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) |