| Deductibles: |
$0, $100, $250, $500, $1,000, $2,500 or $5,000 per Certificate
Period. |
| Coinsurance - Claims incurred in US: |
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 - Claims incurred outside US:
|
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: |
Up to the overall maximum |
| Outpatient Treatment: |
Up to the overall maximum |
| All Other Eligible Expenses: |
Up to the overall maximum. |
| Acute Onset of Pre-existing Condition: |
Overall Maximum Limit (excludes chronic and
congenital conditions). $25,000 lifetime maximum for emergency medical evacuation.
(Only available to Members under age 70) |
| Emergency Dental (acute onset of pain) |
Accident Overall Maximum Limit
Acute Onset of Pain - $250 limit per Certificate Period (not subject to Deductible or Coinsurance) |
| Local Ambulance: |
Up to the overall maximum, when covered illness or injury results in hospitalization as inpatient |
| Emergency Medical Evacuation: |
$1,000,000 Maximum Lifetime Limit (Not Subject to Deductible or Coinsurance ) |
| Repatriation of Remains: |
Overall Maximum Limit (Not Subject to Deductible or Coinsurance ) |
| Emergency Reunion: |
$50,000 limit per Certificate Period, subject to a maximum of 15 days (not subject to Deductible or Coinsurance) |
| Trip Interruption: |
$5,000 limit per Certificate Period (not subject to Deductible or Coinsurance) |
| Lost Checked Luggage: |
$500 limit per Certificate Period (Not Subject to Deductible or Coinsurance ) |
| Hospital Indemnity: |
$100 per day of inpatient hospitalization (not subject to Deductible or Coinsurance) |
| Terrorism: |
$50,000 Maximum Lifetime Limit, Eligible Medical Expenses only |
| Accidental Death and Dismemberment (excludes loss due to common carrier accident): |
Not subject to Deductible or Coinsurance
Members age 18 and older
Lifetime Maximum - $25,000
Death - $25,000
Loss of 2 limbs - $25,000
Loss of 1 limbs - $12,500
Benefits reduce 50% at age 70 and an additional 50% at age 75
Members under 18
Lifetime Maximum - $5,000
Death - $5,000
Loss of 2 limbs - $5,000
Loss of 1 limbs - $2,500
$250,000 maximum benefit any one family |
| Common Carrier Accidental Death: |
Members under age 18: $25,000, Members age 18 - 69: $50,000, Members age 70 - 74: $12,500, Members age 75 and older: $6,250. $250,000 Maximum per family. |
| Hospital Pre-Notification Requirement: |
Hospital Pre-Notification is not required with this insurance plan. |
| Sports Coverage: |
Injuries due to non-contact and non-organized amateur sports and athletic activities (see also sports in Features/Exclusions) |
| Return of Minor Children: |
$50,000 limit per Certificate Period (not subject to Deductible or Coinsurance) |
| Physical Therapy and Chiropractic: |
$50/day maximum (must be ordered by physician) |
| Natural Disaster Benefit: |
Maximum $100 a day for 5 days (not subject to Deductible or Coinsurance) |
| Overall Maximum Limit per Certificate Period (includes all benefits except Accidental Death and Dismemberment, Emergency Medical Evacuation and Common Carrier Accidental Death, Personal Liability and Crisis Response): |
Age 70 to 79 - $50,000, $100,000
Age 80 or older - $10,000 (Atlas International only)
All others - $50,000, $100,000, $200,000, $500,000, $1 Million or $2 Million. |
| Political Evacuation: |
$10,000 lifetime maximum (not subject to Deductible or Coinsurance) |
