|
Benefits |
Limits |
|
Coverage Area |
Worldwide |
| Overall
Maximum Limit |
$5,000,000
Lifetime |
|
Deductibles Available |
$250,
$500, $1,000, $2,500 or $5,000 per person 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 and expenses are submitted to
Underwriters for review and payment directly to the provider |
|
Coinsurance -- Claims Incurred outside US or Canada |
100% of
Eligible Medical Expenses after the Deductible to the Overall Maximum
Limit |
| Acute
Onset of Pre-existing Condition |
$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 60 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 Physical, 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 for covered Illnesses if hospitalized as
Inpatient and for covered Injuries |
| 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.