SCHEDULE OF BENEFITS
Benefit | Treatment Received Inside The United States And Canada | Treatment Received Outside The United States And Canada |
Lifetime Maximum | US $500,000 | US $5,000,000 |
Deductible Options, per person per injury/sickness |
$70, $100, $150, $250, $500, $1000 After the per injury/sickness deductible, the program will pay up to the amount listed below for each injury/sickness. |
|
INPATIENT | ||
Private or semi-private room, per day (maximum of 240 consecutive days) | US $600 | US $900 |
Intensive car, room, per day (maximum of 180 consecutive days) | US $1,500 | US $2,000 |
Surgical Treatment | US $3,000 | US $5,000 |
Anesthetist’s Charges | US $600 | US $1,000 |
Assistant Surgeon | US $600 | US $1,000 |
Physician’s Non-Surgical/Urgent Care Visit | US $60/visit, max 10 | US $75/visit, max 10 |
Laboratory Tests and X-rays | US $450 | US $600 |
Prescription Medication | US $100 | US $125 |
Chemotherapy and Radiation therapy | US $1,000 | US $1,250 |
Organ Transplant | US $100,000 | US $130,000 |
Durable Medical Equipment | US $100 | US $200 |
MATERNITY | ||
Normal and complicated child delivery maximum, including pre- and postnatal care which is reimbursed according to the limits shown within this Schedule of Benefits. Waiting period of 364 days before maternity benefit begins. | US $2,500 per pregnancy | US $4,000 per pregnancy |
Professional service related to hospitalization, per day | US $200 | US $250 |
OUTPATIENT | ||
Surgical Treatment | US $3,000 | US $5,000 |
Anesthetist’s Charges | US $600 | US $1,000 |
Assistant Surgeon | US $600 | US $1,000 |
Physician’s Non-Surgical/Urgent Care Visit | US $60/visit, max 10 | US $75/visit, max 10 |
Hospital Emergency Room (all expenses incurred therein) | US $350 | US $500 |
Prescription Medication | US $100 | US $125 |
Chemotherapy and Radiation Therapy | US $1,000 | US $1,250 |
Laboratory Tests and X-rays | US $450 | US $600 |
OTHER TREATMENT | ||
Dental treatment for Injury to sound, natural teeth | US $500 | US $500 |
Psychiatrist | US $60/visit, max 10 | US $75/visit, max 10 |
Endoscopy (i.e. Gastroscopy, Colonoscopy, Cystoscopy) | US $450 | US $600 |
Various Scans (i.e. MRI, CAT, Echocardiography) | US $450 | US $600 |
Chiropractors | US $60/visit, max 3 | US $75/visit, max 3 |
Physiotherapy | US $60/visit, max 10 | US $75/visit, max 10 |
Well Child Care (not subject to deductible) 180-day waiting period, under age 19 | US $60/visit, max 2 | US $75/visit, max 2 |
Preventative Benefit (females and males, age 19 and over) for checkups, routine physical exams, female preventative exams and mammograms, (not subject to deductible) 180-day waiting period | US $60/visit, max 1 | US $75/visit, max 1 |
NEWBORN COVERAGE | ||
Lifetime maximum for the first 31 days after birth, per limits as stated in the Certificate of Coverage | US $5,000 | US $10,000 |
TRANSPORTATION | ||
Local ground ambulance | US $1,500 | US $2,000 |
Emergency Evacuation, when adequate medical facilities or treatment is not available locally (pre-approval required) | US $25,000 | US $50,000 |
Return of Mortal Remains | US $20,000 | US $25,000 |
ACCIDENTAL DEATH & DISMEMBERMENT | ||
24 Hour Accidental Death and Dismemberment - Insured and Spouse - Dependent Children |
Principal Sum US $10,000 US $2,000 |
Principal Sum US $10,000 US $2,000 |
Common Carrier Accidental Death and Dismemberment - Insured and Spouse - Dependent Children |
US $40,000 US $8,000 |
US $40,000 US $8,000 |