| Benefits |
Limits |
Coverage Area |
Worldwide |
Overall Policy Maximum |
$5,000,000 Lifetime |
Deductibles Available |
$250, $500, $1,000, $2,500 or $5,000 per Certificate Period. |
Coinsurance -- Claims incurred in US or Canada |
80% of the next $5,000 of Eligible Medical Expenses after the Deductible, then 100% to the Overall Maximum Limit. The Coinsurance will be waived if expenses are incurred within the PPO |
Coinsurance -- claims incurred outside US or Canada |
100% of Eligible Medical Expenses after the Deductible to the Overall Policy Maximum. |
Acute Onset of Pre-existing Conditions |
$1,000 during the first Certificate Period and $2,500 during the second Certificate Period |
Pre-existing Conditions |
$5,000 per Certificate Period subject to a Lifetime Maximum of $50,000 (including Acute Onset claims) after 24 months of continuous coverage hereunder |
Maternity |
$5,000 per Pregnancy after 12 months of continuous coverage hereunder, including Inpatient, Outpatient and other benefits as herein provided. Not subject to Coinsurance |
Newborn Care |
$15,000 per covered Pregnancy, including Inpatient, Outpatient and other benefits as herein provided, during the first 31 days of life |
Organ Transplants |
$250,000 Lifetime maximum for covered transplants* |
INPATIENT BENEFITS
(All Subject to Deductible and Coinsurance) |
Hospital Room and Board |
$600 per day, maximum of 240 days per Hospitalization (including ICU days) |
Intensive Care Unit (ICU) |
$1,500 per day, maximum of 240 days per Hospitalization (including non ICU days) |
Lab, x-rays and other covered Inpatient services & supplies |
Usual, Reasonable and Customary Charges (except as limited herein) |
OUTPATIENT BENEFITS
(All Subject to Deductible and Coinsurance) |
Office Visits (Including Physician, Specialist Physician, Psychiatrist, Chiropractor, Surgical Consultant, Physical or Occupational Therapist) |
25 visits per Certificate Period per person as provided herein |
Physician |
$70 per visit |
Specialist Physician |
$70 per visit |
Psychiatrist |
$60 per visit, after 12 months of continuous coverage hereunder |
Chiropractors |
$50 per visit (must be prescribed by another non-Chiropractor Physician) |
Surgical Consultant |
$500 per consultation prior to Surgery |
Physical or Occupational Therapy |
$50 per visit (must be prescribed by a Physician who is not affiliated with the Physical Therapy practice) |
X-rays |
$250 per exam (includes Sonograms, Ultrasounds and diagnostic Mammograms) |
Laboratory |
$300 per exam (includes all procedures carried out on one specimen) |
Emergency Room |
Usual, Reasonable and Customary |
Local Ambulance |
$1,500 per Certificate Period per person |
INPATIENT or OUTPATIENT BENEFITS
(All Subject to Deductible and Coinsurance) |
Prescription Medications |
Usual, Reasonable and Customary |
Surgery |
Usual, Reasonable and Customary |
Assistant Surgeon |
20% of Surgeon benefit |
Anesthesiologist |
20% of Surgeon benefit |
Midwife Services |
$500 per covered Pregnancy |
MRI, CAT Scan, Echocardiography, Endoscopy, Gastroscopy, Colonoscopy and Cystoscopy |
$600 per exam |
Chemotherapy and Radiation Therapy |
Usual, Reasonable and Customary |
WELLNESS BENEFITS
(Not Subject to Deductible) |
Well Child (under age 19) |
$50 per visit for a maximum of 3 visits per Certificate Period (included in Office Visit limit), after 12 months of continuous coverage hereunder |
Wellness (Adult 19+) |
$250 per Certificate Period, after 24 months of continuous coverage hereunder, including Office Visit for $70 and X-Ray and Lab for $180 |
OTHER BENEFITS
(All Subject to Deductible and Coinsurance) |
Durable Medical Equipment |
Usual, Reasonable and Customary charges for Wheelchair, Hospital Bed, and/or Toilet |
Emergency Medical Evacuation |
$50,000 Per Certificate Period |
Repatriation of Remains |
$25,000 Lifetime Maximum |
Emergency Reunion |
$5,000 Lifetime Maximum |
*Covered transplants include Heart, Heart/Lung, Lung, Kidney, Kidney/Pancreas, Liver and Allogenic and Autologous Bone Marrow.
