| 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 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. |
| Coinsurance – Claims incurred outside 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 | Usual, Reasonable and Customary charges up to Overall Maximum Limit. |
| Local Ambulance | Usual, Reasonable and Customary charges up to Overall Maximum Limit. |
| Intensive Care Unit | Usual, Reasonable and Customary charges up to Overall Maximum Limit. |
| 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 up to the Overall Maximum Limit. |
| Physical Therapy and Chiropractic Care | Usual, Reasonable and Customary charges up to Overall Maximum Limit. |
| 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 |
| All Other Eligible Medical Expenses | Usual, Reasonable, and Customary charges up to the Overall Maximum Limit. |
| 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 |
| Return of Minor Children | $50,000 (not subject to Deductible or Coinsurance) |
| Repatriation of Remains | $50,000 (not subject to Deductible or Coinsurance) |
| Emergency Reunion | $15,000, 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) |
| Lost or Stolen Passport/Travel Visa | $100 (not subject to Deductible or Coinsurance) |
| Trip Interruption | $5,000 (not subject to Deductible or Coinsurance) |
| Lost Checked Luggage | $250 limit per bag; $500 per Certificate Period (not subject to Deductible or Coinsurance) |
| Political Evacuation | $50,000 Maximum Lifetime Limit (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 and Emergency Medical Evacuation) | Age 80 or older $10,000; Age 70 to 79: $50,000; All others: $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.