Inter Medical - Plan B

Plan Detail

Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: United States Fire Insurance Company

Benefits


SCHEDULE OF BENEFITS AND LIMITS

Plan Details

Overall Maximum Limit

Age 80 or older $10,000.
All others: $50,000 or$100,000

Maximum per Injury / Illness

Age 80 or older $10,000.
All others: $50,000, or $100,000

Deductibles

$0, $250, $500, or $1,000 per certificate period

Coinsurance – Claims incurred outside U.S.

We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.

Coinsurance – Claims incurred in U.S.

In-Network Payment

Within the PPO: We will pay 100% of eligible expenses, after the deductible, to the overall maximum limit.

Out-of-Network Payment

Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount.

Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.

Benefit

Limit

Hospital Room and Board

Average semi-private room rate, including nursing services

Intensive Care Unit

Up to the overall maximum limit

Local Ambulance

Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.

Emergency Room Co-payment

Claims incurred outside the U.S.
No co-payment
Claims incurred in U.S.
You shall be responsible for a $250 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury.

Urgent Care Center Co-payment

Claims incurred outside the U.S.
No co-payment
Claims incurred in U.S.
For each visit, you shall be responsible for a $50 co-payment, after which coinsurance will apply.
– Co-payment is waived for members with a $0 deductible.
– not subject to deductible

Outpatient Physical Therapy and Chiropractic Care

Usual, reasonable and customary charges. Must be ordered in advance by a physician.

Mental Health Disorders

Up to $5,000

Emergency Dental Treatment due to Accident

Up to $1,000

Emergency Dental (Acute Onset of Pain)

Up to $100 - not subject to deductible or coinsurance

Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions)

Ages 65 and above: $2,500
All others: $10,000

Terrorism

Up to $50,000 lifetime maximum, eligible medical expenses only

Optional Hazardous Activities Rider

Up to the overall maximum limit

Optional Intercollegiate or Interscholastic Sports Rider

Up to $20,000

All Other Eligible Medical Expenses

Up to the overall maximum limit

Emergency Travel Benefits

Limit

Emergency Medical Evacuation

Up to $250,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Repatriation of Remains

Up to $50,000 - not subject to deductible or coinsurance

Emergency Reunion

Up to $15,000, subject to a maximum of 15 days - not subject to deductible or coinsurance

Return of Minor Children

Up to $50,000 - not subject to deductible or coinsurance

Political Evacuation

Up to $50,000 lifetime maximum - not subject to deductible or coinsurance

Trip Interruption

Up to $5,000 - not subject to deductible or coinsurance

Accidental Death & Dismemberment
Ages 18 through 69
Under age 18
Ages 70 through 74
Ages 75 and older

Lifetime Maximum - $50,000
Death - $50,000
Loss of 2 Limbs - $50,000
Loss of 1 Limb - $25,000
Lifetime Maximum - $5,000
Death - $5,000
Loss of 2 Limbs - $5,000
Loss of 1 Limb - $2,500
Lifetime Maximum - $20,000
Death - $20,000
Loss of 2 Limbs - $20,000
Loss of 1 Limb - $10,000
Lifetime Maximum - $10,000
Death - $10,000
Loss of 2 Limbs - $10,000
Loss of 1 Limb - $5,000
$250,000 maximum benefit any one family or group.
- not subject to deductible, coinsurance, or overall maximum limit

Optional Enhanced Accidental Death & Dismemberment Rider (only available to members under age 70)

Lifetime Maximum - $50,000
Death - $50,000
Loss of 2 Limbs - $50,000
Loss of 1 Limb - $25,000
- not subject to deductible, coinsurance, or overall maximum limit

Lost Checked Luggage

Up to $500 - not subject to deductible or coinsurance

Lost or Stolen Passport/Travel Visa

Up to $100 - not subject to deductible or coinsurance

Natural Disaster - Replacement Accommodations

Up to $100 a day for 5 days - not subject to deductible or coinsurance

Hospital Indemnity

$100 per day for 5 days for inpatient hospitalization - not subject to deductible or coinsurance

BENEFIT PERIOD & HOME COUNTRY COVERAGE

BENEFIT PERIOD

While the certificate is in effect, the benefit period does not apply. Upon termination of the certificate, in accordance with this provision, we will pay eligible medical expenses for up to 90 days beginning on the first day of diagnosis or treatment of a covered injury or illness while you are outside your home country. The benefit period applies only to eligible medical expenses related to the injury or illness that began while the certificate was in effect.

In the event you begin a benefit period while the certificate is in effect, and the certificate terminates because you return to your home country, we will pay eligible medical expenses which are incurred in your home country during the benefit period. Home country coverage applies only to eligible medical expenses related to the injury or illness that began while the certificate was in effect.

INCIDENTAL HOME COUNTRY COVERAGE

U.S. home country: For every three month period during which you are covered, eligible medical expenses incurred in the U.S. are covered up to a maximum of 15 days.

Non-U.S. home country: For every three month period during which you are covered, eligible medical expenses incurred in your home country are covered up to a maximum of 30 days.

Any benefit accrued under a single three month period does not accumulate to another period. Failure to continue your international trip or your return to your home country for the sole purpose of obtaining treatment for an illness or injury that began while traveling shall void any home country coverage provided under the terms of this agreement.

Except for a benefit period, coverage provided under this Master Policy is for a maximum duration of 364 days.

Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole option, elect to cancel all members of the same sex, age, class or geographic location, provided we give no less than 30 days advance written notice by mail to your last known address.

Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date.

Coinsurance means your payment of eligible expenses as specified in the Schedule of Benefits and Limits.

Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.

Usual, Reasonable and Customary means the lesser of the following:

1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or

2. Most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; such other factors we, in the reasonable exercise of discretion, determine are appropriate.