Plan Administrator: International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius Group, Sirius Specialty Insurance Corporation
| Maximum Limit | $5,000,000 |
| Deductible Options | $0, $100, $250 or $500 per illness or injury available |
| Maximum Limit Per Illness or Injury | Choice of $50,000, $100,000, $250,000 or $500,000 |
| Coinsurance | Company pays 100% |
| INPATIENT/OUTPATIENT BENEFITS | |
| Hospital Room and Board | Up to the average semi-private room rate |
| Intensive Care Unit | Company pays 100% after deductible is met |
| Physical Therapy | Company pays 100% after deductible is met; one visit per day (Medical order or treatment plan required) |
| Bedside Visit | $1,500 maximum limit. Must be hospitalized in an intensive care unit. Not subject to deductible |
| Physician Visit | Company pays 100% after deductible is met; one visit per day |
| Student Health Center | $5 copay per visit. Not subject to deductible |
| Prescription Drugs |
Company pays 100% after deductible is met 90 day dispensing maximum |
| Urgent Care |
$50 copay. Not subject to deductible. Copay is not applicable if you choose a $0 Deductible |
| Walk-in Clinic |
$20 copay. Not subject to deductible. Copay is not applicable if you choose a $0 Deductible |
| Eligible Medical Expenses | Company pays 100% after deductible is met |
| Emergency Room visit with In-patient Admission | Company pays 100% after deductible is met |
| Emergency Room visit without In-patient Admission | Additional $250 deductible |
|
Interfacility Ambulance Transfer (For Services Rendered in the U.S. ) |
Company pays 100%. Transfer must be a result of an inpatient hospital admission Not subject to deductible |
| Dental | Non-emergency treatment at a dental provider due to an accident: $500 period of coverage limit per injury; Treatment due to unexpected pain to sound, natural teeth: $350 period of coverage limit |
| Mental or Nervous / Substance Abuse |
Not covered if incurred in student health center Inpatient: $10,000 maximum limit Outpatient: $50 maximum limit per day. $500 maximum limit |
| EVACUATION BENEFITS (Not subject to deductible) | |
| Emergency Medical Evacuation | $50,000 maximum limit |
| Emergency Reunion | $15,000 maximum limit |
| Return of Mortal Remains or Cremation/Burial |
$25,000 maximum limit for return of mortal remains or $5,000 maximum limit for cremation/burial |
| Political Evacuation and Repatriation | $10,000 maximum limit |
| ADDITIONAL BENEFITS | |
| Accidental Death & Dismemberment | $25,000 principal sum; Not subject to deductible |
| Terrorism | $50,000 maximum limit; Not subject to deductible |
| Sudden & Unexpected Recurrence of a Pre-existing Condition |
Eligible medical expenses: $5,000 maximum limit Emergency medical evacuation: $25,000 maximum limit |
| Pre-existing Conditions | For conditions existing within 36 months before effective date, charges excluded until after 12 months of coverage and then $500 per period of coverage and $1,500 maximum limit |
| Incidental Trip Coverage (Available for non-U.S. residents only) | Up to a cumulative 14 days |
| OPTIONAL ADD-ON RIDER | |
| Lost Personal Property | $250 per period of coverage limit |
| Legal Assistance | $500 per period of coverage limit |
|
Personal Liability - Injury to third party Personal Liability - Damage to third party’s property |
$2,000 per period of coverage limit after $100 deductible $500 per period of coverage limit after $100 deductible |
| Limited High School and College Sports | Company pays 100% after deductible is met |
Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.