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