Visit USA HealthCare - Superior

Plan Detail

Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London

Benefits


SCHEDULE OF BENEFITS AND LIMITS

Plan Details  
Overall Maximum Limit Up to Age 79: $250,000; Age 80+: $20,000
Maximum per Injury / Illness Up to Age 79: $250,000; Age 80+: $20,000
Deductibles $0, $250, $500, or $1,000 per certificate period
Coinsurance – Claims incurred outside U.S. We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.
Coinsurance – Claims incurred in U.S.  
In-Network Payment Within the PPO: We will pay 100% of eligible expenses, after the deductible, to the overall maximum limit.
Out-of-Network Payment Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount.

Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.

Benefit Limit
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit Up to the overall maximum limit
Local Ambulance Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.
Emergency Room Co-payment Claims incurred outside the U.S.
No co-payment

Claims incurred in U.S.
You shall be responsible for a $200 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury.
Urgent Care Center Co-payment Claims incurred outside the U.S.
No co-payment

Claims incurred in U.S.
For each visit, you shall be responsible for a $50 co-payment, after which coinsurance will apply.
– Co-payment is waived for members with a $0 deductible.
– not subject to deductible
Outpatient Physical Therapy and Chiropractic Care Usual, reasonable and customary charges. Must be ordered in advance by a physician.
Mental Health Disorders Up to $5,000
Emergency Dental Treatment due to Accident Up to $1,000
Emergency Dental (Acute Onset of Pain) Up to $100 - not subject to deductible or coinsurance
Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions) Ages 65 and above: $2,500
All others: $25,000
Terrorism Up to $50,000 lifetime maximum, eligible medical expenses only
Optional Hazardous Activities Rider Up to the overall maximum limit
Optional Intercollegiate or Interscholastic Sports Rider Up to $20,000
All Other Eligible Medical Expenses Up to the overall maximum limit
Emergency Travel Benefits Limit
Emergency Medical Evacuation Up to $500,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit
Repatriation of Remains Up to the overall maximum limit - not subject to deductible or coinsurance
Local Burial or Cremation Up to $5,000 - not subject to deductible or coinsurance
Crisis Response - Ransom, Personal Belongings, and Crisis Response Fees and Expenses Up to $10,000 - not subject to deductible, coinsurance, or overall maximum limit
Emergency Reunion Up to $15,000, subject to a maximum of 15 days - not subject to deductible or coinsurance
Bedside Visit Up to $1,500 - not subject to deductible or coinsurance
Return of Minor Children Up to $50,000 - not subject to deductible or coinsurance
Pet Return Up to $1,000 - not subject to deductible or coinsurance
Political Evacuation Up to $50,000 lifetime maximum - not subject to deductible or coinsurance
Trip Interruption Up to $5,000 - not subject to deductible or coinsurance
Accidental Death & Dismemberment
Ages 18 through 69




Under age 18




Ages 70 through 74




Ages 75 and older

Lifetime Maximum - $50,000
Death - $50,000
Loss of 2 Limbs - $50,000
Loss of 1 Limb - $25,000
Lifetime Maximum - $5,000
Death - $5,000
Loss of 2 Limbs - $5,000
Loss of 1 Limb - $2,500
Lifetime Maximum - $20,000
Death - $20,000
Loss of 2 Limbs - $20,000
Loss of 1 Limb - $10,000
Lifetime Maximum - $10,000
Death - $10,000
Loss of 2 Limbs - $10,000
Loss of 1 Limb - $5,000
$250,000 maximum benefit any one family or group.
- not subject to deductible, coinsurance, or overall maximum limit
Optional Enhanced Accidental Death & Dismemberment Rider (only available to members age 18 through age 69) Lifetime Maximum - $50,000
Death - $50,000
Loss of 2 Limbs - $50,000
Loss of 1 Limb - $25,000
- not subject to deductible, coinsurance, or overall maximum limit
Lost Checked Luggage Up to $500 - not subject to deductible or coinsurance
Travel Delay Up to $100 a day after a 12-hour delay period requiring an unplanned overnight stay. Subject to a maximum of 2 days. - not subject to deductible or coinsurance
Lost or Stolen Passport/Travel Visa Up to $100 - not subject to deductible or coinsurance
Natural Disaster - Replacement Accommodations Up to $100 a day for 5 days - not subject to deductible or coinsurance
Hospital Indemnity $100 per day for 5 days for inpatient hospitalization - not subject to deductible or coinsurance
Personal Liability Up to:
$10,000 lifetime maximum
$10,000 third person injury
$10,000 third person property
$2,500 related third person property
- not subject to deductible, coinsurance, or overall maximum limit