| SCHEDULE OF BENEFITS AND LIMITS |
| Deductibles : |
$100, $250, $500, $1,000 or $2,500 per
Certificate Period. |
| Coinsurance - Claims
incurred in US or Canada: |
For the Certificate Period,
Underwriters will pay 80% of the next $5,000 of Eligible Expenses
after the Deductible, then 100% to the Overall Maximum Limit. |
| Coinsurance - Claims incurred outside US 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: |
Average Semi-private room rate, including
nursing services. |
| Intensive Care Unit: |
Usual, Reasonable and Customary charges |
| Outpatient Treatment: |
Usual, Reasonable and Customary charges |
| All Other Eligible Expenses: |
Usual, Reasonable and Customary charges. |
| Acute Onset of Pre-existing Condition:
|
Atlas Extra - $2,500 limit; Atlas
International - $1,000 Limit; Atlas America - No Coverage |
| Emergency Dental - Acute onset of pain: |
$100 limit per Certificate Period |
| Local Ambulance: |
Usual, Reasonable and Customary charges. |
| Emergency Evacuation: |
Overall Maximum Limit |
| Repatriation of Remains: |
Overall Maximum Limit |
| Emergency Reunion: |
$10,000 limit per Certificate Period |
| Trip Interruption: |
$5,000 limit per Certificate Period
|
| Lost Checked Luggage: |
$250 limit per Certificate Period (not subject to Deductible
or Coinsurance) |
| Accidental Death and Dismemberment:
|
Death - $25,000 Loss of 2 Limbs -
$25,000 Loss of 1 Limb - $12,500 .Benefits reduce 50% at age 70 and
an additional 50% at age 75. |
| Common Carrier Accidental Death: |
$50,000 |
| Hospital Pre-Certification Penalty:
|
50% of Eligible Medical Expenses. |
| Optional Hazardous Sports Rider: |
Overall Maximum Limit |
| Overall Maximum Limit per Certificate Period (includes
all benefits except Accidental Death and Dismemberment and Common
Carrier Accidental Death): |
Age 14 days to 69 - $50,000, $100,000, $250,000, $500,000
or $1,000,000.
Age 70 to 79 - $50,000
Age 80 or older - $10,000. |
| Return of Minor Children |
$5,000 limit |
| Physical Therapy |
$50 per visit |
