Global Medical Insurance

Plan Detail

Plan Administrator: International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius International

Benefits


The following is a summary schedule of benefits. Benefits are subject to the deductible and coinsurance unless otherwise noted. NA (Not Applicable); URC (Usual, Reasonable and Customary); SAAI (Same As Any Illness).

Benefit

Bronze

Silver

Gold

(1st 36 months of continuous coverage)

Gold

(Beginning the 1st day of the 37th month)

Gold Plus

Platinum

Lifetime Maximum Limit $1,000,000 per individual $5,000,000 per individual $5,000,000 per individual $5,000,000 per individual $5,000,000 per individual $8,000,000 per individual

Deductible


(Per period of coverage)
$250 to $10,000 $250 to $10,000 $250 to $25,000 $250 to $25,000 $250 to $25,000 $100 to $25,000
Deductible Carry Forward Included Included Included Included Included Included
Treatment outside the U.S. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance.
Treatment inside the U.S. using Medical Concierge 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance. 50% of deductible waived, up to a maximum of $2,500. No coinsurance.
Treatment inside the U.S. - PPO Network Subject to deductible.
No coinsurance.
Subject to deductible.
No coinsurance.
Subject to deductible.
No coinsurance.
Subject to deductible.
No coinsurance.
Subject to deductible.
No coinsurance.
Subject to deductible.
No coinsurance.
Treatment inside the U.S. - Non-PPO Network Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage.
Hospitalization/Room & Board In U.S. – 100% of average semi-private room rate. Outside of U.S. - 100% of private room rate (not to exceed 150% of semi-private room rate). In U.S. – 100% of average semi-private room rate. Outside of U.S. - 100% of private room rate (not to exceed 150% of semi-private room rate). In U.S. – 100% of average semi-private room rate. Outside of U.S. - 100% of private room rate (not to exceed 150% of semi-private room rate). Up to a limit of $2,250 per day In U.S. – 100% of average semi-private room rate. Outside of U.S. - 100% of private room rate (not to exceed 150% of semi-private room rate). Private room rate
Intensive Care Unit 100% $1,500 per day - 180 days of coverage per event 100% Up to a limit of $4,500 per day 100% 100%
Surgery 100% 100% 100% 100% 100% 100%
Assistant Surgeon 20% of primary surgeon’s charge 20% of primary surgeon’s charge 20% of primary surgeon’s charge 20% of primary surgeon’s charge 20% of primary surgeon’s charge 20% of primary surgeon’s charge
Outpatient
1) Office visits
2) Diagnostic/X-Ray
1) Specialists/consultants (preinpatient) - up to $500 prior to inpatient treatment; Specialists/ consultants (post-inpatient) - up to $500 following outpatient surgery or inpatient treatment for 90 days after leaving hospital.

2) Lab tests - up to $300 per visit; Diagnostic X-Rays limited to $250 per visit. No family doctor coverage.
1) 25 visits: $70 doctor/specialist maximum limit; $60 psychiatrist maximum limit; $50 chiropractor maximum limit; $500 surgery intervention consultation maximum limit

2) $250 X-Ray per exam maximum limit; $300 lab tests per exam maximum limit.
100% 1) Physician Charges - limit of $150 per visit; Hospital Charge - $100 co-pay unless admitted; Urgent Care Facility - $25 co-pay.

2) Diagnostic Lab and X-Rays limited to $5,000 per period of coverage.
100% 100%
Chemotherapy or Radiation Therapy URC URC URC $10,000 Maximum per Period of Coverage, $50,000 Lifetime Maximum URC URC
Transplants $250,000 lifetime maximum $250,000 lifetime maximum $1,000,000 lifetime maximum $5,000,000 lifetime maximum $1,000,000 lifetime maximum $2,000,000 lifetime maximum
Emergency Room Illness
(Additional $250 deductible if not admitted as an inpatient)
Covered only if admitted as Inpatient 100% 100% 100% 100% 100%
Emergency Room Accident 100% 100% 100% 100% 100% 100%
Supplemental Accident NA NA $300 of Eligible Medical
Expenses following an accident
$300 of Eligible Medical
Expenses following an accident
$300 of Eligible Medical
Expenses following an accident
$500 of Eligible Medical
Expenses following an accident
Local Ambulance due to Injury or Illness resulting in Hospitalization $1,500 maximum limit per event - not subject to deductible or coinsurance. $1,500 maximum limit per event - not subject to deductible or coinsurance. 100% $100 maximum limit per event - not subject to deductible or coinsurance 100% 100%
Mental/Nervous NA Outpatient after 12 months of continuous coverage. $10,000 per period - $50,000 maximum -
Available after 12 months of continuous coverage.
$30,000 lifetime maximum, and $2,500 maximum per period of coverage.
Additional Sub-limit: Inpatient: limited to 25 days per period of coverage.
Outpatient: Plan pays 70% of Eligible Medical Expenses up to $75 maximum per visit. Limited to 20 visits per period of coverage.
$10,000 maximum per period of coverage with a $50,000 lifetime maximum - Available after 12 months of continuous coverage. $50,000 lifetime maximum - Available after 12 months of continuous coverage.
Emergency Evacuation Up to $50,000 maximum per period of coverage.
Not subject to deductible or coinsurance.
$50,000 maximum per period of coverage.
Not subject to deductible or coinsurance.
Up to maximum limit.
Not subject to deductible or coinsurance.
$250,000 maximum per period of coverage.
Not subject to deductible or coinsurance.
Up to maximum limit.
Not subject to deductible or coinsurance.
Up to maximum limit.
Not subject to deductible or coinsurance.
Emergency Reunion $10,000 lifetime maximum NA $10,000 lifetime maximum $10,000 lifetime maximum $10,000 lifetime maximum $10,000 lifetime maximum
Return of Mortal Remains $10,000 lifetime maximum - not subject to deductible or coinsurance. $25,000 lifetime maximum - not subject to deductible or coinsurance. $25,000 lifetime maximum - not subject to deductible or coinsurance. $15,000 lifetime maximum - not subject to deductible or coinsurance. $25,000 lifetime maximum - not subject to deductible or coinsurance. $50,000 lifetime maximum - not subject to deductible or coinsurance.
Remote Transportation NA NA NA NA NA Up to $5,000 per period of coverage up to $20,000 lifetime maximum
Political Evacuation and Repatriation NA NA NA NA NA Up to $10,000 lifetime maximum
Child Wellness(Through age 18) NA 3 visits per period of coverage - $70 maximum per visit. Available after 12 months of continuous coverage. $200 maximum per period of coverage - not subject to deductible or coinsurance. Available after 12 months of continuous coverage. $200 maximum per period of coverage - not subject to deductible or coinsurance. $200 maximum per period of coverage - not subject to deductible or coinsurance. Available after 12 months of continuous coverage. $400 maximum per period of coverage - not subject to deductible or coinsurance. Available after 6 months of continuous coverage.
Adult Wellness(Age 19 or older) NA NA $250 per period of coverage - not subject to deductible or coinsurance. Available after 12 months of continuous coverage. $250 per period of coverage - not subject to deductible or coinsurance. $250 per period of coverage - not subject to deductible or coinsurance. Available after 12 months of continuous coverage. $500 per period of coverage - not subject to deductible or coinsurance. Available after 6 months of continuous coverage.
Recreational Scuba NA NA 100% 100% 100% 100%
Rx Coverage Inpatient: 100%.
Outpatient: Available for 90 days following related inpatient treatment or outpatient surgery.
$600 outpatient maximum limit per inpatient event.
100% 100% $5,000 per period of coverage - outpatient only. 90-day supply per prescription. 100% Outside U.S. - 100%.
Inside U.S. - Rx drug card co-pay:
$20 for generic / $40 for brand name where generic is not available.
Physical Therapy Inpatient: 100%
Outpatient: $40 maximum limit per visit, and 10 visit per event, available for 90 days following Inpatient Treatment or Outpatient Surgery.
Maximum $40 per visit - 30 visit maximum Maximum $50 per visit. Maximum $50 per visit. Maximum $50 per visit - $1,000 maximum per period of coverage.
$10,000 lifetime maximum.
Maximum $50 per visit.
Complementary Medicine NA NA Acupuncture $150;
Aroma Therapy $50;
Herbal Therapy $50; Magnetic
Therapy $75; Massage Therapy
$150; Vitamin Therapy $100.
Each per period of coverage.
Not subject to deductible or coinsurance.
Acupuncture $150;
Aroma Therapy $50;
Herbal Therapy $50; Magnetic
Therapy $75; Massage Therapy
$150; Vitamin Therapy $100.
Each per period of coverage.
Not subject to deductible or coinsurance.
Acupuncture $150;
Aroma Therapy $50;
Herbal Therapy $50; Magnetic
Therapy $75; Massage Therapy
$150; Vitamin Therapy $100.
Each per period of coverage.
Not subject to deductible or coinsurance.
Acupuncture $150;
Aroma Therapy $50;
Herbal Therapy $50; Magnetic
Therapy $75; Massage Therapy
$150; Vitamin Therapy $100.
Each per period of coverage.
Not subject to deductible or coinsurance.
Non-Emergency Dental Optional Rider Optional Rider Optional Rider Optional Rider Optional Rider $750 maximum per period of coverage; $50 individual deductible per period of coverage. Schedule of Benefits: Class I 90% (deductible is waived); Class II 70%; Class III 50%; 6-month waiting period.
Emergency Dental due to Accident $1,000 per period of coverage $1,000 per period of coverage 100% $500 per period of coverage 100% 100%
Emergency Dental due to Sudden Unexpected Pain NA NA $100 per period of coverage $100 per period of coverage $100 per period of coverage See Non-Emergency Dental benefit.
Vision Optional Rider Optional Rider Optional Rider Optional Rider Optional Rider Exams - up to $100 maximum per 24 months. Materials - up to $150 per 24 months.
Maternity
Delivery, wellness, new born care & congenital disorders, Family Matters Maternity Program (available after 10 months of coverage)
NA NA NA NA NA $2,500 deductible per pregnancy.
$50,000 lifetime maximum.
$200 newborn wellness benefit for the first 12 months after birth.
Newborn care & congenital disorders maximum of $250,000 for the first 31 days after birth.
Hospital Indemnity
(Outside the U.S. only)
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage.
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage.
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage.
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage.
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage.
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage.
Pre-Existing Conditions Limitation Excluded $50,000 lifetime maximum;
$5,000 per period of coverage after 24 months
$50,000 lifetime maximum;
$5,000 per period of coverage after 24 months
$50,000 lifetime maximum;
$5,000 per period of coverage after 24 months
$50,000 lifetime maximum;
$5,000 per period of coverage after 24 months
Same as any illness

Optional Riders

Global Medical Insurance is designed to help protect individuals and families from the high cost of medical expenses. In addition to tailored benefits packages, the program offers several optional coverages. You may review and choose any from the following list that meet your needs. To apply, simply add in the appropriate information and premiums, as outlined in the application, into the calculation for the total premium due.
Rider Description
Global Term Life Insurance
(Amounts shown are the Principal Sums per unit)
Age 31 days - 18 years: $5,000
Age 19 - 29 years: $75,000
Age 30 - 39 years: $50,000
Age 40 - 44 years: $35,000
Age 45 - 49 years: $25,000
Age 50 - 54 years: $20,000
Age 55 - 59 years: $15,000
Age 60 - 64 years: $10,000
Age 65 - 69 years: $7,500
Accidental Death & Dismemberment (AD&D) - included with Global Term Life Insurance Accidental Loss of Life: Principal Sum*
Accidental Total Loss of 2 Members**: Principal Sum*
Accidental Total Loss of 1 Member**: 50% of Principal Sum*

(* Benefit based on age at time of death ** “Member” means hand, foot or eye)
Terrorism (Platinum plan option) $50,000 lifetime maximum for Eligible Medical Expenses arising out of Injury or Illness incurred by the Insured as a result of or in connection with an act of terrorism
(Refer to rider for more details)
Adventure Sports
(Gold Plus and Platinum plan options)
$25,000 lifetime coverage for adventure sports
(Refer to rider for a comprehensive list of adventure sports excluded)
Dental & Vision
(Bronze, Silver, Gold, Gold Plus plan options)
Dental$750 calendar maximum
$50 deductible (max. 2 per family)
Class I - 90% (deductible is waived),
Class II - 70%, Class III - 50%
6 month waiting period
VisionExams - up to $100
per 24 months
Materials - up to $150
per 24 months