard & Poor's
rating of A+ (with a stable outlook), the Vienna Insurance Group is the best ranked company on the Vienna Stock Exchange's ATX index of leading companies.
The list of Cover and Benefits forms part of the Insurance Conditions where the complete terms for the plan document are stated. For a detailed
representation, including all restrictions and exemptions from coverage, please read the detailed insurance terms and conditions.

Disclaimer: This is not your official insurance ID card. If you don't have an official copy of your insurance ID card, please download or
print it at www.esecutive.com/myinsurance

Please be advised this document is only a summary. Please refer to the policy for complete details. In the event of a discrepancy
between this document and the policy, the policy is the prevailing document.

Powered by TCPDF (www.tcpdf.org)

 11. EXCLUSIONS

Unless stated otherwise on the Schedule of Benefits, the following services and benefits are excluded from coverage under this Policy:
1) Medical Treatment received due to a Pre-Existing Condition or complication thereof within the first 12 months of coverage, and
limited to $5,000 thereafter;
2) Medical Treatment which is not Medically Necessary, as defined in the Policy;
3) Charges which are in excess of Usual, Reasonable and Customary;
4) Charges Reimbursable by Another Entity: Services, supplies, or treatment that are provided by or payment is available from:
a. Workers’ Compensation law, Occupational Disease law or similar law concerning job related conditions of any country;
b. Another insurance company or government;
c. A government entity due to an epidemic or public emergency;
5) Hearing aids, eye glasses, or contact lenses and the fitting or servicing thereof, examinations, or prescriptions except that the
Policy will cover these expenses if the need for such results directly from a Covered Injury or covered eye surgery;
6) Birth control devices and surgical procedures, or any drug or treatment that promotes or prevents conception, or prevents
childbirth, including but not limited to artificial insemination, treatment for infertility or impotency, tubal ligation, vasectomy,
sterilization or reversal thereof;
7) Elective or preventive surgery or any Medical Treatment related to an elective or preventive surgery including, but in no way
limited to breast reduction or enlargement, circumcision, immunization antibody testing, allergy tests, antitoxins; or the
correction or treatment of a deviated septum;
8) Cosmetic, plastic, reconstructive, or restorative surgery unless such are Eligible expenses incurred for repair of a disfigurement
caused from:
a) A Covered Injury;
b) a birth defect of an insured Eligible Dependent born while the mother was insured under this Policy; or
c) a mastectomy (refer to the Post-Mastectomy Coverage provision);
9) Medical Treatment related to organ transplants, whether as donor or recipient; this includes expenses incurred for the evaluation
process, the transplant surgery, post-operative treatment, and expenses incurred in obtaining, storing or transporting a donor
organ. In relation to a bone marrow or stem cell transplant this exclusion would include harvesting & mobilization charges;
10) Medical Treatment for injuries sustained in practice for or participation in professional or semi-professional sports; or in practice
for or participation in interscholastic or intercollegiate sports in excess of benefits provided elsewhere in this coverage, if any;
11) War or any act of war, declared or undeclared or the Commission or attempt to commit an assault or felony, or that occurs while
being engaged in an illegal occupation; or the Voluntary, active participation in a civil war, riot, rebellion, insurrection, or
revolution; or participation in the armed forces, national guard, military, naval, or air services.
12) Medical treatment arising out of aeronautics or air travel, except while riding as a passenger on a regularly scheduled commercial
airline,
13) Suicide, attempted suicide (including drug overdose) self-destruction, attempted self-destruction or intentional self-inflicted
Injury while sane or insane
14) Medical Treatment for Injuries sustained while taking part in: Mountaineering; hang gliding; Parachuting; bungee jumping; racing
by horse, motor vehicle or motorcycle; motorcycle/motor scooter riding or any other two or three wheeled motorized vehicle;
scuba diving, involving underwater breathing apparatus, unless PADI or NAUI certified; spelunking; parasailing;.
15) Medical Treatment for Injury or Sickness sustained by reason of a motor vehicle or motorcycle accident
a) to the extent that benefits are paid or payable by any other valid and collectible insurance whether or not claim is made for
such benefits,
b) if the Insured was operating the motor vehicle or motorcycle while Intoxicated under the laws of the state in which the
accident occurred,
c) if the Insured was operating the motor vehicle or motorcycle without a driver's license or permit recognized as valid under
the laws of the state in which the accident occurred, or
 d) if the Insured was not operating the motor vehicle or motorcycle in conformity with the restrictions of the driver’s license or
permit;
16) Medical Treatment for an Injury or Sickness resulting from the Insured's intoxication or use of illegal drugs or any drugs or
medication that is intentionally not taken in the dosage recommended by the manufacturer or for the purpose prescribed by
the Insured's Physician;
17) Charges incurred for Surgery or treatments which are, Experimental/Investigational, or for research purposes or for Compound,
Specialty, and Experimental drugs;
18) Medical Treatment for obesity, including bariatric surgery and anorectics;
19) Medical Treatment related to sex transformation surgery or the reversal thereof;
20) Genetic medicine, genetic testing, surveillance testing and/or screening procedures for genetically predisposed conditions
indicated by genetic medicine or genetic testing, including but not limited to amniocentesis, genetic screening, risk assessment,
preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine genetic pre-
disposition, provide genetic counseling, or administration of gene therapy;
21) Medical Treatment for the diagnosis and testing for or related to any learning disability or congenital condition, except this does
not include congenital conditions for a child if the delivery is covered under this insurance;
22) Expenses incurred for an Accident or Sickness after the Policy Period shown in the Schedule of Benefits or incurred after the
termination date of coverage;
23) Regular health checkups, routine physical or health examinations, sports physicals, gynecologic health screenings, routine baseline
or screening mammograms, prostate and/or colorectal examinations and related laboratory tests, annual health checkups,
immunizations indicated on the Recommended Immunization Schedule by the Centers for Disease Control and Prevention, and
tuberculosis tests in excess of benefits provided elsewhere in this coverage, if any.
24) Insured being exposed to the Utilization of Nuclear, Chemical or Biological Weapons of Mass Destruction.
25) Benefits for enrolling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or
while traveling against the advice of a Physician;
26) Pregnancy & maternity:
a. all expenses related to Pregnancy including but not limited to prenatal care, childbirth, miscarriage, abortion, premature
birth, and all complications related to the mother or child,
b. maternity or delivery preparation classes,
c. elective Caesarean section,
d. care or treatment for an individual acting as a surrogate;
27) AIDS/HIV, Acquired Immune Deficiency Syndrome (AIDS), AIDS-related Complex Syndrome (ARC), HIV infection, and all secondary
diseases;
28) Alcohol and Drug Abuse:
a. Treatment related to the detoxification, rehabilitation, and all support service;
b. Treatment of any Sickness or Injury arising directly or indirectly from alcohol or illegal drug abuse or other addiction, or any
drugs or medicines that are not taken in the dosage or for the purposed prescribed;

29) Extended Care: All expenses related to Extended Care from an Extended Care Facility;
30) Hospice Care: Palliative and supportive services to terminally ill Insured’s and their families;
31) Over-the-Counter and Non-Prescription Drugs: Over the counter drugs or non-prescribed drugs or medical devices, even if
recommended by a Physician, including but not limited to the following:
a. Tobacco dependency
b. Weight reduction or appetite suppressant,
c. Cosmetic drugs, even if ordered for non-cosmetic purposes
d. Acne and rosacea drugs (including hormones and Retin-A), except for cystic and pustular acne, Vitamins, supplements, or
herbs.
32) Personal Comfort and Convenience Items: Expense for items that are provided solely for personal comfort or convenience such
as television, private rooms, housekeeping services, guest meals and accommodations, special diets, telephone charges, and take
home supplies.
33) Podiatric Care: Routine foot care, orthopedic shoes or other supportive devices such as; arch supports, orthotic devices, or any
other preventative services or supplies to treat the diagnosis of weak, strained, or flat feet or fallen arches.
34) Search and Rescue: Any expenses relating to search and rescue operations to find a Plan Participant in mountains, at sea, in the
desert, in the jungle and similar remote locations including air/sea rescue charges for evacuation to shore from a vessel or from
the sea;
35) Sexual Dysfunction: Any procedures, supplies, or drugs used to treat male or female sexual enhancement or sexual dysfunction
such as erectile dysfunction, premature ejaculation, and other similar conditions;
36) Sleep Studies: Sleep studies and other treatments relating to sleep apnea;
37) Smoking Cessation: Treatments whether or not recommended by a Physician;

The Insurer shall not be deemed to provide cover and shall not be liable to pay any claim or provide any benefit under this policy to
the extent that the provision of such cover, payment of such claim or provision of such benefit would expose the Insurer to any
sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the
European Union, Bulgaria, Germany, the United Kingdom or the United States of America (provided this does not violate any regulation
or specific national law applicable to the undersigned insurer).

Please refer to your plan document for a detailed listing of all benefits and exclusions. This participant document is only a
summary of your benefits and exclusions.
Insurance Guide for travel to the USA / Canada / Mexico
Your exchange organization has enrolled you in an illness and injury health
insurance policy which is underwritten by KOOPERATIVA poisťovňa, a. s., Vienna
Insurance Group and serviced by One Team Health (OTH). Please contact OTH if
you have any questions regarding your medical benefits, how to file a claim, or
status of a claim you have filed. OTH can also help you find a provider in the
preferred provider organization (PPO) network (Aetna) in the United States.

One Team Health

PMB 309-266 Elmwood Avenue
Buffalo, New York 14222 USA
Email: oneteamhealth@dhig.net
Hotline: 1.844.805.9444*
* For claims questions and if you need help to find a provider, please call the hotline.

Carry your insurance ID card with you at all times.

When you go to a Doctor’s office or to the Hospital, be sure to bring your insurance identification card.

Create your account in MyInsurance and view all

important contact details and service hotlines, search
for a doctor or hospital near your location and view the
summary of your benefits.

If you become ill or injured: How to find

a medical provider within the PPO
Network?

Your policy utilizes the Aetna Passport to Healthcare Network.

Medical providers who belong to this network are considered
preferred providers and have a contract with your policy’s
administrator to bill them direct for services rendered to their
participants. This means for eligible expenses under your
policy, a preferred provider will bill One Team Health (OTH)
direct at the time of service and you would only be responsible
for any deductible or copayment. You can search for a
preferred network provider yourself via the link below or call
OTH for assistance at 1.844.805.9444*

Search for an Urgent Care or Walk-in Clinic at:

Passport to Healthcare
or call Customer Service at: 1.844.805.9444
Pre-Authorization is required for certain services. Call 1-844.805.9444
The following treatments and/or supplies must always be pre-authorized. Failure to Pre-Authorize will result
in 50% reduction of eligible expenses up to $1,000 maximum penalty:
• In-Patient Hospitalization
• Outpatient Surgery
• All CAT scans, MRIs, PET Scans
• Air Ambulance (this service will be coordinated by the underwriter’s Air Ambulance Provider)
• Specialty Treatments and Highly Specialized Drugs
• Physical Therapy and Rehabilitation Services

Medical emergency Notifications must be received within 48 hours of the Admission or procedure.
Please submit a completed Pre-Authorization Request Form to OTH a minimum of 5 business days prior to the
scheduled procedure or treatment date. For more information, please call 1.844.805.9444

Don't use an Emergency Room (ER) unless you are having a serious or life-
threatening medical problem! Unless you have a life-threatening illness or injury,
OTH requires that you contact them for triage prior to seeking medical care.

Services rendered in the emergency room are extremely expensive in the USA so you need to carefully determine
whether or not it is appropriate to go there for treatment. Do not go to the ER only
because it is the only place open or for treatment of a minor illness or injury. There
are alternatives to the ER. In fact, if you go to the ER for a non-serious condition, be
prepared to wait a very long time as patients with more serious conditions will take
priority. In addition, if you are not admitted to the hospital, you will be billed a
$350 copayment in addition to any applicable deductible or co-insurance. Go to the
emergency room only for serious or life threatening conditions such as: uncontrolled
bleeding, difficulty breathing, severe burns, slurred speech, chest pains.

NOTE: Non-Emergency Use of a hospital Emergency Room for an illness that DOES NOT
result in admission will have a 350 USD deductible that must be paid by you, the insured.

Use an Urgent Care or Walk-In Clinic

The alternative to the ER is an Urgent Care Center sometimes referred to as either Walk-In Clinics or Convenient
Care. Urgent Care is for same day treatment, but it is not for serious or life threatening conditions. If the condition you
have is one that you would normally visit your doctor’s office, then you should go to Urgent Care instead of the ER
although Urgent Care is not intended for routine preventive care. Urgent Care has extended hours and is open
weekends and some holidays. No appointment is necessary although you do want to visit one in network if possible
(Passport to Healthcare) - and select Passport to Healthcare Primary PPO
Network or call OTH Customer Service at 1.844.805.9444. Go to Urgent Care for
non-emergency conditions such as:

✓ Sore throat, Common Cold or Respiratory Infections

✓ Ear pain, Eye or Skin Infections
✓ Allergies
✓ Painful urination
✓ Vomiting
✓ Minor injury (sprains/strains)
✓ Minor broken bones (such as hand, fingers, foot, toes)

Search for an Urgent Care or Walk-in Clinic at:

Passport to Healthcare
or call Customer Service at: 1.844.805.9444
 All pre-existing medical conditions are excluded from coverage
under this policy.
Pre-Existing Condition means any Illness or injury, physical or mental condition, for which an
Insured Person received any diagnosis, medical advice or treatment, or had taken any
prescribed drug, or where distinct symptoms were evident prior to the effective date. The
Terms and Conditions related to this plan’s Pre-Existing Conditions are described in the
insurance conditions (available in your MyInsurance Area).

Routine health checkups or preventive

care are NOT covered under this policy.
This policy is only intended to cover you for an eligible illness or injury which you
incur during your program. The policy does not provide any coverage for routine
care such as annual gynecological exams, school or sports physicals, or
immunizations.

How to file a claim?

For detailed information about claims handling and reimbursements
please go to the "File a claim" section under Services and Claims in
your MyInsurance area at www.esecutive.com/MyInsurance.

To access your complete insurance information please login to your personal MyInsurance area at:
www.esecutive.com/MyInsurance