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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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