Benefit Description
Subject to deductible and
coinsurance unless otherwise noted |
Silver |
Gold |
Platinum |
|
Coverage Area |
Two
options: worldwide or worldwide
excluding the U.S. and Canada |
Two
options: worldwide or worldwide
excluding the U.S. and Canada |
Two
options: worldwide or worldwide
excluding the U.S. and Canada |
|
Policy Maximum |
$5,000,000
lifetime per individual |
$5,000,000
lifetime per individual |
$8,000,000
lifetime per individual |
|
Deductible |
Ranges from $250
to $10,000 per period of coverage, 50% reduction within PPO |
Ranges from $250
to $10,000 per period of coverage, 50%
reduction within PPO, Carry forward deductible - last 30 days of
certificate year |
Ranges from $100
to $10,000 per period of coverage, 50% reduction within PPO,
Carry forward deductible - last 30 days of certificate year |
|
Family
Deductible |
3x the single |
3x the single |
2x the single |
|
Coinsurance within the U.S. and Canada |
80% of the next
$5,000 of eligible expenses after the deductible, then 100% to
the overall maximum per period of coverage |
80% of the next
$5,000 of eligible expenses after the deductible, then 100% to
the overall maximum per period of coverage |
90% of the next
$5,000 of eligible expenses after the deductible, then 100% to
the overall maximum per period of coverage |
|
Coinsurance within the PPO network and
outside the U.S. and Canada |
100% |
100% |
100% |
|
Hospitalization / Room & Board |
$600 per day
(maximum of 240 consecutive days per covered event) |
Average semi-private room rate |
Private room rate |
|
Intensive Care
Unit |
$1,500 per day
(maximum of 180 consecutive days per covered event) |
Usual,
Reasonable and Customary (URC) |
Usual,
Reasonable and Customary (URC) |
|
Surgery |
URC |
URC |
URC |
|
Anesthetist's Charges Associated with
Surgery |
20% of surgery benefit |
URC |
URC |
|
Transplants |
$250,000
per transplant |
$1,000,000
lifetime maximum |
$2,000,000
lifetime maximum |
|
Outpatient |
Visits/Exams -
25 visits per insured
person per period of coverage to the maximum limit as outlined:
physician
$70; specialist $70;
psychiatrist $60;
chiropractor
$50;
surgical
intervention consultation
$500;
X-rays - $250 per exam maximum limit;
Lab Tests -
$300 per exam maximum limit |
URC |
URC |
|
Rx Coverage |
URC |
URC |
URC |
|
Emergency Room Illness |
URC
-
subject to an additional $250 deductible if not admitted |
URC
-
subject to an additional $250 deductible if not admitted |
URC
-
subject to an additional $250 deductible if not admitted |
|
Emergency Room Accident |
URC |
URC |
URC |
|
Local Ambulance |
$1,500
per covered event - not subject to deductible or coinsurance |
URC |
URC |
|
Emergency
Evacuation |
$50,000
per period of coverage - not subject to deductible or
coinsurance |
Limited to
policy maximum - not subject to deductible or coinsurance |
Limited to
policy maximum - not subject to deductible or coinsurance |
|
Emergency
Reunion |
NA
(Not Applicable) |
$10,000
lifetime maximum |
$10,000
lifetime maximum |
|
Return of Mortal Remains |
$25,000
lifetime maximum per insured - not subject to deductible or
coinsurance |
$25,000
lifetime maximum per insured -not
subject to deductible or coinsurance |
$50,000
lifetime maximum per insured -not subject to deductible or
coinsurance |
|
Maternity |
Optional Rider -
$50,000 lifetime
maximum, maximum of $5,000 for normal delivery, $7,500 for
C-section, $200 child wellness benefit for first 12 months - not
subject to deductible or coinsurance.
Available after 10 months of
coverage benefits reduced by 50% for births that occur in11th or
12th month of continuous coverage |
Optional Rider -
$50,000 lifetime
maximum, maximum of $5,000 for normal delivery, $7,500 for
C-section, $200 child wellness benefit for first 12 months - not
subject to deductible or coinsurance.
Available after 10 months of
coverage benefits reduced by 50% for births that occur in11th or
12th month of continuous coverage |
Same As Any
Illness (SAAI) $1,000 additional deductible, $50,000 lifetime
maximum, $200 child wellness benefit for first 12 months.
Available after 10 months of
coverage |
|
Supplemental
Accident |
NA |
$300
per occurrence - not subject to
deductible or coinsurance |
$500
per occurrence - not subject to deductible or coinsurance |
|
Mental/Nervous |
Outpatient only
-
(see Outpatient) Available after 12 months of continuous coverage |
$10,000
per period of coverage up to a $50,000 lifetime maximum.
Available after 12
months of continuous coverage |
SAAI
$50,000 lifetime maximum.
Available after 12 months of
continuous coverage |
|
Adult Wellness |
NA |
$250 per period
of coverage - not subject to deductible or coinsurance
Available for those 30 years of
age and over after 12 months of continuous coverage |
$500 per period
of coverage - not subject to deductible or coinsurance
Available for those 18 years of
age and over after 12 months of continuous coverage |
|
Child Wellness |
Three visits per
period of coverage -maximum $70 per visit.
Available for children under 18
years of age after 12 months of continuous coverage |
$200 maximum per
period of coverage -not subject to deductible or coinsurance
Available for children
under 18 years of age after 12 months of continuous coverage |
$400 maximum per
period of coverage - not subject to deductible or coinsurance
Available for children
under 18 years of age after 12 months of continuous coverage |
|
Other Services |
Extended Care -
limited to first 30
days of confinement
Radiation
Treatment - URC
Home Nursing Care
- limited 30 days per
covered event
Hospice Care -
limited 30 days per
covered event
Prosthetic
Devices - all URC |
URC |
URC |
|
Physical
Therapy |
Maximum $40 per
visit 30 visit maximum per period of coverage |
Maximum $50 per visit |
Maximum $50 per visit |
|
High School
Sports Injury |
NA |
NA |
Up to $5,000 maximum |
|
Recreational
SCUBA |
NA |
URC |
URC |
|
Remote
Transportation |
NA |
NA |
Limited to
$5,000 per certificate period up to a $20,000 lifetime maximum |
|
Political Evacuation and Repatriation |
NA |
NA |
Limited to $10,000 lifetime
maximum |
|
Complementary Medicine |
NA |
Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period
of coverage |
Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period
of coverage |
|
Non-emergency
Dental |
NA |
NA |
Calendar year
maximum - $750
Individual deductible - $50
Schedule of benefits -
Class I: 90% Class II: 70%
Class III: 50% Ortho 0%
(6 month waiting period) |
|
Emergency Dental due to
Accident |
$1,000 per period of coverage |
URC |
URC |
|
Emergency Dental due to Sudden
Unexpected Pain |
NA |
$100 per period of coverage |
See non-emergency dental
benefits |
|
Vision |
NA |
NA |
Exams - up to
$100 per 24 months
Materials - up to $150 per 24 months |
|
Global Concierge & Assistance Services |
NA |
NA |
Included |
|
Pre-existing
Conditions |
$5,000 per
period of coverage up to a $50,000 lifetime maximum.
Available after 24 months of
continuous coverage |
$5,000 per
period of coverage up to a $50,000 lifetime maximum.
Available after 24 months of
continuous coverage |
SAAI |
|
NA (Not Applicable) /
URC (Usual, Reasonable and Customary) / SAAI
(Same As Any Illness) |
