Diplomat America Insurance | Be Safe Insurance

Comprehensive benefits plan
For Non-U.S. citizens traveling to U.S.A. only
After deductible, Plan pays 80% of $5,000 and then 100% to policy maximum
Cancelable and Not Renewable
Deductible and Policy Maximum are per coverage period per person
Coverage is available from 15 days to 12 months for ages 14 days to 100 years
No PPO Network
Administrator: Global Underwriters
Underwriter: US Fire Insurance Company
Other Benefits: • Accidental Death and Dismemberment •Coma Benefit •Emergency Dental Treatment (Palliative) •Emergency Medical Evacuation and Repatriation •Emergency Medical Reunion •Felonious Assault Benefit •Home Alteration and Vehicle Modification •Interruption of Trip •Loss of Baggage •Paralysis Benefit •Political and Natural Disaster Evacuation •Return of Minor Child(ren) •Return of Mortal Remains •Seat Belt and Airbag Benefit
Optional Riders: • Athletic, Sports, and Hazardous Activity •Enhanced AD&D •Enhanced Political & Natural Disaster

Benefits

Feature	Coverage
Medical Maximum	Plan A - $50,000, Plan B - $100,000, Plan C - $250,000, Plan D - $500, 000, Plan E - $1,000,000; Persons age 60-69 are eligible for plan A, B, and C. Persons age 70 – 79 are eligible for plans A and B; Persons age 80+ are eligible for a maximum benefit of $20,000.
Co-insurance	After you pay the selected deductible, the plan pays 80% up to $5,000 of eligible costs, then 100% to the Medical Maximum. There will be an additional $250 deductible for each emergency room visit as a result of an Illness. The emergency room deductible will be waived if hospital admittance is within 12 hours of the incident.
Deductible Choices	$0, $50, $100, $250, $500, $1,000, $2,500, $5,000 per person/policy period.
OUTPATIENT TREATMENT
Doctor/ urgent care visits	To policy maximum
Hospital emergency room (all expenses incurred therein)	To policy maximum. Extra $250 penalty/visit if ER visit for a sickness (not injury/accident) does not result in hospital admission within 12 hours of incident
Prescription drugs	To policy maximum
Diagnostic x-rays lab services	To policy maximum
Surgical treatment	To policy maximum
Anesthetist	To policy maximum
Assistant surgeon	To policy maximum
Outpatient surgical facility	To policy maximum
INPATIENT TREATMENT
Hospital room and board including miscellaneous	To policy maximum, average semi-private room
Intensive care unit	To policy maximum, 2 times average semi-private room rate
Surgical treatment	To policy maximum
Anesthetist	To policy maximum
Assistant surgeon	To policy maximum
Physician's non-surgical visits	To policy maximum
Consult physician, when requested by attending physician	To policy maximum
Private duty nurse	To policy maximum
Pre-admission tests within 7 days before hospital admission	To policy maximum
OTHER TREATMENT AND SERVICES
Cardiovascular event	Same as any other eligible medical expense
Local ambulance	To policy maximum
Initial orthopedic prosthesis/brace	To policy maximum
Physical therapy	To policy maximum
Pre-Existing Condition Exclusion	24 Months prior to the start date of coverage
PPO within USA	None
PPO outside USA	None
Hazardous sports	Optional
Benefit period for continued treatment following termination date of policy	52 weeks
DENTAL
Dental - Acute, unexpected pain	100
Dental - Accident related emergency	To policy maximum
TRAVEL BENEFITS
Emergency medical evacuation/repatriation	500000
Return of mortal remains	50000
Emergency reunion	50000
Return of minor child(ren)	50000
Trip interruption	5000
Loss of checked luggage	$50 per bag, $250 max
LIFE
Accidental Death & Dismemberment (AD&D)	25000
Common carrier accidental death	25000
OTHER BENEFITS
Terrorism coverage	To policy maximum
Natural disaster benefit	50000
Renewable	No, This policy is not renewable
Cancellation policy	Before effective date, full refund minus $25 cancellation fee. After effective date, no refund.
Policy durations	Min 15 days to Max 1 year (multiples of 15 days only)