INF Premier 2

Plan Detail

Plan Administrator: INF Healthcare I AM Best Rating : "A++" I Underwriter: CHUBB American Insurance Company.

Examples of Covered Pre-Existing Condition

Benefits


INF PREMIER INPATIENT BENEFITS

COVERED SERVICES

$100,000 Policy Coverage

$150,000 Policy Coverage

Hospital Room (average semi-private) and Board and Miscellaneous

Up to $1,750 a day maximum, to 30 days

Up to $1,900 a day maximum, to 30 days

Hospital Intensive Care Unit

Up to $750 maximum additional a day, to 8 days

Up to $850 maximum additional a day, to 8 days

Surgeon

Up to $5,000 maximum

Up to $6,000 maximum

Anesthetist

Up to $1,250 maximum

Up to $1,500 maximum

Assistant Surgeon

Up to $1,250 maximum

Up to $1,500 maximum

Doctor’s Non-Surgical Visits

Up to $100 maximum a visit, 1 visit a day, to 30 visits

Up to $125 maximum a visit, 1 visit a day, to 30 visits

Consultant Doctor, when requested by attending Doctor

Up to $450 maximum

Up to $500 maximum

Pre-Admission Tests within 14 days before hospital admission

Up to $1,100 maximum

Up to $1,200 maximum

Surgical Room and Supply Expenses

Up to $1,100 maximum

Up to $1,200 maximum

Surgeon

Up to $5,000 maximum

Up to $6,000 maximum

Anesthetist

Up to $1,250 maximum

Up to $1,500 maximum

Assistant Surgeon

Up to $1,250 maximum

Up to $1,500 maximum

Doctor’s Non-Surgical Visits

Up to $100 a visit maximum, 1 visit a day, to 10 visits

Up to $125 a visit maximum, 1 visit a day, to 10 visits

Diagnostic X-rays and Lab Services

Up to $650 maximum

Up to $750 maximum

CAT Scan, PET Scan or MR

Up to $650 additional

Up to $1,000 additional

Hospital Emergency Room

Up to $500

Up to $750

Prescription Drugs

Up to $150 maximum

Up to $200 maximum

Ambulance Services

Up to $450 maximum

Up to $500 maximum

Rehabilitative Braces or Appliances

Up to $1,100 maximum

Up to $1,200 maximum

Dental Treatment injury to sound, natural teeth- due to accident

Up to $500 maximum. There are no benefits for dental services for immediate relief of pain

Up to $550. There are no benefits for dental services for immediate relief of pain.

Chemotherapy and/or Radiation Therapy

Up to $1,150 maximum

Up to $1,250 maximum

Physical and Occupational Therapy

Up to $45 a visit max, 1 visit a day to 12 visits

Up to $50 a visit max, 1 Visit a day to 12 visits

Private Duty Nurse

Up to $500 maximum

Up to $550 maximum

Pregnancy and Childbirth (conception must occur after the Trip begins)

Up to $5,000 maximum

Up to $5,500 maximum

Medical Evacuation

$20,000 maximum

$25,000 maximum

Repatriation of Remains

$15,000 maximum

$20,000 maximum

Intercollegiate Sports

No Benefits

No Benefits

Pre-existing Conditions Coverage

Options for Members Age 69 & Under: $20,000 Benefit with $1,000 Deductible $40,000 Benefit with $5,000 Deductible

Options for Members Age 70-99: $15,000 Max Benefit with $1,000 Deductible $25,000 Maximum Benefit with $5,000 Deductible

Options for Members Age 69 & Under*: $30,000 Maximum Benefit/$1,000 Deductible $60,000 Maximum Benefit/$5,000 Deductible

*This coverage is not available forMembers Age 70-99.

THIS IS THE DESCRIPTION OF COVERAGE FOR POLICY NO. GLMN10783513P. THIS POLICY IS ADMINISTEREDBY INF AND UNDERWRITTEN BY ACE AMERICAN INSURANCE COMPANY, A MEMBER OF THE CHUBB GROUP OF COMPANIES, PHILADELPHIA, PA.

MEDICAL EXPENSE BENEFITS

The Plan will pay Medical Expense Benefits for Covered Expenses that result directly, and from no other cause, from a Covered Accident or Sickness. These benefits are subject to a Deductible of $75/$250 (Age 0-69) & $250/$500 (Age 70-99)per person for each Injury and each Sickness. Medical Expense Benefits are only payable: (1) for Usual andCustomary Charges incurred after the Deductible, if any, has been met; (2) for those Medically Necessary Covered Expenses that the Covered Person incurs; (3). for charges incurred for services rendered to the Covered Person while on a covered Trip; and (4) provided the first charge is incurred within 90 days of the Covered Accident or Sickness. Payment for Covered Expenses will not exceed the benefit limits shown below. The total amount payable under the policy for you and your Dependents (if you have elected Dependent coverage and paid the required premium) will not exceed the Policy Maximums shown below.