BENEFIT | LIMIT |
---|---|
Deductibles | $0, $100, $250, $500, $1,000 or $2,500 per certificate period. |
Coinsurance - Claims incurred in U.S. 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 are submitted to underwriters for review and payment directly to the provider. |
Coinsurance - Claims incurred out- side U.S. 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. |
Local Ambulance | Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient. |
Intensive Care Unit | Usual, reasonable and customary charges. |
Emergency Room Co-payment | In addition to coinsurance, the member shall be responsible for a $200 co-payment for each use of emergency room for an Illness unless the member is admitted to the hospital. There will be no copayment for emergency room treatment of an injury. |
Urgent Care Center | For each visit, the member shall be responsible for a $50 co-payment, after which coinsurance will apply. Not subject to deductible. |
Hospital Indemnity (in addition to medical expenses) | $100 per day of inpatient hospitalization for member's use to offset miscellaneous expenses (not subject to deductible or coinsurance). |
Physical Therapy | $50 maximum per day. |
All Other Eligible Medical Expenses | Usual, reasonable and customary charges. |
Acute Onset of Pre-existing Condition (only available to members younger than 70) | Limited benefit up to the medical coverage maximum (excludes chronic and congenital conditions). $25,000 lifetime maximum for emergency medical evacuation. |
Emergency Dental (acute onset of pain) | $250 limit per certificate period (not subject to deductible or coinsurance). |
Emergency Medical Evacuation | $1,000,000 lifetime maximum, except as provided under acute onset of pre-existing condition (not subject to deductible or coinsurance). |
Return of Minor Children | $50,000 per certificate period (not subject to deductible or coinsurance). |
Pet Return | Up to $1,000 to return a traveling pet home if member is hospitalized. |
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). |
Natural Disaster | Maximum $100 a day for 5 days (not subject to deductible or coinsurance). |
Trip Interruption | $5,000 limit per certificate period (not subject to deductible or coinsurance). |
Trip Delay | $100 for a 12-hour delay requiring an unplanned overnight stay (2 days maximum). |
Lost Checked Luggage | $500 limit per certificate period (not subject to deductible or coinsurance). |
Political Evacuation | $10,000 lifetime maximum (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; $250,000 maximum benefit per one family or group) | Not subject to deductible or coinsurance. |
Members up to age 18 | Lifetime max. - $5,000; Death - $5,000; Loss of 2 limbs - $5,000; Loss of 1 limb - $2,500. |
Members age 18 through 69 | Lifetime max. - $50,000; Death - $50,000; Loss of 2 limbs - $50,000; Loss of 1 limb - $25,000. |
Members age 70 through 74 | Lifetime max. - $12,500; Death - $12,500; Loss of 2 limbs - $12,500; Loss of 1 limb - $6,250. |
Members age 75 and older | Lifetime max. - $6,250; Death - $6,250; Loss of 2 limbs - $6,250; Loss of 1 limb - $3,125. |
Common Carrier Accidental Death ($250,000 maximum benefit per any one family or group) | Not subject to deductible or coinsurance. Up to age 18 - $25,000 per member; Age 18 to 69 - $50,000 per member; Age 70 to 74 - $12,500 per member; Age 75 and older - $6,250. |
Hospital Pre-certification Penalty | 50% of eligible medical expenses. |
Overall Maximum Limit Per Certificate Period | Age 80 or older - $10,000; Age 70 to 79 - $50,000, $100,000; All others - $50,000, $100,000, $200,000, $500,000 or $1,000,000. |
Crisis Response | $10,000 limit per certificate period; Includes access to Unity Crisis Group services. |
Personal Liability | $10,000 lifetime maximum. |
Bedside Visit | $1,500 (economy ticket for family member to visit if member admitted to ICU). |