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Plan Detail

Plan Administrator: Seven Corners | AM Best Rating: A "Excellent" | Underwriter: Lloyd's

Benefits


Schedule of benefits

If your covered injury or sickness requires medical treatment, we will pay the coverage amounts in the schedule of benefits, minus your chosen per person deductible. Please note that treatment for your injury or sickness must be received within 26 weeks of your injury or sickness.

Covered services per injury and per sickness benefit maximums

Age 14 Days through 69

Plan A

Plan B

Plan C

Plan D

Plan E

INPATIENT

$25000 Max per Injury/Sickness

$45000 Max per Injury/Sickness

$65,000 Max per Injury/Sickness

$85,000 Max per Injury/Sickness

$120,000 Max per Injury/Sickness

Hospital Room & Board including Laboratory Tests, X-rays, Prescription Medical and other miscellaneous

Up to $910/day, 30 day max

Up to $1,260/day, 30 day max

Up to $1,565/day, 30 day max

Up to $1,725/day, 30 day max

Up to $2,340/day, 30 day max

Hospital Intensive Care Unit

Add’l $430/day, 8 day max

Add’l $595/day, 8 day max

Add’l $720/day, 8 day max

Add’l $790/day, 8 day max

Add’l $1020/day, 8 day max

Surgical Treatment

Up to $2,150

Up to $2,970

Up to $3,960

Up to $4,840

Up to $6,600

Anesthetist

Up to $500

Up to $740

Up to $990

Up to $1,210

Up to $1,650

Assistant Surgeon

Up to $500

Up to $740

Up to $990

Up to $1,210

Up to $1,650

Physician’s Non-Surgical Visits

Up to $40/visit, 1/day, 30 visits max

Up to $60/visit, 1/day, 30 visits max

Up to $65/visit,1/day, 30 visits max

Up to $75/visit, 1/day, 30 visits max

Up to $100/visit, 1/day, 30 visits max

Consultant Physician, when requested by attending Physician

Up to $350

Up to $405

Up to $465

Up to $485

Up to $600

Pre-Admission Tests w/in 7 days before Hospital admission

Up to $750

Up to $990

Up to $1,100

Up to $1,100

Up to $1,100

Private Duty Nurse

Up to $400

Up to $495

Up to $550

Up to $550

Up to $660

OUTPATIENT

         

Surgical Treatment

Up to $2,150

Up to $2,970

Up to $3,960

Up to $4,840

Up to $6,600

Anesthetist

Up to $500

Up to $740

Up to $990

Up to $1,210

Up to $1,650

Assistant Surgeon

Up to $500

Up to $740

Up to $990

Up to $1,210

Up to $1,650

Physician’s Non-Surgical /Urgent Care Visits

Up to $50/visit, 1/day, 10 visits max

Up to $60/visit, 1/day, 10 visits max

Up to $65/visit, 1/day, 10 visits max

Up to $75/visit, 1/day, 10 visits max

Up to $100/visit, 1/day, 10 visits max

Diagnostic X-rays & Lab Services

Up to $295 - Additional $250- One CAT scan, PET scan or MRI

Up to $405 - Additional $250 - One CAT scan, PET scan or MRI

Up to $465 – additional $375 - One CAT scan, PET scan or MRI

Up to $485 - Additional $450 - One CAT scan, PET scan or MRI

Up to $600 - Additional $500 - One CAT scan, PET scan or MRI

Hospital Emergency Room

Up to $215

Up to $295

Up to $395

Up to $465

Up to $660

Prescription Drugs

Up to $150 Per Coverage Period

Up to $250 Per Coverage Period

Up to $125 Per Coverage Period

Up to $135 Per Coverage Period

Up to $180 Per Coverage Period

Outpatient Surgical Facility

Up to $750

Up to $900

Up to $1,030

Up to $1,070

Up to $1,320

OTHER TREATMENT AND SERVICES

         

Ambulance Services

Up to $295

Up to $450

Up to $450

Up to $475

Up to $475

Initial Orthopedic Prosthesis/Brace

Up to $715

Up to $990

Up to $1,160

Up to $1,240

Up to $1,560

Chemotherapy and/or Radiation Therapy

Up to $715

Up to $990

Up to $1,175

Up to $1,275

Up to $1,620

Dental Treatment for Injury to Sound, Natural Teeth

Up to $360

Up to $550

Up to $550

Up to $550

Up to $550

Mental & Nervous Disorder & Substance Abuse

Same as any Sickness

Same as any Sickness

Same as any Sickness

Same as any Sickness

Same as any Sickness

Physiotherapy

Up to $30/visit, 1/day, 12 visits max

Up to $40/visit, 1/day, 12 visits max

Up to $40/visit, 1/day, 12 visits max

Up to $40/visit, 1/day, 12 visits max

Up to $40/visit, 1/day, 12 visits max

Emergency Evacuation

$50,000

$50,000

$50,000

$50,000

$50,000

Extended Care Facility

Covered under the Hospital Room & Board

Covered under the Hospital Room & Board

Covered under the Hospital Room & Board

Covered under the Hospital Room & Board

Covered under the Hospital Room & Board

Return of Remains/Local Cremation & Burial Benefit

$25,000/$5,000

$25,000/$5,000

$25,000/$5,000

$25,000/$5,000

$25,000/$5,000

Common Carrier AD&D Principal Sum

$25,000

$25,000

$25,000

$25,000

$25,000

Acute Onset of a Pre-existing Condition

$25,000 for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 for Emergency Medical Evacuation.

$45,000 for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 for Emergency Medical Evacuation.

$65,000 for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 for Emergency Medical Evacuation.

$85,000 for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 for Emergency Medical Evacuation.

$120,000 for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 for Emergency Medical Evacuation.

If you turn 70 years old during the purchased coverage period, the 70 and over benefit schedule becomes effective on the day you turn 70. If you have the $25,000 or $45,000 per injury/sickness maximum, you will receive the $40,000 maximum. If you have the $65,000 or $85,000 per injury/sickness maximum, you will receive the $60,000 maximum. If you have the $120,000 per injury/sickness policy maximum, you will receive the $100,000 per injury/sickness maximum.

Covered services injury and sickness benefit maximums (cont.)

Age 70To 99Yrs

Plan J - $40000 Policy Max

Plan K - $60,000 Policy Max

Plan L - $100,000 Policy Max

INPATIENT

Hospital Room & Board including Laboratory Tests, X-rays, Prescription Medical and other miscellaneous

Up to $870/day, 30 day max

Up to $1,260/day, 30 day max

Up to $2,050/day, 30 day max

Hospital Intensive Care Unit

Additional $380/day, 8 day max

Additional $550/day, 8 day max

Additional $900/day, 8 day max

Surgical Treatment

Up to $2,285

Up to $3,300

Up to $5,365

Anesthetist

Up to $570

Up to $825

Up to $1,340

Assistant Surgeon

Up to $570

Up to $825

Up to $1,340

Physician’s Non-Surgical Visits

Up to $45/visit, 1/day, 30 visits max

Up to $65/visit, 1/day, 30 visits max

Up to $100/visit, 1/day, 30 visits max

A Consulting Physician, when requested by attending Physician

Up to $330

Up to $480

Up to $780

Private Duty Nurse

Up to $375

Up to $450

Up to $880

Pre-Admission Tests w/in 7 days before Hospital admission

Up to $775

Up to $775

Up to $1,500

OUTPATIENT

Surgical Treatment

Up to $2,285

Up to $3,300

Up to $5,365

Anesthetist

Up to $570

Up to $825

Up to $1,340

Assistant Surgeon

Up to $570

up to $825

Up to $1,340

Physician’s Non-Surgical / Urgent Care Visits

Up to $45/visit, 1/day, 10 visits max

Up to $65/visit, 1/day, 10 visits max

Up to $100/visit, 1/day, 10 visits max

Diagnostic X-rays & Lab Services

Up to $330 - Additional $250 - One CAT scan, PET scan or MRI

Up to $480 – additional $300 - One CAT scan, PET scan or MRI

Up to $780 – additional $300 - One CAT scan, PET scan or MRI

Hospital Emergency Room (all expenses incurred therein)

Up to$208

Up to $300

Up to $480

Prescription Drugs

Up to $250

Up to $250

Up to $250

Outpatient Surgical Facility

Up to $705

Up to $1,020

Up to $1,660

OTHER TREATMENT AND SERVICES

Ambulance Services

Up to $450

Up to $450

Up to $880

Initial Orthopedic Prosthesis/brace

Up to $705

Up to $1,020

Up to $1,660

Chemotherapy and/or radiation therapy

Up to $705

Up to $1,020

Up to $1,660

Dental Treatment for Injury to Sound, Natural Teeth

$550

Up to $550

Up to $1,075

Mental & Nervous Disorder & Substance Abuse

Same as any Sickness

Same as any Sickness

Same as any Sickness

Physiotherapy

Up to $40/visit, 1/day, 12 visits max

Up to $40/visit, 1/day, 12 visits max

Up to $80/visit, 1/day, 12 visits max

Extended Care Facility

Covered under the Hospital Room & Board benefit

Covered under the Hospital Room & Board benefit

Covered under the Hospital Room & Board benefit

Emergency Evacuation

$50,000

$50,000

$50,000

Return of Remains/Local Creamation/Burial

$25,000/$5,000

$25,000/$5,000

$25,000/$5,000