Summary of Benefits
All amounts shown are in U.S. dollars.
|Choice of Coverage Area||1) Worldwide 2) Worldwide excluding U.S. & Canada 3) Country of Assignment|
|Maximum Lifetime Benefit per person||$50,000 - $8,000,000|
|Deductible - Calendar Year||$0 - $25,000|
|Deductible when using PPO Network inside the U.S. or Medical Concierge||Deductible is reduced by 50%|
|Deductibles per Family||3 Deductibles per Family|
|Deductible Carry Forward||If the Deductible has not been met during the Calendar Year, then Expenses incurred during the last 90 days of the Calendar Year will be applied toward satisfaction of the Deductible for the next Calendar Year|
|Coinsurance - Calendar Year||Treatment received outside the U.S.:
Plan pays 100%, and Insured pays 0% of Eligible Medical Expenses.
For Treatment received within the U.S.:
In the PPO Network – Plan pays 100%, and Insured pays 0% of Eligible Medical Expenses.
Utilizing Medical Concierge Provider – Plan pays 100% and Insured pays 0% of Eligible Medical Expenses.
Outside the PPO Network – Plan pays 80%, and Insured pays 20% of Eligible Medical Expenses until reaching $5,000, then Insured pays 0%. Plan pays 100%.
In-patient/ Out-patient Services
|Hospital Room & Board||Within the U.S.: URC average private room rate, including nursing service.
Outside of the U.S.: URC average private room rate, including nursing service, up to a maximum of 150% of the average semi-private room rate.
|Intensive Care Unit||URC|
Additional $250 deductible applied if visit is a result of an illness and you are not admitted
|Physical Therapy||$50 Maximum per visit|
|Home Nursing Care||URC|
|Durable Medical Equipment||URC|
|Transplants||$1,000,000 lifetime maximum. Subject to special provisions|
|Mental & Nervous Disorder and Substance Abuse
Available after 12 months of continuous coverage
|$20,000 Maximum Limit per Lifetime
Outpatient Treatment: 50% patient responsibility, plan pays up to $100 Maximum Limit per visit and maximum of 52 visits per Insured Person per Calendar Year
Inpatient Treatment: $10,000 per Insured Person per Calendar Year.
|Prescription Drugs||Outside the U.S.: URC
Inside the U.S.: Must utilize Universal RX card. Copay (per 30 day supply):
Tier 1 - $5; Tier 2 - 30%; Tier 3 - $50 plus 30%. Maximum Limit of 90 day supply per prescription.
|Adult Wellness Not subject to deductible and coinsurance||$250 per calendar year|
|Child Wellness Not subject to deductible and coinsurance||$150 per calendar year|
|Hospital Indemnity (outside US only)||Private Hospitals: $400 per overnight and $4,000 Maximum Limit per Calendar Year.
Public Hospitals: $500 per overnight and $5,000 Maximum Limit per Calendar Year when Other Coverage exists and Company is not obligated to pay any benefits.
|Return of Mortal Remains to Home Country Not subject to deductible and coinsurance||$25,000 maximum limit|
|Political Evacuation & Repatriation Not subject to deductible and coinsurance||$10,000 lifetime benefit|
|Emergency Medical Evacuation Not subject to deductible and coinsurance||$1,000,000 lifetime maximum|
|Emergency Reunion||$10,000 lifetime benefit|
|Maternity Coverage Available after 10 months of continuous coverage||URC|
|Newborn’s Care & Congenital Disorders||$250,000 Maximum Limit per Lifetime for Newborn’s Care and Congenital Disorders during 31 days after birth|
|Complementary Medical Service||Maximum Limits Per Insured Person: Acupuncture: $150 Magnetic Therapy: $75 Herbal Therapy: $50 Massage Therapy: $150 Aroma Therapy: $50 Vitamin Therapy: $100|
|Chiropractic Care Not subject to deductible and coinsurance||$25 per visit (maximum of 20 visits per policy period)|
|Vision Care Expenses Not subject to deductible and coinsurance||$100 Maximum Limit per 24 months for routine eye exams and $150 Maximum Limit per 24 months for corrective lenses, contacts to correct vision, and frames.|
|Supplemental Accident Benefit Not subject to deductible and coinsurance||$300 per covered accident|
|Dental Emergency||URC for necessary treatment due to accident|
|Vision Not subject to deductible and coinsurance||Exams - Up to $100 per 24 months
Materials, frames, lenses, contacts - Up to $150 per 24 months