INF Standard

Plan Detail

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

Benefits


THIS IS THE POLICY DOCUMENT FOR POLICY NO. GLM N10783513S. THIS POLICY IS ADMINISTERED BY INFAND UNDERWRITTEN BY ACE AMERICAN INSURANCE COMPANY, A MEMBER OF CHUBB GROUP OF COMPANIES, PHILADELPHIA, PA.

SCHEDULE OF BENEFITS IN-PATIENT, OUT-PATIENT, AND OTHER FOR INF STANDARD PLAN.

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) or $250/$500 (Age 70-99) per person for each Injury and each Sickness as seen in the table below. Medical Expense Benefits are onlypayable:(1) for Usual and Customary Charges incurred after the Deductible, if any, has been met; (2) for those MedicallyNecessary Covered Expenses that the Covered Person incurs; (3). for charges incurred for services rendered to theCovered Person while on a covered Trip; and (4) provided the first charge is incurred within 90 days of the CoveredAccident or Sickness. Payment for Covered Expenses will not exceed the benefit limits shown below. The total amountpayable under the policy for you and your Dependents (if you have elected Dependent coverage and paid the requiredpremium) will not exceed the Policy Maximums shown below. Only $50,000 and $100,000 options are available for 70-99years age visitors.

Policy Maximum

New Sickness Deductible

$50,000 (Age 0-99)

$75 & $250 (Age 0-69) | $250 & $500 (Age 70-99

$100,000 (Age 0-99)

$75 & $250 (Age 0-69) | $250 & $500 (Age 70-99)

$150,000 (Age 0-69)

$75 & $250 (Age 0-69)

INF Standard In-Patient Benefits

COVERED SERVICES

$50,000 Policy Coverage

$100,000 Policy Coverage

$150,000 Policy Coverage

Hospital Room and Board

Charges up to $1,300 maximum a day, to 30 days

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

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

Hospital Intensive Care Unit Room and Board

Up to $525 maximum additional a day, to 8 days

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

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

Doctor Surgical Expenses

Charges up to $3,000 maximum

Charges Up to $5,000 maximum

Charges Up to $6,000 maximum

Anesthetist

Charges up to $750 maximum

Charges Up to $1,250 maximum

Charges Up to $1,500 maximum

Assistant Surgeon Expenses

Charges up to $750 maximum

Charges Up to $1,250 maximum

Charges Up to $1,500 maximum

Doctors’s Non-Surgical Treatment/Examination Expenses

Charges up to $60 a visit, 1 visit a day, to 30 visits

Charges 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

Charges up to $400 maximum

Charges Up to $450 maximum

Charges Up to $500 maximum

Pre-Admission Tests within 14 days before hospital admission

Charges up to $1,000 maximum

 

Charges Up to $1,100 maximum

 

Charges Up to $1,200 maximum

 

INF Standard Out-Patient Benefits

 

 

 

 

COVERED SERVICES

 

$50,000 Policy Coverage

 

$100,000 Policy Coverage

 

$150,000 Policy Coverage

 

 

Surgical Room and Supply Expenses

Charges up to $1,000 maximum

 

Charges Up to $1,100 maximum

 

Charges Up to $1,200 maximum

 

Doctor Surgical Expenses

 

Charges up to $3,000 maximum

 

Charges Up to $5,000 maximum

 

Charges Up to $6,000 maximum

 

Anesthetist

 

Charges up to $750 maximum

 

Charges Up to $1,250 maximum

 

Charges Up to $1,500 maximum

 

Assistant Surgeon Expenses

 

Charges up to $750 maximum

 

Charges Up to $1,250 maximum

 

Charges Up to $1,500 maximum

 

DoctorNon-Surgical Treatment Examination Expenses

Charges up to $60 a visit, 1 visit a day, to 10 visits

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

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

X-rays and LaboratoryProcedures

Charges up to $400 maximum

Charges Up to $650 maximum

Charges Up to $750 maximum

CAT Scan, PET Scan or MRI

Charges up to $400 additional

Charges Up to Up to $650 additional

Charges Up to $1,000 additional

Hospital Emergency Room

Up to $350

Up to $500

Up to $750

Prescription Drug Expenses

Up to $100 maximum

Up to $150 maximum

Up to $200 maximum

INF Standard Other Benefits

     

COVERED SERVICES

$50,000 Policy Coverage

$100,000 Policy Coverage

$150,000 Policy Coverage

Ambulance Services

Charges up to $400 maximum

Charges Up to $450 maximum

Charges Up to $500 maximum

Rehabilitative Braces or Appliances

Charges up to $1,000 maximum

Charges Up to $1,100 maximum

Charges Up to $1,200 maximum

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

Charges up to $450 maximum. There are no benefits for dental services for immediate relief of pain.

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

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

Chemotherapy and/or Radiation Therapy

Charges up to $1,000 maximum

Charges Up to $1,150 maximum

Charges Up to $1,250 maximum

Physical and Occupational Therapy

Charges up to $35 a visit maximum, 1 visit a day to 12 visits

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

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

Private Duty Nurse

Charges up to $400 maximum

Charges Up to $500 maximum

Charges Up to $550 maximum

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

Charges up to $4,500 maximum

Charges Up to $5,000 maximum

Charges Up to $5,500 maximum

Emergency Medical Evacuation*

$15,000 maximum

$20,000 maximum

$25,000 maximum

Repatriation of Remains

$10,000 maximum

$15,000 maximum

$20,000 maximum

Accidental Death and Dismemberment

$25,000 Principal Sum

$25,000 Principal Sum

$25,000 Principal Sum

Pre-existing Conditions

No Benefits

No Benefits

No Benefits

EMERGENCY MEDICAL EVACUATION AND REPATRIATION OF REMAINS BENEFITS*

Emergency Medical Evacuation Benefit- We will pay up to the maximum indicated above in the Schedule of Benefits for your medical evacuation if you: 1) suffer a Medical Emergency during the course of the Trip; 2) require Emergency Medical Evacuation; and 3) are traveling on a covered Trip.

Covered Expenses include;

1)Medical Transport: expenses for transportation under medical supervision to a different hospital, treatment facility or toyour place of residence for Medically Necessary treatment in the event of your Medical Emergency and upon the request of the Doctor designated by Our assistance provider in consultation with the local attending Doctor.

2)Dispatch of a Doctor or Specialist: the Doctor’s or specialist’s travel expenses and the medical services provided onlocation, if, based on the information available, your condition cannot be adequately assessed to evaluate the need for transport or evacuation and a doctor or specialist is dispatched by Our service provider to your location to make the assessment.

3)Return of Dependent Child (ren):expenses to return each Dependent child who is under age 18 to his or her principalresidence if a) you are age 18 or older; and b) you are the only person traveling with the minor Dependent child(ren); and c)you suffer a Medical Emergency and must be confined in a Hospital.

4)Escort Services: expenses for an Immediate Family Member or companion who is traveling with you to join you duringyour emergency medical evacuation to a different hospital, treatment facility or your place of residence.

Benefits for these Covered Expenses will not be payable unless: 1) the Doctor ordering the Emergency Medical Evacuation certifies the severity of your Medical Emergency requires an Emergency Medical Evacuation; 2) all transportation arrangements made for the Emergency Medical Evacuation are by the most direct and economical conveyance and route possible; 3) the charges incurred are Medically Necessary and do not exceed the Usual and Customary Charges for similar transportation, treatment, services or supplies in the locality where the expense is incurred; and 4) do not include charges that would not have been made if there were no insurance.

Benefits will not be payable unless We authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our assistance provider. In the event you refuse to be medically evacuated, we will not be liable for any medical expenses incurred after the date medical evacuation is recommended.

Repatriation of Remains Benefit

We will pay up to the maximum indicated above in the Schedule of Benefits for the preparation and return of your body to your home if you die as a result of a Medical Emergency while traveling on a covered Trip.

Covered expenses include: 1) expenses for embalming or cremation;2) the least costly coffin or receptacle adequate for transporting the remains; 3) transporting the remains; and 4) Escort Services which include expenses for an Immediate Family Member or companion who is traveling with you to join your body during the repatriation to your place of residence.

All transportation arrangements must be made by the most direct and economical route and conveyance possible and may not exceed the Usual and Customary Charges for similar transportation in the locality where the expense is incurred. Benefits will not be payable unless We authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our assistance provider

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS of $25,000**

Definition of Injury and Scope of Coverage – 24 Hour Coverage Principal Sum for Covered Injury: $25,000

Accidental Death and Dismemberment Benefits - If your Injury results, within 365 days from the date of a Covered Accident, in any one of the losses shown below, We will pay the Benefit Amount shown below for that loss. Principal Sum for you and your Dependents (if you have elected Dependent coverage and the required premium has been paid) is $25,000. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Covered Accident.

Schedule of Covered Losses

Covered Loss Benefit Amount

Life......................... 100% of the Principal Sum

Two or more Members....................... 100% of the Principal Sum

One Member...................... 50% of the Principal Sum

“Member means Loss of Hand or Foot, and Loss of Sight. “Loss of Hand or Foot" means complete Severance through or above the wrist or ankle joint. “Loss of Sight? means the total, permanent Loss of Sight of one eye. “Severance? means the complete separation and dismemberment of the part from the body.

Aggregate Limit - We will not pay more than $125,000 for all losses. If, in the absence of this provision, We would pay more than this amount for all losses under the policy, then the benefits payable to each person with a valid claim will be reduced proportionately.