Reside Prime

Plan Detail

Plan Administrator: Seven Corners | AM Best Rating: A "Excellent" | Underwriter: Lloyd's of London and Tramont Insurance Company Limited
Benefits Description Exclusions Renewal Claims

Benefits

 

Benefit Limit
PRIMARY SCHEDULE OF BENEFITS
This Schedule of Benefits applies for your first three Policy Periods. After completion of three consecutive and continuous Policy Periods, the Extended Coverage Schedule of Benefits applies. A Policy Period is 364 days in length.
Lifetime Maximum $5,000,000 per insured person.
Policy Period Deductible Options  $250; $500; $1,000; $2,500; $5,000
Maximum of 3 deductible payments for families enrolling on one application.
Inside of the United States and Canada After the deductible, we pay 80% of the next $5,000 of eligible expenses, then 100% to the policy maximum.
If treatment is received from an approved PPO service provider while you are in the U.S., we will reduce the applicable deductible by 50% & waive coinsurance. 
Outside of the United States and Canada After the deductible, we pay 100% of eligible expenses to the policy maximum. 
Inpatient Hospital Expenses  Average semi-private room & board; usual, reasonable, & customary physician charges; prescription medications; durable medical equipment; nursing; & x-rays to the policy maximum.
Intensive Care Intensive Care room & board; usual, reasonable, & customary physician charges; prescription medications; durable medical equipment; nursing; & x-rays to the policy maximum.
Surgery Usual, reasonable, & customary charges for surgery, physician & anesthetics to the policy maximum.
Hospital Daily Indemnity Benefit  $50 per day ($1,000 maximum per policy period) while hospitalized outside of the U.S. & Canada. This payment is not related to the hospital charges & is paid in addition to other eligible benefits. Please see Benefit Options on the following page for an optional rider to increase this benefit to $200 per day.
Outpatient Treatment Usual, reasonable, & customary charges for emergency treatment; surgery; physician’s   office; & prescription medication to the policy maximum.
Physiotherapy, Chiropractic Up to $75 per visit, when referred in advance by a physician. Lifetime maximum of $10,000.
Medical Supplies Usual, reasonable, & customary charges to the policy maximum.
Ambulance Usual, reasonable, & customary charges to the policy maximum.
Well Child Care (under age 19) Up to $200 per policy period for checkups & routine visits after a 180-day waiting period. Not subject to deductible or coinsurance.
Maternity

Usual, reasonable, & customary to the limits below per pregnancy. You must pre-notify within the first 90 days of pregnancy.

Waiting period of 364 days.

  • After completion of 1 continuous policy period:                                $1,000
  • After completion of 2 continuous and consecutive policy periods:   $2,000
  • After completion of 3 continuous and consecutive policy periods:   $3,000
  • After completion of 4 continuous and consecutive policy periods:   $4,000
  • After completion of 5 continuous and consecutive policy periods:   $5,000
Newborn Benefit 

Maximums listed below per pregnancy for the first 31 days after birth.

  • After completion of 1 continuous policy period:                                $1,000
  • After completion of 2 continuous and consecutive policy periods:   $2,000
  • After completion of 3 continuous and consecutive policy periods:   $3,000
  • After completion of 4 continuous and consecutive policy periods:   $4,000
  • After completion of 5 continuous and consecutive policy periods:   $5,000 
Mental & Nervous Usual, reasonable, & customary to $10,000 per policy period after a 364-day waiting period. Inpatient limited to 45 days per policy period. Outpatient limited to 40 visits per policy period at 70% of eligible expenses. Lifetime maximum of $30,000.
Dental $500 per policy period for usual, reasonable, & customary charges for repair & replacement of sound, natural teeth damaged in an accident. An optional Dental Rider may be purchased. Please see details in this brochure.
Emergency Medical Evacuation $250,000 per person per policy period, when adequate medical facilities or treatment are not available (Pre-approval required). 
Repatriation/Return of Remains $25,000 per person (Pre-approval required).
Emergency Medical Reunion $10,000 per person per ocurrence (Pre-approval required).
Preventive Benefits (age 19 and over) $175 per policy period for checkups & routine physical exams for all members & female preventative exams & mammograms after a 180-day waiting period. Not subject to deductible or coinsurance.
Accidental Death & Dismemberment (AD&D) 24-Hour AD&D: Principal Sum: $10,000 for insured & spouse, $2,000 for dependent children. Common Carrier AD&D: Principal Sum: $40,000 for insured & spouse, $8,000 for dependent children. To increase this benefit, please see Benefit Options below. 
Lifetime Transplant Benefit  Up to $1,000,000 per insured person.
BENEFIT OPTIONS
Seven Corners offers optional benefits to enhance your coverage. These cannot be purchased independently.
AD&D Principal Sum Rider  A standard accidental death & dismemberment (AD&D) benefit is provided. Additional amounts include $100,000; $200,000; $300,000; $400,000 or $500,000 for the primary insured (these amounts may not exceed 7 times annual income), $100,000 for the spouse, and $10,000 for each child.
Dental Rider Optional worldwide dental coverage. Please see details included later in this brochure.
Sports Rider  $25,000 lifetime maximum for mountaineering up to 4500 meters where ropes or guides are normally used, hang gliding, parachuting & bungee jumping and $7,500 lifetime maximum for amateur sports or interscholastic athletics sponsored by a school or organization when not engaged for wage or profit.
Hospital Daily Indemnity Rider $150 per night (in addition to the standard benefit of $50) when you are hospitalized outside the U.S. and Canada. This benefit is not related to the hospital charges & is paid in addition to all other eligible benefits.
EXTENDED COVERAGE
After the completion of three policy periods, the following schedule of benefits applies beginning on the 1st day of your fourth policy period. Below is a listing of the benefits that will be adjusted with this change in schedules. If not listed below, the benefit will remain the same as the Primary Schedule of Benefits. All other conditions of the policy continue to apply.
Lifetime Maximum Benefit $2,500,000 per insured person.
Policy Period Deductible Options Deductibles will be increased by $250 as follows:
$250 becomes $500; $500 becomes $750; $1,000 becomes $1,250; $2,500 becomes $2,750;   $5,000 becomes $5,250
Maximum of 3 deductible payments for families enrolling on one application.
Inpatient Hospital Expenses Average semi-private room and board; usual, reasonable, and customary physician charges; prescription medications; durable medical equipment; nursing services; and x-rays. These benefits are covered to the policy maximum with a limit of $2,000 per day.
Intensive Care Intensive Care room and board; usual, reasonable, and customary physician charges; prescription medications; durable medical equipment; nursing services; and x-rays. These benefits are covered to the policy maximum with a limit of $4,000 per day.
Emergency Evacuation, when adequate medical facilities or treatment is not available locally (pre-approval required) US $25,000
Outpatient Treatment Usual, reasonable, and customary charges for emergency treatment; surgery; physician’s   office; & prescription medication to the policy maximum.
- physician charges, limit of $150 per visit
- hospital charge, $100 co-pay unless admitted, then waived
- urgent care facility, $25 co-pay
- diagnostic lab and x-rays, limited to $5,000 per policy period
Physiotherapy, Chiropractic Up to  $75 per visit, when referred in advance by a physician. Maximum of $1,000 per policy period & lifetime maximum of $10,000.
Medical Supplies Usual, reasonable, and customary charges to the policy maximum.
Ambulance $100 per incident.
Mental & Nervous $2,000 maximum per policy period. Inpatient limited to 25 days per policy period. Outpatient limited to 20 visits per policy period at 70% of eligible expenses, up to $75 maximum per visit. Lifetime maximum of $30,000.
Repatriation/Return of Remains $15,000 limit per person (Pre-approval required).
Lifetime Transplant Benefit $500,000 per insured person.
Chemotherapy or Radiation Therapy $10,000 per policy period, lifetime maximum of $50,000.
Outpatient Prescription Medications Limit of $5,000 per policy period for each insured person.
OPTIONAL DENTAL COVERAGE
Benefits (covered for usual, reasonable, and customary cost)
Class I: Preventative
  • Two oral exams per policy period
  • One set of full mouth x-rays every 180 days
  • One set of bitewing x-rays per policy period
  • One cleaning & scaling of teeth (oral prophylaxis) every 180 days
  • One topical fluoride treatment per policy period for children up to & including age 12
  • Space maintainers
  • Sealants for children up to & including age 12
Class II: basic restoration, endodontic, periodontal, oral surgery, diagnostic benefit dental services
  • Fillings – amalgam, silicate, acrylic, synthetic porcelain or composite fillings
  • X-rays, extractions, root canals, emergency palliative treatment, injections of antibiotics
  • Treatment of periodontal disease & other gum & mouth tissue disease
  • Oral surgery except procedures covered under any medical plan
  • Administration of general anesthesia, when medically necessary during oral surgery
Class III: crowns, bridges, dentures   Installation or replacement of 1 or more natural teeth which are lost for:
  • Initial Installation of fixed bridgework and installation for the first time of a partial removable denture or full removable denture
  • Replacement of an existing removable denture or fixed bridgework
  • Replacement of an existing immediate temporary full denture by a new permanent full denture
  • Adding teeth to an existing partial removable denture or to bridgework
  • Inlays and onlays
  • Crowns and their replacements (not more than 1 replacement per crown every 5 years)
  • Repair or re-cementing of crowns; or inlays or onlays; or dentures; or bridgework
If dental expenses are expected to exceed $250, you must pre-notify Seven Corners before treatment.

 

Benefit (covered for usual,reasonable, and customary cost) Policy Period 1 Policy Period 2 Policy Period 3 and after
Class I Preventative Benefits (90-day waiting period) ages 8 through 17 years only 100% 100% 100%
Class II standard benefits  (180-day waiting period) 55% 70% 85%
Class III significant dental benefits (180-day waiting period) 30% 40% 50%
Deductible (per person per policy period) $100 $100 $100
Maximum Benefit (per person per policy period $500 $750 $1,000