What Are The Policy Limits?
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Benefit
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Coverage Area
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Worldwide
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Overall Policy Maximum
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$5,000,000 Lifetime
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Deductibles Available
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$250, $500, $1,000 or $2,500 per Certificate Period.
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Coinsurance -- Claims incurred in US or Canada
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80% of the next $5,000 of Eligible Medical Expenses
after the Deductible, then 100% to the Overall Policy Maximum. The
Coinsurance will be waived if expenses are incurred within the PPO.
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Coinsurance -- claims incurred outside US or Canada
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100% of Eligible Medical Expenses after the Deductible
to the Overall Policy Maximum.
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Hospital Room and Board -- In US or Canada
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Average Semi-private room rate.
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Hospital Room and Board -- Outside US or Canada
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Average Private room rate.
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Intensive Care Unit -- In US or Canada
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Usual, Reasonable and Customary.
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Intensive Care Unit -- Outside US or Canada
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Usual, Reasonable and Customary.
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Mental or Nervous Disorders
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$10,000 per Certificate Period (after 12 months of
continuous coverage); $25,000 Lifetime Maximum.
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Maternity -- Normal Delivery
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Same as any other Illness (after 12 months of continuous
coverage) including pre-natal, Delivery and post-natal care.
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Maternity -- Complicated Delivery
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Same as any other Illness (after 12 months of continuous
coverage).
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Maximum for Maternity
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$50,000 Lifetime
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Newborn Care
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$25,000 Maximum Limit for maximum of 31 days.
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Pre-existing Conditions
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Same as any other Injury or Illness if disclosed on
Application and not excluded or limited by Rider.
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Local Ambulance
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Usual, Reasonable and Customary.
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Physical Therapy
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$50 Maximum per visit.
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Wellness
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$50 per visit (including immunizations), maximum of
3 visits per year for children under the age of 19(after 12 months
of continuous coverage). $150 per Certificate Period (after 12
months of continuous coverage) for Members age 35 or older. Not
subject to Deductible.
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Human Organ/Tissue Transplants
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Same as any other Illness for Covered Transplants.
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All Other Eligible Expenses
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Usual, Reasonable and Customary.
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Emergency Medical Evacuation
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$50,000 Lifetime Maximum.
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Repatriation of Remains
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$25,000 Limit
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Emergency Reunion
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$10,000 Lifetime Maximum.
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Pre-certification Penalty
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50%
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Prescription Drugs
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Usual, reasonable and customary (subject to deductible
and co-insurance)
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Benefit
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Coverage Area
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Worldwide, except US and Canada
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Overall Policy Maximum
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$1,000,000 Lifetime
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Deductibles Available
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$250, $500, $1,000 or $2,500 per Certificate Period.
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Coinsurance–Claims incurred in US or Canada
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No coverage in US or Canada.
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Coinsurance–claims incurred outside US or Canada
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100% of Eligible Medical Expenses after the Deductible
to the Overall Policy Maximum.
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Hospital Room and Board–In US or Canada
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No coverage in US or Canada.
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Hospital Room and Board–Outside US or Canada
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Average Private room rate.
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Intensive Care Unit–In US or Canada
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No coverage in US or Canada.
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Intensive Care Unit–Outside US or Canada
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3 times the Average Private room rate.
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Mental or Nervous Disorders
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$5,000 per Certificate Period (after 24 months of
continuous coverage); $10,000 Lifetime Maximum.
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Maternity–Normal Delivery
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$3,500 per Pregnancy (after 24 months of continuous
coverage) including pre-natal, Delivery and post-natal care.
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Maternity–Complicated Delivery
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$6,000 per Pregnancy (after 24 months of continuous
coverage) including pre-natal, Delivery and post-natal care.
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Maximum for Maternity
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$10,000 Lifetime
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Newborn Care
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$5,000 Maximum Limit for maximum of 31 days.
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Pre-existing Conditions
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$25,000 Lifetime Maximum (after 24 months of continuous
coverage).
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Local Ambulance
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$1,000 Lifetime Maximum.
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Physical Therapy
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No coverage.
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Wellness
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No coverage.
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Human Organ/Tissue Transplants
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Same as any other Illness for Covered Transplants.
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All Other Eligible Expenses
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Usual, Reasonable and Customary.
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Emergency Medical Evacuation
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No coverage.
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Pre-certification Penalty
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50%
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Age
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Basic Life Principal Sum
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Supplemental Life Principal Sum
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19 to 59
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$50,000
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$50,000
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60 to 64
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$25,000
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$25,000
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65 to 69
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$10,000
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Not Available
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Dependent Child
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$5,000
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Not Available
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Accidental Death
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Principal Sum
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Accidental Loss of Two Members
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Principal Sum
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Accidental Loss of One Member
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50% of Principal Sum
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The Benefit is based on your age at time of Death or Dismemberment.
"Member" means hand, foot or eye.
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