Atlas Premium America

Plan Detail

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

Benefits


Schedule of Benefits and Limits

Plan Details

Overall Maximum Limit Age 80 or older: $20,000.
Age 65 to 79: $50,000 or $100,000
All others: $50,000, $100,000, $250,000, $500,000, $1,000,000 or $2,000,000
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, or 2,000,000
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 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 outside the 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.

– Co-payment is waived for members with a $0 deductible.

– not subject to deductible

Claims incurred outside the U.S.

No co-payment

Outpatient Physical Therapy and Chiropractic Care

Up to $50 maximum per day. Must be ordered in advance by a physician. -

Emergency Dental (Acute Onset of Pain)

Up to $300 - not subject to deductible

Emergency Eye Exam for a Covered Loss

Up to $150. $50 deductible per occurrence (plan deductible is waived).

Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions) (only available to members under age 80)

 

Age 70 to 79: Up to the overall maximum limit or $100,000, whichever is lower

Under age 70: Up to the overall maximum limit

$25,000 lifetime maximum for Emergency Medical Evacuation

Terrorism

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

All Other Eligible Medical Expenses

Up to the overall maximum limit

EMERGENCY TRAVEL BENEFITS

LIMIT

Emergency Medical Evacuation

Up to $1,000,000 lifetime maximum, except as provided under Acute Onset of Pre-existing Condition

- not subject to deductible or overall maximum limit

Repatriation of Remains

Up to the overall maximum limit - not subject to deductible

Local Burial or Cremation

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

Crisis Response - Ransom, Personal Belongings, Crisis Response Fees and Expenses, and Natural Disaster Evacuation

Up to $100,000 per certificate period, with $10,000 maximum for Natural Disaster Evacuation - not subject to deductible or overall maximum limit.

Emergency Reunion

Up to $150,000, subject to a maximum of 15 days - not subject to deductible

Bedside Visit

Up to $1,500 - not subject to deductible

Return of Minor Children

Up to $50,000 - not subject to deductible

Pet Return

Up to $1,000 - not subject to deductible

Political Evacuation

Up to $150,000 lifetime maximum - not subject to deductible

Trip Interruption

Up to $15,000 - not subject to deductible

Accidental Death & Dismemberment (excludes loss due to Common Carrier Accident)

Ages 18 through 69

 

 

 

 

Under age 18

 

 

 

 

Ages 70 through 74

 

 

 

 

Ages 75 and older

 

 

 

Lifetime Maximum - $100,000

Death - $100,000

Loss of 2 Limbs - $100,000

Loss of 1 Limb - $50,000

 

Lifetime Maximum - $5,000

Death - $5,000

Loss of 2 Limbs - $5,000

Loss of 1 Limb - $2,500

 

Lifetime Maximum - $12,500

Death - $12,500

Loss of 2 Limbs - $12,500

Loss of 1 Limb - $6,250

 

 

Lifetime Maximum - $6,250

Death - $6,250

Loss of 2 Limbs - $6,250

Loss of 1 Limb - $3,125

$250,000 maximum benefit any one family or group.

- not subject to deductible or overall maximum limit

 

Common Carrier Accidental Death

Ages 18 through 69

Under age 18

Ages 70 through 74

Ages 75 and older

$100,000

$10,000

$25,000

$12,500

Subject to a maximum of $250,000 any one family or group.

- not subject to deductible or overall maximum limit

Lost Checked Luggage

Up to $2,000 - not subject to deductible

Travel Delay

Up to $200 a day after a 12-hour delay period requiring an unplanned overnight stay. Subject to a maximum of 2 days.

- not subject to deductible

Lost or Stolen Passport/Travel Visa

Up to $100 - not subject to deductible

Border Entry Protection

Up to $500 if traveling on a valid B-2 visa and denied entrance at the U.S. border. - not subject to deductible

Natural Disaster - Replacement Accommodations

Up to $500 a day for 5 days - not subject to deductible

Hospital Indemnity

$100 per day of inpatient hospitalization - not subject to deductible

Personal Liability

Up to:

$100,000 lifetime maximum

$100,000 third person injury

$100,000 third person property

$2,500 related third person property

- not subject to deductible or overall maximum limit

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. Emergency treatment of an injury, even if hospital confinement is not required; and

f. 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. Drugs which require prescription by a physician for treatment of a covered injury or illness, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of 60 days per prescription.

12. Care in a licensed extended care facility upon direct transfer from an acute care hospital.

13. 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.

14. Emergency local ambulance transport necessarily incurred in connection with injury or illness resulting in inpatient hospitalization.

15. 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.

16. Emergency dental treatment necessary to resolve acute onset of pain, provided treatment is obtained within 24 hours of the acute onset of pain.

17. Emergency Eye Exam if your prescription corrective lenses are lost or damaged due to a covered loss and an exam is required to obtain a lens prescription for medically necessary correction lenses, but not for the replacement cost of prescription corrective lenses or contact lenses.

18. 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.

19. Outpatient physical therapy or chiropractic care if prescribed by a physician who is not affiliated with the physical therapy or chiropractic practice, necessarily incurred to continue recovery from a covered injury or illness.

20. 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.

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; and

3. 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. 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.

Notwithstanding 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

Trip Interruption

YOU ARE COVERED:

1. The cost of an economy one-way air or ground transportation ticket for you to the terminal serving the area of your principal residence, and/or

2. The cost of an economy one-way air and/or ground transportation ticket for you from the area where you were hospitalized following an 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. You provide proof of one or more of the following events: destruction, after departure from home country, resulting from fire or weather of more than 40% of your principal residence, or death of a parent, spouse, sibling, child, or grandchild; or

2. Following a covered Emergency Medical Evacuation, 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.

YOU ARE NOT COVERED IF:

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

Return of Minor Children

YOU ARE COVERED:

1. The cost of a one-way economy air and/or ground transportation ticket for each covered minor child to the terminal serving the area of the principle residence of each minor child.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You are the only person age 18 or older, traveling with one or more minor children under the age of 18 who are also covered hereunder; and

2. You are hospitalized for treatment of a covered illness or injury, resulting in the children being left unattended for a period of time expected to exceed 36 hours; and

3. The Return of Minor Children benefit must be agreed upon by you and/or by an authorized adult relative of the affected, covered minor children.

YOU ARE NOT COVERED IF:

1. 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.

Political Evacuation

YOU ARE COVERED: 1. The cost of transportation by the most economical means possible for you to the nearest country of safety or to your home country. We will determine to which country you will be evacuated.

YOU ARE NOT COVERED unless you fulfill the following conditions: 1. The U.S. Department of State has issued a level 3 or level 4 travel advisory after your arrival in the destination country; and 2. Your coverage was effective prior to the advisory being issued; and 3. You contact us within 10 days of the date the travel advisory is issued.

YOU ARE NOT COVERED IF: 1. Expenses arise directly or indirectly from anything in the General Exclusions

1. The U.S. Department of State has issued a level 3 or level 4 travel advisory after your arrival in the destination country; and

2. You contact us within 10 days of the date the travel advisory is issued.

YOU ARE NOT COVERED IF:

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

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.

Indemnity Benefit & Visitation Expenses

Hospital Indemnity

YOU ARE COVERED:

1. The Hospital Indemnity benefit for each night you spend in the hospital. 1. You must provide verification of an eligible inpatient hospitalization.

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.

1. You have a covered Emergency Medical Evacuation.

Emergency Reunion

YOU ARE COVERED:

1. The cost of an economy round-trip air or ground transportation ticket for one relative for transportation to the terminal serving the area where you are hospitalized or are to be hospitalized following Emergency Medical Evacuation; and

2. Reasonable expenses for lodging and meals for the relative, which are incurred in the area where you are hospitalized for a period not to exceed 15 days.

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.

Bedside Visit

YOU ARE COVERED:

1. The cost of an economy round-trip air or ground transportation ticket for one relative for transportation to the terminal serving the area where you are hospitalized or are to be hospitalized.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You are confined to a hospital intensive care unit following a covered life-threatening bodily injury or life-threatening illness.

YOU ARE NOT COVERED IF:

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

Travel Assistance

Travel Delay

YOU ARE COVERED:

1. Reimbursement for reasonable accommodations and meals when your delay requires an unplanned overnight stay.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The delay must be twelve (12) hours or more and certified due to the following reasons:

a. Delay of common carrier (which is certified by the common carrier); or

b. A traffic accident while en route to the point of departure from an airport outside of your home country (substantiated by a police report); or

c. Organized labor strike, or you being hijacked or quarantined; or

d. Stolen passports or travel documents (substantiated by a police report).

YOU ARE NOT COVERED IF:

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

Common Carrier means an airplane, bus, train or watercraft operating for commercial purposes and carrying fare-paying passengers on regularly scheduled and published routes.

Lost Checked Luggage

YOU ARE COVERED:

1. Replacement of clothes and personal hygiene items, not to exceed $50 any one item.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The lost checked luggage must have been checked, in accordance with routine luggage checking procedures, for transportation with you, on board a regularly scheduled commercial airline or cruise line, upon which you were a fare-paying passenger; and

2. You must file a formal claim for lost luggage with the transportation provider, and follow all instructions and take all measures as directed by the transportation provider to locate and retrieve the lost checked luggage; and

3. You must provide us with copies of all documentation of the claim filed with the transportation provider, and a written statement from the transportation provider confirming that the luggage was checked and after careful search, the luggage remains missing; and

4. The lost checked luggage must be lost as of the date of our payment and as of that date, must have been lost for at least 10 days.

YOU ARE NOT COVERED IF:

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

Lost or Stolen Passport/Travel Visa

YOU ARE COVERED:

1. Reimbursement for reasonable cost in replacing your passport or travel visa.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You exercise reasonable care for the safety and supervision of the passport or travel visa; and

2. Loss or theft is reported to the police within 24 hours and a written police report is obtained; and

3. You provide receipts for the costs associated with the passport or travel visa replacement.

YOU ARE NOT COVERED IF:

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

Natural Disaster - Replacement Accommodations

YOU ARE COVERED:

1. Replacement accommodations in the event you are displaced from planned paid accommodations due to evacuation from forecasted natural disaster or following a natural disaster strike.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. Following receipt of proof of payment for the accommodations from which you were displaced.

YOU ARE NOT COVERED IF:

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

Displaced means required to depart a destination due to an evacuation ordered by prevailing authorities.

Natural Disaster means an event of natural cause, including wildfire, earthquake, windborne dust or sand, volcanic eruption, tsunami, snow, rain or wind, that results in widespread and severe damage. Natural disaster does not include the direct or indirect effect of rain, wind or water associated with named storms meeting the definition of hurricane or typhoon, except in instances where:

1. The path of the named storm deviates by a distance of greater than 200 miles within a 72-hour period from the path forecast by a nationally recognized meteorological service; or

2. Less than 72 hours advance notice of a potential landfall for a named storm exists.

Border Entry Protection

YOU ARE COVERED:

If you are traveling on a Visitor Visa B-2 for tourism, for visiting family or friends, or on holiday, and you are denied entry to the United States at the border by customs officials:

1. Reimbursement for the cost of an economy one-way air or ground transportation ticket to the original country of origin; or

2. Common carrier change fee to the original country of origin less the amount credited for any unused portion of the return travel arrangements.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You must return to the country of origin; and

2. You must not be a citizen or of the United States, have home country of the United States, and/or have permanent residency in the United States.

YOU ARE NOT COVERED IF:

1. You are traveling to the United States without a Visitor Visa B-2, or you are travelling illegally; or

2. You are from a country named on any active executive order at the time of purchase; or

3. You are on the United States terror watch list; or

4. You were denied entry to the United States upon arrival or while en route to the United States because you have violated any rule, law, condition of or guideline regarding the visa upon which you are traveling; or

5. You are visiting the United States for medical treatment, participation by amateurs in musical, sports, or similar events or contests, if compensation is received; or

6. You are visiting the United States for studies that receive credits towards a degree; or

7. You committed a crime en route or upon entry to the United States which caused or would have caused you to be returned to your country of origin; or

8. The United States government or the common carrier has paid, offered to pay, or will pay for your repatriation to your country of origin; or

9. You have an unused return ticket or credit issued by the common carrier. If credit is not used, the amount reimbursed will be reduced by the amount of the credit.

Country of Origin means the country you were in when you first departed for the United States.

Executive Order means a rule or order issued by the United States President on how federal agencies are to use their resources and having the force of law.

Pet Return

YOU ARE COVERED:

1. The cost of a one-way economy air and/or ground transportation ticket for a pet to be returned to the terminal serving the area of your principle residence.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You are the only person aged 18 or older traveling with the pet; and

2. You are hospitalized for treatment of a covered illness or injury, resulting in the pet being left unattended for a period of time expected to exceed 36 hours.

YOU ARE NOT COVERED IF:

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

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: