| Benefit | Limit |
|---|---|
| Deductibles | $0, $100, $250, $500, $1,000 or $2,500 per Certificate Period |
| Coinsurance – Claims incurred in U.S. | For Home Country Coverage or during a Benefit Period, Underwriters will pay 90% of the next $10,000 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 expenses are submitted to Underwriters for review and payment directly to the provider. There is no U.S. coverage unless Member is under Home Country Coverage or a Benefit Period. |
| Coinsurance – Claims incurred outside U.S. or Canada | Underwriters will pay 100% of Eligible Expenses after the Deductible up to the Overall Maximum Limit |
| Hospital Room and Board | Usual, Reasonable and Customary charges |
| 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 | The Member shall be responsible for a $250 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. |
| Outpatient Treatment | Usual, Reasonable, and Customary charges |
| Physical Therapy and Chiropractic Care | Usual, Reasonable and Customary charges |
| Hazardous Activities (Available only under the optional Hazardous Activities Rider) | Overall Maximum Limit |
| Intercollegiate or Interscholastic Sports (Available only under the optional Intercollegiate Sports Rider) | Usual, Reasonable and Customary charges up to $20,000 |
| Mental Health Disorders | Usual, Reasonable and Customary charges up to $5,000 |
| Hospital Indemnity | $100 per day of Inpatient hospitalization for a maximum amount of $500 (not subject to Deductible or Coinsurance). |
| All Other Eligible Medical Expenses | Usual, Reasonable, and Customary charges |
| Acute Onset of Pre-existing Condition | For members age 14 days through age 64 inclusive, $10,000; for members Age 65 and over, $2,500 |
| Emergency Dental Treatment due to Accident | $1,000 |
| Emergency Dental (Acute Onset of Pain) | $100 (not subject to Deductible or Coinsurance) |
| Emergency Medical Evacuation | $250,000 Maximum Lifetime Limit (not subject to Deductible or Coinsurance) |
| Return of Minor Children | $50,000 (not subject to Deductible or Coinsurance) |
| Repatriation of Remains | $50,000 (not subject to Deductible or Coinsurance) |
| Political Evacuation | $50,000 Maximum Lifetime Limit (not subject to Deductible or Coinsurance) |
| Lost or Stolen Passport/Travel Visa | $100 (not subject to Deductible or Coinsurance). |
| Trip Interruption | $5,000 (not subject to Deductible or Coinsurance). |
| Emergency Reunion | $15,000, maximum of 15 days (not subject to Deductible or Coinsurance) |
| Natural Disaster | Maximum $100 a day for 5 days (not subject to Deductible) |
| Lost Checked Luggage | $250 limit per bag; $500 per Certificate Period (not subject to Deductible or Coinsurance). |
| Terrorism | $50,000 Maximum Lifetime Limit, Eligible Medical Expenses only |
| Overall Maximum Limit per Certificate Period (includes all benefits except Accidental Death and Dismemberment, Emergency Medical Evacuation and Common Carrier Accidental Death) | Age 80 or older $10,000; Age 70 to 79: $50,000; All others: $25,000, $50,000, $100,000, $200,000, $500,000 or $1,000,000. |
| Accidental Death and Dismemberment Members | |
| under age 18. | Lifetime Maximum - $5,000 Death – Principal Sum Loss of 2 Limbs – Principal Sum Loss of 1 Limb - 50% of Principal Sum |
| Members age 18 to age 70. | Lifetime Maximum - $50,000 Death – Principal Sum Loss of 2 Limbs – Principal Sum Loss of 1 Limb - 50% of Principal Sum |
| Members age 70 to age 74 inclusive. | Lifetime Maximum - $20,000. Death – Principal Sum Loss of 2 Limbs – Principal Sum Loss of 1 Limb - 50% of Principal Sum |
| Members Age 75 and over: | Lifetime Maximum - $10,000 Death – Principal Sum Loss of 2 Limbs – Principal Sum Loss of 1 Limb - 50% of Principal Sum |
| *$250,000 Maximum Benefit any one family or Group |
The term Usual, Reasonable and Customary charges (URC) refers to the prevailing charges for services delivered within a geographic area.