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 |