4 Ever Life Insurance Company
2 Mid America Plaza, Suite 200
Oakbrook Terrace, Illinois 60181
(800) 621-9215
Administrative Office: c/o Worldwide Insurance Services, One Radnor Corporate Center, Suite 100, Radnor, Pennsylvania 19087

Certificate of Coverage

Global Citizens Association

Navigator
Group Short Term Medical Coverage

Non-Renewable
Certificate of Coverage Number: 4EL-5007-14
Effective Date: July 1, 2014

The Insurance Coverage Area is any place that is anywhere in the world.
The benefits provided by this Certificate are not subject to the guaranteed renewability and portability provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Insured Person may not purchase insurance for a period longer than the current Period of Coverage.

Table of Contents
I.

Introduction

Page 2

II.

Who is eligible for coverage?

Page 8

III.

Definitions

Page 11

IV.

How the Plan Works

Page 21

V.

Benefits: What the Plan Pays

Page 23

VI.

Exclusions and Limitations: What the Plan does not pay for

Page 29

VII.

Prescription Drug Benefits

Page 31

VIII.

General Provisions

Page 34

Limited Benefit, Please Read Carefully

1
Form 54.1403

I. Introduction
About This Plan
This Certificate of Coverage is issued by 4 Ever Life Insurance Company (“Insurer”) through a policy issued to the Global Citizen Association.
In this Plan, “Insurer” means the 4 Ever Life Insurance Company. The “Eligible Participant” is the person who meets the eligibility criteria of this
Certificate. The term “Insured Person,” means the Eligible Participant and any Insured Dependents.
The benefits of this Plan are provided only for those services that the Insurer determines are Medically Necessary and for which the Insured Person has benefits. The fact that a Physician prescribes or