Meridian Clear

Plan Detail

Plan Administrator: Azimuth Risk Solutions | AM Best Rating: A "Excellent" | Underwriter: Lloyd's of London

Benefits


SCHEDULE OF BENEFITS/LIMITS — Subject to the Terms of this insurance, which would include without limitation the Deductible and Coinsurance (unless otherwise expressly set forth to the contrary), and the various limits and Sub-Limits set forth below, the Scheme Administrator promises to provide the Participating Member the following Benefits and coverage arising out of Injury sustained or Illness suffered or charges, cost or Expenses Incurred while the Evidence of Insurance is in effect.

THE MERIDIANIES CLEAR SCHEDULE OF BENEFITS
Maximum Limit $2,000,000 Maximum Limit
Deductibles $500; $1,000; $2,500; $5,000; $10,000 per Participating Member per Coverage Period
Coverage Area Area 1- Worldwide Including US & Canada Area 2- Worldwide Excluding US & Canada
Coinsurance – Claims incurred inside US or Canada After the Deductible the Plan will pay 80% of the next $5,000 of Eligible Medical Expenses, then 100% to the Maximum Limit. Coinsurance will be waived if Eligible Medical Expenses are incurred within the Preferred Provider Organization Network
Coinsurance – Claims incurred outside US or Canada After the Deductible the Plan will pay 100% of Eligible Medical Expenses to the Maximum Limit
Pre-notification Penalty 50% Eligible Medical Expenses
Pre-existing Condition $5,000 Sub-Limit per Coverage Period, $50,000 Maximum Sub-Limit (After 728 of continuous coverage)
INPATIENT BENEFITS ONLY
Hospital Room and Board – Coverage Area 1 $ $400 Sub-Limit per day, 240 day Maximum per Hospitalization (Includes ICU days)
Hospital Room and Board – Coverage Area 2 $300 Sub-Limit per day, 240 day Maximum per Hospitalization (Includes ICU days)
Intensive Care Unit – Coverage Area 1 $1,000 Sub-Limit per day, 240 day Maximum per Hospitalization (Includes Non-ICU days)
Intensive Care Unit – Coverage Area 2 $800 Sub-Limit per day, 240 day Maximum per Hospitalization (Includes Non-ICU days)
INPATIENT/OUTPATIENT BENEFITS
Chemotherapy and Radiation Usual, Reasonable, and Customary
Surgical Consultant $350 Sub-Limit per consultation prior to Surgery
Surgeon/Surgery Usual, Reasonable, and Customary
Assistant Surgeon 20% of Surgeon benefit
Anesthesiologist 20% of Surgeon benefit
Diagnostic Laboratory $250 per exam (Includes all procedures carried out on one specimen)
Diagnostic Radiology $250 per exam (Includes X-Rays, Ultrasounds, Sonograms and Diagnostic Mammograms)
Diagnostic MRI, Scans and Scopes $500 Sub-Limit per exam, (Includes MRI, CAT Scans, PET Scans, Echocardiography, Endoscopy, Gastroscopy, Colonoscopy and Cystoscopy)
Physician $70 Sub-Limit per visit, 15 visits per Coverage Period
Physician Specialist $70 Sub-Limit per visit, 15 visits per Coverage Period
Physical Therapist $50 Sub-Limit per visit, 15 visits per Coverage Period
Local Ambulance $1,500 Sub-Limit per Coverage Period when Illness or Injury results in Hospitalization
OUTPATIENT BENEFITS ONLY  
Wellness - Adult $250 Sub-Limit per Coverage Period for Participating Members age 30 and over, Not subject to Deductible or Coinsurance (After 728 of continuous coverage)
Wellness - Dependent Child $150 Sub-Limit per Coverage Period for Participating Members age 18 and under, Not subject to Deductible or Coinsurance (After 364 days of Continuous Coverage)
Mental & Nervous Disorders $50 Sub-Limit per visit, 15 visits per Coverage Period for Outpatient Treatment, After 364 days of Continuous Coverage
Chiropractor $50 Sub-Limit per visit, 15 visits per Coverage Period, Must be prescribed by a Licensed Medical Physician (After 364 days of Continuous Coverage)
EMERGENCY BENEFITS
Emergency Room - Illness/Accident Usual, Reasonable, and Customary, Subject to additional $250 Deductible if Illness or Injury does not result in Hospitalization
Emergency Medical Evacuation $30,000 Maximum Sub-Limit
Emergency Reunion Reimbursement up to $7,500 for Expenses related to the Emergency Reunion of a relative or friend resulting from an Emergency Medical Evacuation of a Participating Member
MATERNITY BENEFITS  
Maternity - Normal or Complicated Delivery $10,000 Sub-Limit per Coverage Period, $50,000 Maximum Sub-Limit (After 728 day of Continuous Coverage)
Newborn Care Included as part of Maternity benefit for the first 31 days of life
Midwife Services $350 Sub-Limit per covered Pregnancy
OTHER BENEFITS
Human Organ/ Tissue Transplant $250,000 Sub-Limit per Covered Transplants
Return of Mortal Remains Reimbursement up to $30,000 for the return of a Participating Members Mortal Remains to his/her Home Country, Not subject to Deductible or Coinsurance
Prescription Drug Coverage Reimbursement Only. Inpatient drugs are Usual, Reasonable and Customary. Prescription drugs are Subject to 20% Coinsurance in the US, Maintenance drugs are not covered
Durable Medical Equipment Usual, Reasonable and Customary charges, Limited to a standard Wheelchair and/or Hospital Bed

Home Country: The country of which the Participating Member is a citizen or national; or maintains his/her residence or usual place of abode; or the country of which the Participating Member is the possessor of a validly issued passport

Pre-Existing Condition — Any Illness, Injury, Mental or Nervous Disorder, sickness, disease, physical, or any other condition or ailment for which medical advice , diagnosis, care, or treatment (which would include but not limited to receiving services and supplies, consultations, diagnostic tests, or prescription medications) was recommended or received during the 730 days immediately preceding the Effective Date of Coverage ; any condition that manifested itself (whether known or unknown) in such a manner that would cause a reasonably prudent person to seek medical attention, treatment, advice, diagnosis, or care that with reasonable medical certainty; and

Pre-existing Condition: Any Illness, Injury or Mental or Nervous Disorder that, with reasonable medical certainty, existed on or at any time prior to the Effective Date of Coverage, whether or not previously manifested or symptomatic, diagnosed, treated or disclosed on the Application or on any Claim Form or otherwise, which would include any chronic, subsequent or recurring complications or consequences associated therewith or arising or resulting therefrom.

ELIGIBLE MEDICAL EXPENSES — Subject to the Terms of this insurance, which would include without, limitation the Deductible, Coinsurance, Maximum Limits and Sub-Limits set forth in the Schedule of Benefits/Limits, Section 21, and the Exclusions set forth in Section 30, below, the Scheme Administrator will reimburse the Participating Member for the following costs, charges and Expenses Incurred by the Participating Member with respect to an Illness suffered or Injury sustained by the Participating Member while the Evidence of Insurance issued by the Master Policy is in effect, so long as the costs, charges or Expenses Incurred are Usual, Reasonable and Customary:

29.1 Charges Incurred at a Hospital for Inpatient Care:

29.1.1 Daily room and board, and nursing services up to $400 inside the US or $300 outside the US for a semi-private room rate per day, up to a Maximum of two hundred and forty (240) days; and

29.1.2 Daily room and board, and nursing services not to exceed $1,000 inside the US or $800 outside US for charges Intensive Care Unit, up to a Maximum of two hundred and forty (240) days; and

29.1.3 Use of operating, treatment or recovery room; and

29.1.4 Services and supplies that are routinely provided by the Hospital to persons for use while Inpatient; and

29.2 Charges Incurred for at an Inpatient/Outpatient Treatment or Surgery:

29.2.1 Radiation therapy or Treatment, and chemotherapy; and 29.2.2 Up to $350 for charges for a surgical consult per consult prior to Surgery

29.2.3 Usual, Reasonable and Customary charges related to an Eligible Surgery; and

29.2.4 Usual, Reasonable and Customary charges of the Primary Surgeon related to an eligible surgery; and

29.2.5 Provided, however, that charges by or for an assistant surgeon will be limited and covered at the rate of twenty (20%) percent of the Usual, Reasonable and Customary charge of the primary surgeon; and

29.2.6 Provided, however, that charges by the anesthesiologist will be limited and covered at the rate of twenty (20%) percent of the Usual, Reasonable and Customary charge of the primary surgeon; and

29.2.7 Provided, however, that charges by or for a registered nurse anesthetist will be limited and covered at the rate of twenty (20%) percent of the Usual, Reasonable and Customary charge of the primary anesthesiologist; and

29.2.8 Provided, further, that stand by availability of a Physician or surgeon will not be deemed to be a professional service and is not eligible for coverage; and

29.3 Other Charges Incurred For Inpatient/Outpatient Treatment or Surgery:

29.3.1 Service and supplies; and

29.3.2 Dressings, sutures, casts or other supplies that are Medically Necessary; and

29.3.3 Up to $250 per Diagnostic laboratory services, which would include all procedures carried out on one specimen; and

29.3.4 Up to $250 per Diagnostic Radiology service, which would include x-rays, ultrasounds, sonograms and diagnostic mammograms; and

29.3.5 Up to $500 per MRI, CAT Scans, PET Scans, Echocardiography, Endoscopy, Gastroscopy, Colonoscopy and Cystoscopy; and

29.3.6 Up to $70 per visit, 15 visits per Coverage Period for General Physician visits

29.3.7 Up to $70 per visit, 15 visits per Coverage Period for Specialist Physician visits

29.3.8 Up to $50 per visit, 15 visits per Coverage Period for Physical therapy prescribed by a Physician and performed by a licensed physical therapist, and necessarily incurred to continue recovery from a covered Injury or covered Illness; and

29.3.9 Up $1,5000 for Emergency local ambulance transport necessarily incurred in connection with Illness or Injury resulting in Hospitalization; and

29.3.10 Reconstructive Surgery when directly related to a Surgery that is eligible and covered under this insurance; and

29.3.11 Basic functional artificial limb(s) or eye(s), but not the replacement or repair thereof; and

29.3.12 Hemodialysis and the charges by a Hospital for processing and administration of blood or blood components, but not the cost of the actual blood or blood components; and

29.3.13 Oxygen and other gasses and their administration; and

29.3.14 Care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital;

4 Other Outpatient Benefits:

29.4.1 Wellness —or as specified in Section 21 Schedule of Benefits/Limits, and subject to the Terms and conditions of this insurance, the Scheme Administrator will reimburse the Participating Member for the following Expenses Incurred while the Coverage Period is in effect:

29.4.2.1 For Participating Members age thirty (30) years and older: one Routine Physical Exam, limited to $250 per Coverage Period, which would include Expenses Incurred for mammography exams and pap smears, provided the Participating Member has Continuously Coverage under this Insurance plan for not less than seven hundred and twenty-eight (728) days; and

29.4.2.2 For Participating Members eighteen (18) years of age or younger: one Routine Physical Exam, limited to $150 per Coverage Period, which would include Routine inoculations and vaccinations commonly administered to Dependent Children less than eighteen (18) years of age in accordance with standard medical practice, provided the Participating Member has Continuously Coverage under this Insurance plan for not less than three hundred and sixty-four (364) days; and and

29.4.3 Mental or Nervous Disorders — $50 per visit, 15 visit per Coverage period for Outpatient Treatment provided the Participating Member has been continuously insured under this insurance plan for not less than three hundred and sixty-four (364) days immediately preceding Treatment; and

29.4.4 Chiropractor — $50 per visit, 15 visit per Coverage period, must be prescribed by a Licensed Medical Physician, provided the Participating Member has been continuously insured under this insurance plan for not less than three hundred and sixty-four (364) days immediately preceding Treatment; and

Emergency Benefits:

29.5.1 Emergency Room Treatment — Usual, Reasonable and Customary charges, an additional $250 Deductible will be required unless the Participating Member is directly admitted to the Hospital as Inpatient for further treatment of that Illness or Injury; and

29.5.2 Emergency Medical Evacuation — The Scheme Administrator will arrange Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary Treatment to prevent the Participating Member's loss of life. The Scheme Administrator will use its best efforts to arrange with independent, third-party contractors any Emergency Medical Evacuation within the least amount of time reasonably possible. The Participating Member understands and agrees that the timeliness, duration and outcome of an Emergency Medical Evacuation can be affected by events and/or circumstances that are not within the direct control of the Scheme Administrator, which would include, but not limited to, availability and performance of competent transportation equipment and staff; delays or restrictions on flights or other modes of transportation caused by mechanical problems, government officials, telecommunications problems, and/or geographical and weather conditions. The Participating Member agrees to hold the Scheme Administrator, its agents and representatives harmless from, and agrees that the Scheme Administrator, its agents and representatives shall not be held liable for, any delays, losses, damages or other claims that arise from or are caused by the acts or omissions of such independent thirdparty contractors, or that arise from or are caused by any acts, omissions, events or circumstances that are not within the direct and immediate control of the Scheme Administrator and/or its authorized agents and representatives, which would include, without limitation, the events and circumstances set forth above. The Scheme Administrator will reimburse the Participating Member for the following Expenses Incurred by the Participating Member arising out of or in connection with an Emergency Medical Evacuation occurring while the Evidence of Insurance is in effect. Subject to the Maximum Sub-Limit set forth in the Schedule of Benefits/Limits and the other Terms of this insurance, which would include the Conditions and Restrictions set forth below:

29.5.2.1 Emergency air transportation to a suitable airport nearest to the Hospital where the Participating Member will receive treatment; and

29.5.2.2 Emergency ground transportation necessarily preceding Emergency air transportation and from the destination airport to the Hospital where the Participating Member will receive treatment; and

29.5.2.3 The Participating Member must be in compliance with all Terms of this insurance; and

29.5.2.4 The Scheme Administrator will provide Emergency Medical Evacuation Benefits only when the Illness or Injury giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance, except when provided under the Sudden Onset of Pre-existing condition; and

29.5.2.5 Medically Necessary Treatment cannot be provided locally to prevent Participating Member(s) loss of life; and

29.5.2.6 Transportation by any other method would result in loss of the Participating Member's life; and

29.5.2.7 Emergency Medical Evacuation is recommended by the attending Physician who certifies to the matters in subsections 29.5.2.5 and 29.5.2.6 above; and

29.5.2.8 Emergency Medical Evacuation is agreed to by the Participating Member or a Relative of the Participating Member; and

29.5.2.9 Emergency Medical Evacuation is approved in advance and all arrangements are coordinated by the Scheme Administrator; and

29.5.2.10 The Illness or Injury giving rise to the Emergency Medical Evacuation occurred suddenly and/or spontaneously, and without: (i) advance warning, (ii) advance treatment, diagnosis or recommendation for treatment by a Physician, or (iii) prior manifestation of symptoms or conditions that would have caused a prudent person to seek medical attention prior to the onset of the Emergency; and

29.5.3 Emergency Reunion — Subject to the Terms of this insurance, Emergency Reunion Expenses Incurred will be reimbursed to the Participating Member as outlined in the Schedule of Benefits/Limits in cases where there has been an Emergency Medical Evacuation covered under the Terms of this insurance. Subject to the Deductible, Coinsurance, Maximum Limits and Sub-Limits as specified in the Schedule of Benefits/Limits, and subject to the following Expenses Incurred in respect of travel by a Relative or friend of the Participating Member upon the recommendation and prior approval of the Scheme Administrator and the Conditions and Restrictions set forth below:

29.5.3.1 The cost of an economy air ticket for one Relative or friend to the airport serving the area where the Participating Member is Hospitalized as a result of the Emergency or is to be Hospitalized as a result of the Emergency Medical Evacuation, and return from either of such locations to the point of their original departure; and

29.5.3.2 Reasonable and necessary travel, meals (maximum of $25 per day), transportation and accommodation Expenses Incurred in relation to the Emergency Reunion (but excluding entertainment); and

29.5.3.3 The Coverage Period for the Emergency Reunion shall not exceed fifteen (15) days, including travel days; and

29.5.3.4 The Emergency Reunion must be due to an Emergency Medical Evacuation covered under the Terms of this insurance; and

29.5.3.5 The attending Physician must deem the Illness or Injury as a threat to the Participating Members life and recommends the presence of a Relative or friend to either the location where the Participating Member is being evacuated from or the destination of the evacuation, whichever is considered by the attending Physician and the Scheme Administrator to be the more reasonable; and

29.5.3.6 Emergency Reunion travel, transportation and accommodation arrangements and benefits must be coordinated and approved in advance by the Scheme Administrator in order to be eligible for coverage under this insurance; and

29.6 Maternity Benefits:

29.6.1 Maternity — Treatment for routine and Medically Necessary Maternity care of the Participating Member, if the Normal or Complicated Delivery of the Newborn and the charges incurred are eligible for coverage and are covered under the Terms of this insurance the plan will pay up to $10,000 Sub-Limit per Coverage Period up to $50,000 Maximum Sub-Limit, provided the Participating Member has Continuously Coverage under this Insurance plan for not less than seven hundred and twenty-eight (728) days; and

29.6.2 Newborn Care — Newborn care will be covered under the maternity benefit up to the Maximum Limit an/or for during the first thirty-one (31) days of life. Subject to all Term, conditions, limitations and exclusion set forth in Section 29.6.1; and

29.6.3 Midwife Service — covered under the maternity benefit up to $350 per covered pregnancy. Subject to all Term, conditions, limitations and exclusion set forth in Section 29.6.1; and

29.7 Other Covered Benefits:

29.7.1 Human Organ & Tissue Transplants — Subject to the Terms of this insurance, which would include without limitation the Deductible, Coinsurance, and Sub-Limits set forth in the Schedule of Benefits/Limits set forth in Section 21, above, the Pre-notification provisions set forth in Section

29.7.2, below, and the Exclusions set forth in Section 30 below, the Scheme Administrator will reimburse the Participating Member up to $250,000 Sub-Limit for the following costs, charges and Expenses Incurred by the Participating Member with respect to a Covered Transplant obtained or received by the Participating Member while the Evidence of Insurance issued by the Master Policy is in effect, so long as such costs, charges or Expenses Incurred are Usual, Reasonable, and Customary:

29.7.1.1 Eligible Medical Expenses Incurred by a live donor will be treated as if they were the Eligible Medical Expenses of the Participating Member receiving a Covered Transplant if the Participating Member received an organ or tissue of the live donor; and

29.7.1.2 Organ procurement and harvesting costs, excluding acquisition or purchase of the actual organ or tissue, up to a maximum of $10,000; and

29.7.1.3 Charges incurred for pre-transplant evaluation, the Covered Transplant procedure, re-transplantation, if incurred during the initial Covered Transplant Hospitalization, and post-transplant care; and

29.7.1.4 Reasonable travel and lodging Expenses Incurred for the Participating Member if travel of more than fifty (50) miles is necessary to receive the Covered Transplant Treatment and supplies from a Managed Transplant System Network Provider, up to a maximum of $5,000; and

29.7.2 Transplant Pre-notification — To become eligible for the transplant benefits under this insurance, the transplant must be a Covered Transplant, the Participating Member must receive all Covered Transplant Treatment and supplies from an independent transplant network provider or a Managed Transplant System Network approved by the Scheme Administrator, and the Covered Transplant Must Be Pre-certified by the Scheme Administrator in accordance with the Terms of this insurance. If the Participating Member receives Covered Transplant Treatment and supplies from a provider that is not an approved member of the Scheme Administrator's independent Managed Transplant System Network, or if the transplant is not a Covered Transplant or is not properly Pre-certified, no transplant benefits shall be available under this insurance. The Scheme Administrator shall not have any right, obligation, or authority of any kind to ultimately select Physicians, Hospitals, or other healthcare providers for the Participating Member or to make any medical Treatment decisions for or on behalf of the Participating Member regarding transplants, and all such decisions shall be made solely and exclusively by the Participating Member and/or his/her Family members and treating Physicians and other healthcare providers. All claims for transplant benefits are subject to the Terms of this insurance; and

29.7.3 Return of Mortal Remains — In the event of the Death of the Participating Member as a result of an Illness or Injury covered under this insurance while the Participating Member is outside of his/her Home Country, the Scheme Administrator will reimburse the estate of the Participating Member up to US $30,000 for the return of the Participating Member's Mortal Remains to his/her Home Country (but not including any costs of burial); provided, however, that the Scheme Administrator must coordinate and approve all costs related to the return of the Participating Member's Mortal Remains in advance as a condition to this benefit; and

29.7.4 Prescription Drugs — After the Deductible the Scheme Administrator will reimburse the Participating Member eighty (80%) percent of charges for prescription drugs prescribed by a Licensed Physician for treatment of a covered Illness or Injury, but not for Maintenance drugs, the replacement of lost, stolen, damaged, expired or otherwise compromised drugs; and

29.7.5 Durable Medical Equipment (DME) — Rental of DME when Medically Necessary, limited to a standard Hospital bed and/or standard wheelchair; and

29.7.6 Charges Incurred for Hospice Care — Room and board charged by the Hospice and parttime nursing by a Registered Nurse when the following conditions apply:

29.7.6.1 The Physician must certify that the Participating Member is terminally ill with six (6) months or less to live; and

29.7.6.2 Services for the Participating Member must be received in an Inpatient Hospice facility or in the Participating Member's home.