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Maximum Lifetime Medical Benefit —
US$5,000,000
Annual Deductible Options — US$500; $1,000; $2,500; $5,000
Maximum of 3 times the deductible for family coverage.
Coinsurance — After the deductible, the plan pays 80% of
the next $5,000 of eligible charges, then 100% up to the
Policy Maximum. The maximum out of pocket expenses
incurred by an individual after satisfying the deductible
is $1000. The maximum out of pocket expenses incurred by a
family unit (after satisfying the deductible) is $3000.
- Emergency
Medical Evacuation—US$50,000.
-
Repatriation—US$20,000.
- Emergency
Reunion—US$10,000.
- Local
Ambulance Expense—Reasonable and Customary
charges for ground transportation.
- Hospital
Room and Board Expenses—Average Semi-private
room rate.
- Surgery—Usual,
reasonable and customary charges for surgery, physician
and anesthetics.
- Intensive
Care—Average Intensive Care room and board.
- Outpatient
Treatment—Usual, reasonable and customary
charges for surgery, doctors visits, emergency treatment
and prescriptions.
- Skilled
Care Facility—Usual, reasonable and customary
charges following hospital confinement.
- Hospice—Usual,
reasonable and customary charges for nursing, physical
therapy, medical supplies, and physician services.
- Spinal
Manipulation—50% of usual, reasonable and
customary, when referred by a physician, up to $50 per
visit, 12 visits per policy period. $5,000 Lifetime
Maximum.
- Mental and
Nervous—$25,000 Lifetime Maximum, with
$10,000 Annual Maximum per Insured Person, up to 45 days
inpatient, and 40 visits outpatient at 70%, per policy
period.
- Alcohol or
Drug Abuse—$10,000 Lifetime Maximum per
insured Person, up to 20 days inpatient, 30 days
outpatient per policy period.
- Dental
(accident only)—$500 Maximum per Policy
Period, after a $50 deductible.
- AD&D
(Accidental Death & Dismemberment)—$10,000
for insured and spouse,
$2,000 for each dependent child.
- Amateur
and Interscholastic Athletics—$5,000
deductible with a Lifetime maximum of $25,000.
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