Atlas Essential International

Plan Detail

Plan Administrator: Tokio Marine HCC - Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's

Benefits


Schedule of Benefits and Limit

Plan Details  
Overall Maximum Limit Age 80 or older: $10,000.
Age 65 to 79: $50,000 or $100,000
All others: $50,000, $100,000, $250,000, $500,000, $1,000,000
Maximum per Injury / Illness Age 80 or older: $10,000.
Age 65 to 79: $50,000 or $100,000
All others: $50,000, $100,000, $250,000, $500,000, $1,000,000
Deductibles $0, $100, $250, $500, $1,000, $2,500, or $5,000 per certificate period
Coinsurance We will pay 100% of eligible expenses, after the deductible, to the overall maximum limit

Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.


BENEFIT

LIMIT

Hospital Room and Board

Average semi-private room rate, including nursing services

Intensive Care Unit

Up to the overall maximum limit

Local Ambulance

Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.

Emergency Room Co-payment

Claims incurred in U.S.
You shall be responsible for a $200 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury.
Claims incurred in U.S.
No co-payment

Urgent Care Center Co-payment

Claims incurred in U.S.
For each visit, you shall be responsible for a $15 co-payment, after which coinsurance will apply.
– Co-payment waived for members with a $0 deductible.
– not subject to deductible
Claims incurred in U.S.
No co-payment

Terrorism

Up to $50,000 lifetime maximum, eligible medical expenses only.

All Other Eligible Medical Expenses
Emergency Travel Benefits

Up to the overall maximum limit
Limit

Emergency Medical Evacuation

Up to $500,000 lifetime maximum - not subject to deductible or coinsurance

Repatriation of Remains

Up to $25,000 lifetime maximum - not subject to deductible or coinsurance

Local Burial or Cremation

Up to $5,000 lifetime maximum - not subject to deductible or coinsurance

Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date

Coinsurance means your payment of eligible expenses as specified in the Schedule of Benefits and Limits.

Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.

Usual, Reasonable and Customary means the lesser of the following:

1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or

2. Most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: the  level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; such other factors we, in the reasonable exercise of discretion, determine are appropriate

Article 11 - Eligible Expenses

Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions and restrictions contained in this provision, we will pay the following expenses incurred while this insurance is in effect.

Medical & Repatriation Expenses

Medical Expenses

YOU ARE COVERED:

1. Charges made by a hospital for:
a. Daily room and board and nursing services not to exceed the average semi-private room rate; and
b. Daily room and board and nursing services in Intensive Care Unit; and
c. Use of operating, treatment or recovery room; and
d. Services and supplies which are routinely provided by the hospital to persons for use while inpatients; and
e. Prescription drugs administered while inpatient for treatment of a covered injury or illness; and
f. Emergency treatment of an injury, even if hospital confinement is not required; and
g. Emergency treatment of an illness; subject to emergency room co-pay as outlined in the Schedule of Benefits and Limits. ER co-payment is waived when you are directly admitted to the hospital as inpatient for further treatment of that illness.

2. Surgery at an outpatient surgical facility, including services and supplies.
3. Charges made by a physician for professional services, including surgery. Charges for an assistant surgeon are covered up to 20% of the usual, reasonable and customary charge of the primary surgeon, but standby availability will not be deemed to be a professional service and therefore is not covered hereunder.
4. Dressings, sutures, casts or other supplies which are medically necessary and administered by or under the supervision of a physician, but excluding nebulizers, oxygen tanks, diabetic supplies, other supplies for use or application at home, and all devices or supplies for repeat use at home, except durable medical equipment.
5. Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included).
6. Artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof.
7. Reconstructive surgery when the surgery is directly related to surgery which is covered hereunder.
8. Hemodialysis and the charges by the hospital for processing and administration of blood or blood components but not the cost of the actual blood or blood components.
9. Oxygen and other gasses and their administration by or under the supervision of a physician.
10. Anesthetics and their administration by a physician.
11. Care in a licensed extended care facility upon direct transfer from an acute care hospital.
12. Home nursing care in bed by a qualified licensed professional, provided by a home health care agency upon direct transfer from an acute care hospital and only in lieu of medically necessary inpatient hospitalization.
13. Emergency local ambulance transport necessarily incurred in connection with injury or illness resulting in inpatient hospitalization.
14. Emergency dental treatment and dental surgery necessary to restore or replace sound natural teeth lost or damaged in an accident which was covered under this insurance.
15. Medically necessary rental of durable medical equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.
16. Physical therapy while inpatient if prescribed by a physician who is not affiliated with the physical therapy practice, necessarily incurred to continue recovery from a covered injury or illness.
17. Injury or illness resulting from participation in sports or athletic activities not otherwise excluded under this insurance.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

Emergency Medical Evacuation

YOU ARE COVERED:

1. Emergency air transportation to a suitable airport nearest to the hospital where you will receive treatment; and
2. Emergency ground transportation necessarily preceding emergency air transportation; and from the destination airport to the hospital where you will receive treatment.
3. The cost of an economy one-way air and/or ground transportation ticket for you from the area where you were hospitalized following a covered Emergency Medical Evacuation to the area where you were initially evacuated from or to the terminal serving the area of your principal residence.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The evacuation is recommended by the attending physician who certifies that it is medically necessary and that transportation by any other method would result in the loss of your life or limb; and
2. The evacuation is agreed upon by you or your relative; or
3. Following a covered Emergency Medical Evacuation when the attending physician states that it is medically necessary for you to return to your home country or to the area from which you were initially evacuated for continued treatment, recuperation and recovery; and
4. Travel arrangements, excluding Emergency Local Ambulance, are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. The illness or injury giving rise to the expense is not covered under this insurance; or
2. Medically necessary treatment, services and supplies can be provided locally; or
3. For emergency air or ground transportation, if transportation by any other method would not result in the loss of your life or limb; or
4. The condition giving rise to the Emergency Medical Evacuation did not occur spontaneously and without advance warning, either in the form of physician recommendation or symptoms which would have caused a prudent person to seek medical attention prior to the onset of the emergency; or
5. Expenses are directly or indirectly from anything in the General Exclusions.

We will provide Emergency Medical Evacuation only to the nearest hospital that is qualified to provide the medically necessary treatment, services and supplies to prevent your loss of life or limb.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

Not with standing the foregoing, and if you are visiting the U.S., we will pay for expenses to return you to your home country if the attending physician and our medical consultant agree that transfer to your home country is more appropriate than transfer to the nearest qualified hospital.

1. The illness or injury giving rise to the expense are covered under this insurance; and
2. Travel arrangements are approved in advance and coordinated by us.

Repatriation of Remains

YOU ARE COVERED:

1. Air or ground transportation of bodily remains or ashes to the airport or ground transportation terminal nearest your principal residence; and
2. Reasonable costs of preparation of the remains necessary for transportation.

YOU ARE NOT COVERED unless you fulfill the following conditions:

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

We are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the repatriation process or otherwise.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

Local Burial or Cremation

YOU ARE COVERED:

1. For you to be buried or cremated in the country of death in lieu of Repatriation of Remains up to the specified benefit maximum.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The illness or injury giving rise to the expense is covered under this insurance; and
2. Travel arrangements are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. The death occurs in your home country; or
2. The Emergency Medical Evacuation or Repatriation of Remains benefit is used; or
3. Expenses arise directly or indirectly from anything in the General Exclusions.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

1. You are covered for taking part in amateur/non-professional sports and activities, unless it is excluded below. Coverage is for recreational purposes incidental to a trip. 1. You must ensure the activity is adequately supervised and that appropriate safety equipment (such as protective headwear, life jackets etc.) are worn at all times.

Leisure, Recreational, Entertainment, or Fitness Sports & Activities

YOU ARE COVERED:

1. You are covered for taking part in amateur/non-professional sports and activities, unless it is excluded below. Coverage is for recreational purposes incidental to a trip.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You must ensure the activity is adequately supervised and that appropriate safety equipment (such as protective headwear, life jackets etc.) are worn at all times.

YOU ARE NOT COVERED IF:

1. The activity is organized athletics involving regular or scheduled practice and/or games; or
2. The activity is performed in a professional capacity or for any wage, reward, or profit; or
3. Expenses arise directly or indirectly from anything in the General Exclusions; or
4. Any of the excluded items listed below:

Article 12 - Terrorism

YOU ARE COVERED:

1. Eligible Medical Expenses for treatment of injuries and illnesses resulting from an Act of Terrorism, up to the limit set forth in the Schedule of Benefits and Limits, provided all of the following conditions are met.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The injury or illness does not result from the use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon;
2. You have no direct or indirect involvement in the Act of Terrorism;
3. The Act of Terrorism is not in a country or location where the U.S. Department of State has issued a level 3 or level 4 travel advisory that has been in effect within the 6 months immediately prior to your date of arrival; and
4. You have not failed to depart a country or location within 10 days following the date a level 3 or level 4 travel advisory for that country or location is issued by the United States government.

YOU ARE NOT COVERED IF:

1. Loss, damage, cost or expense directly or indirectly caused by, resulting from or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, damage, cost or expense:
a. War, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power;
b. The use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon; however, this exclusion shall not apply where you are exposed to nuclear radioactive and/or radioactive material for the purpose of medical treatment;
c. Any Act of Terrorism, not specifically covered above;
d. Coverage for loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (a), (b) or (c) above;
e. Expenses arise directly or indirectly from anything in the General Exclusions.

For the purpose of this insurance, an “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

If we allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be upon you.

In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.

Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.