| Deductibles: |
$0, $100, $250, $500, $1,000 or $2,500 per Certificate
Period. |
| Coinsurance - Claims incurred in US or Canada: |
For the Certificate Period, Underwriters will pay 80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit. Coinsurance will be waived if expenses are incurred within the PPO and expenses are submitted to Underwriters for review and payment directly to the provider |
| Coinsurance - Claims incurred outside US or Canada:
|
For the Certificate Period, Underwriters will pay 100%
of Eligible Expenses after the Deductible up to the Overall Maximum
Limit. |
| Hospital Room and Board: |
Average Semi-private room rate, including nursing
services. |
| Intensive Care Unit: |
Usual, Reasonable and Customary charges |
| Outpatient Treatment: |
Usual, Reasonable and Customary charges |
| All Other Eligible Expenses: |
Usual, Reasonable and Customary charges. |
| Acute Onset of Pre-existing Condition: |
$15,000 Lifetime Limit for Eligible Medical Expenses
$25,000 Lifetime Limit for Emergency Medical Evacuation
(Only available to Members under age 70) |
| Emergency Dental |
Accident Overall Maximum Limit
Acute Onset of Pain - $100 limit per Certificate Period (not subject to Deductible or Coinsurance) |
| Local Ambulance: |
Usual, Reasonable and Customary charges. |
| Emergency Medical Evacuation: |
$500,000 Maximum Lifetime Limit, except as provided under Acute Onset of Pre-existing Condition (not subject to Deductible or Coinsurance) |
| Repatriation of Remains: |
Overall Maximum Limit (not subject to Deductible or Coinsurance) |
| Emergency Reunion: |
$15,000 limit per Certificate Period (not subject to Deductible or Coinsurance) |
| Trip Interruption: |
$5,000 limit per Certificate Period (not subject to Deductible or Coinsurance) |
| Lost Checked Luggage: |
$250 limit per Certificate Period (not subject to
Deductible or Coinsurance) |
| Hospital Indemnity: |
$100 per day (not subject to Deductible or Coinsurance) |
| Terrorism: |
$50,000 Maximum Lifetime Limit, Eligible Medical Expenses only |
| Accidental Death and Dismemberment: |
Not subject to Deductible or Coinsurance
Lifetime Maximum - $25,000 Principal Sum
$25,000 Adults age 18-69
$12,500 Adults age 70-74
$ 6,250 Adults age 75 and above
Lifetime Maximum - $5,000
$ 5,000 Children age 17 and below |
| Common Carrier Accidental Death: |
$50,000 per adult, $25,000 children under age 18; $250,000 Maximum per family (not subject to Deductible or Coinsurance). |
| Hospital Pre-Notification Penalty: |
50% of Eligible Medical Expenses. |
| Optional Sports Rider: |
Overall Maximum limit |
| Return of Minor Children |
$5,000 limit per Certificate Period (not subject to Deductible or Coinsurance) |
| Physical Therapy |
$50 per visit |
| Natural Disaster Benefit |
Maximum $100 a day for 5 days (not subject to Deductible or Coinsurance) |
| Maximum per Injury / Illness |
Age 14 days to 69 - $50,000, $100,000, $200,000, $500,000 or $1,000,000; Age 70 to 79 - $50,000; Age 80 or older - $10,000 |
| Overall Maximum Limit per Certificate Period (includes all benefits except Accidental Death and Dismemberment, Emergency Medical Evacuation and Common Carrier Accidental Death): |
Age 14 days to 69 - $50,000, $100,000,
$200,000, $500,000 or $1,000,000.
Age 70 to 79 - $50,000
Age 80 or older - $10,000. |
