Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London
| Plan Details | |
| Overall Maximum Limit |
Age 80 or older: $20,000 Age 65 to 79: $100,000 All others: $250,000 |
| Maximum per Injury / Illness |
Age 80 or older: $20,000 Age 65 to 79: $100,000 All others: $250,000 |
| 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. |
| 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 |