| Medical Maximum per Policy: | $50,000, $100,000, $250,000, $500,000, $1,000,000 |
| Deductible Options per Policy: | $0, $50, $100, $250, $500, $1,000, $2,500, $5,000 |
| Co-insurance per Policy: | 80% of the first $5,000 of Covered Expenses then 100% up to the policy maximum
After you pay your deductible this plan will pay 80% of the first $5,000 of Covered Expenses then 100% up to the policy maximum. This plan covers Accident and Sickness Medical Expenses after the Insured satisfies any Deductible, without regard to any other Health Care Plan Benefits or to any Coordination of Benefits provision in any other Health Care Plan payable.
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| Medical Expense Benefits (subject to Policy Maximum, Deductible and Co-Insurance) | |
| Hospital Room and Board Charges: | The average semi private room rate |
| ICU Room and Board Charges: | three times the average semi private room rate |
| Outpatient Medical: | Usual customary charge to the selected Medical Maximum |
| Emergency Medical Treatment of Pregnancy: | $1,000 per Policy Period |
| Mental or Nervous Disorders: | $2,500 per Policy Period |
| Physiotherapy/Physical Medicine/ Chiropractic: | $50 per visit per day; up to 10 visits per Policy Period |
| Dental Treatment (Injury and emergency alleviation of pain): | $250 per Policy Period |
| Doctor Visits, X-rays and Prescriptions, Ambulance: | Usual customary charge to the selected Medical Maximum |
| Unexpected Recurrence of a Pre-existing Condition: | The first $1,000 of Covered Expenses
The pre-existing condition exclusion is waived for the first $1,000 of Covered Expenses resulting from a sudden, unexpected recurrence of a Preexisting Condition while traveling in the United States. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the Effective Date of coverage.
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| Benefit Period: | 1 year from the date of the Covered Accident or Sickness |
| Additional Benefits (not subject to Policy Maximum, Deductible or Co-Insurance) | |
| Accidental Death & Dismemberment Principal Sum: | $25,000 |
| Coma Benefit: | $10,000 |
| Felonious Assault and Violent Crime: | 100% up to $50,000 |
| Adaptive Home and Vehicle: | $5,000 |
| Seatbelt Benefit: | 10% up to $50,000 |
| Airbag Benefit: | 10% up to $50,000 |
| Hijacking and Air or Water Piracy: | Covered |
| Emergency Medical Evacuation: | 100% up to $2,000,000 |
| Political/Natural Disaster Evacuation: | $25,000 |
| Repatriation of Remains: | 100% up to $1,000,000 |
| Emergency Reunion: | $15,000 |
| Return of Minor Child(ren) or Travel Companion: | $5,000 |
| Hospital Confinement: | $50 per day 10 day Maximum |
| Basic Lost Baggage: | $1,000 per Policy Period |
| Trip Interruption: | $5,000 per Policy Period |
| Optional Benefits | |
| Enhanced Baggage | Up to $3,500 |
| Upgrade AD&D | Up to $1,000,000 |
| Home Country Coverage/Follow Me Home Coverage | See benefit page 11 in brochure |
| Athletic Sports Coverage | See benefit page 12 in brochure |
| Hazardous Activities | See benefit page 12 in brochure |
