Atlas Premium America

Plan Detail

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

Benefits


Except as specifically indicated otherwise, all benefits are subject to deductible, coinsurance, and are per certificate period.

Overall Maximum Limit
(Excludes Emergency Medical Evacuation, Accidental Death and Dismemberment, Common Carrier Accidental Death, Personal Liability, and Crisis Response)
Age 80 or older $20,000.
Age 70 to 79: $50,000, $100,000.
All others: $50,000, $100,000, $200,000, $500,000, $1,000,000, or $2,000,000.
Maximum per Injury / Illness Age 80 or older $20,000.
Age 70 to 79: $50,000, $100,000.
All others: $50,000, $100,000, $200,000, $500,000, $1,000,000, or $2,000,000
Deductibles $0, $100, $250, $500, $1,000 or $2,500 per certificate period
Coinsurance – Claims incurred in U.S. or Canada We will pay 90% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum limit. Coinsurance will be waived if expenses are incurred within the Preferred Provider Organization (PPO) and expenses are submitted to us for review and payment directly to the provider.
Coinsurance – Claims incurred outside U.S. or Canada We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.
Benefit Limit
Subject to deductible, coinsurance, and per certificate period unless specifically indicated otherwise
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit Usual, reasonable and customary charges
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. or Canada 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.
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 is waived for members with a $0 deductible.
– not subject to deductible
Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions) (only available to members under age 80) Age 70 to 79: Up to $100,000
Under age 70: Up to the overall maximum limit
$25,000 lifetime maximum for Emergency Medical Evacuation
Terrorism $50,000 lifetime maximum, eligible medical expenses only.
Physical Therapy $50 maximum per day
All Other Eligible Medical Expenses Usual, reasonable and customary charges
Benefit Limit
Not Subject to Deductible or Coinsurance
Emergency Medical Evacuation $1,000,000 lifetime maximum, except as provided under Acute Onset of Pre-existing Condition
Repatriation of Remains Overall maximum limit
Local Burial or Cremation $5,000 lifetime maximum
Crisis Response- Ransom, Personal Belongings, and Crisis Response Fees and Expenses $100,000
Emergency Reunion $50,000, subject to a maximum of 15 days
Bedside Visit $1,500
Return of Minor Children $50,000
Pet Return $1,000
Political Evacuation $25,000 lifetime maximum
Trip Interruption $10,000
Accidental Death & Dismemberment (excludes loss due to Common Carrier Accident)  
Ages 18 through 69 Lifetime Maximum - $250,000
Death - $250,000
Loss of 2 Limbs - $250,000
Loss of 1 Limb - $125,000
Under age 18 Lifetime Maximum - $5,000
Death - $5,000
Loss of 2 Limbs - $5,000
Loss of 1 Limb - $2,500
Ages 70 through 74 Lifetime Maximum - $12,500
Death - $12,500
Loss of 2 Limbs - $12,500
Loss of 1 Limb - $6,250
Ages 75 and older 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.
Common Carrier Accidental Death
Ages 18 through 69
Under age 18
Ages 70 through 74
Ages 75 and older
$50,000
$25,000
$12,500
$6,250

Subject to a maximum of $250,000 any one family or group.
Lost Checked Luggage $1,000
Travel Delay Maximum $200 a day after a 12-hour delay period requiring an unplanned overnight stay. Subject to a maximum of 2 days.
Emergency Dental (Acute Onset of Pain) $250
Natural Disaster Maximum $250 a day for 5 days
Hospital Indemnity $100 per day of inpatient hospitalization
Personal Liability $100,000 lifetime maximum
$100,000 third person injury
$100,000 third person property
$2,500 related third person property