|
PLAN A |
PLAN B |
PLAN C |
Maximum Coverage Limit |
Age 15 days to 79 years: US$25,000 per Period of Coverage, and for the life of the plan
Age 80+ years: US$10,000 per Period of Coverage, and for the life of the plan |
Age 15 days to 79 years: US$50,000 per Period of Coverage, and for the life of the plan |
Age 15 days to 79 years: US$100,000 per Period of Insurance, and for the life of the plan |
Deductible |
All Deductibles are per Period of Coverage and are shown on the Declaration |
All Deductibles are per Period of Coverage and are shown on the Declaration |
All Deductibles are per Period of Coverage and are shown on the Declaration |
Inpatient Treatment: |
Hospital Room & Board including miscellaneous |
Up to $825 per day, limited to 30 days per Period of Coverage |
Up to $1400 per day, limited to 30 days per Period of Coverage |
Up to $1,950 per day, limited to 30 days per Period of Coverage |
Intensive Care |
Up to an additional $400 per day, limited to 8 days per Period of Coverage |
Up to an additional $660 per day, limited to 8 days per Period of Coverage |
Up to an additional $850 per day, limited to 8 days per Period of Coverage |
Pre-admission Testing |
Up to $750 per Period of Coverage |
Up to $1100 per Period of Coverage |
Up to $1100 per Period of Coverage |
Surgery |
Surgeon |
Up to $2,000 per Surgical session |
Assistant Surgeon |
Up to $450 per Surgical session |
Anesthetist |
Up to $450 per Surgical session |
|
Surgeon |
Up to $3,300 per Surgical session |
Assistant Surgeon |
Up to $825 per Surgical session |
Anesthetist |
Up to $825 per Surgical session |
|
Surgeon |
Up to $5,500 per Surgical session |
Assistant Surgeon |
Up to $1,375 per Surgical session |
Anesthetist |
Up to $1,375 per Surgical session |
|
Inpatient Physician Visits |
Up to $40 allowable charge per visit and 1 visit per day, limited to 30 visits per Period of Coverage |
Up to $55 allowable charge per visit and 1 visit per day, limited to 30 visits per Period of Coverage |
Up to $85 allowable charge per visit and 1 visit per day, limited to 30 visits per Period of Coverage |
Physician Consult |
Up to $350 per Period of Coverage, when requested by attending Physician |
Up to $450 per Period of Coverage, when requested by attending Physician |
Up to $500 per Period of Coverage, when requested by attending Physician |
Private Duty Nurse |
Up to $400 per Period of Coverage |
Up to $550 per Period of Coverage |
Up to $550 per Period of Coverage |
Outpatient Treatment: |
Surgery |
session |
Surgical Facility Fee |
Up to $750 per Surgical |
session |
Surgeon |
Up to $2,000 per Surgical |
session |
Assistant Surgeon |
Up to $450 per Surgical |
session |
Anesthetist |
Up to $450 per Surgical |
|
session |
Surgical Facility Fee |
Up to $900 per Surgical |
session |
Surgeon |
Up to $3,300 per Surgical |
session |
Assistant Surgeon |
Up to $825 per Surgical |
session |
Anesthetist |
Up to $825 per Surgical |
|
session |
Surgical Facility Fee |
Up to $1,000 per Surgical |
session |
Surgeon |
Up to $5,500 per Surgical |
session |
Assistant Surgeon |
Up to $1,375 per Surgical |
session |
Anesthetist |
Up to $1,375 per Surgical |
|
Outpatient Physician Visits |
Up to $50 allowable charge per day and 1 visit per day, limited to 10 visits per Period of Coverage |
Up to $55 allowable charge per day and 1 visit per day, limited to 10 visits per Period of Coverage |
Up to $85 allowable charge per day and 1 visit per day, limited to 10 visits per Period of Coverage |
Diagnostic Lab & Xray |
Up to $650 per Period of Coverage, limited to $325 allowable charge per procedure |
Up to $800 per Period of Coverage, limited to $400 allowable charge per procedure |
Up to $950 per Period of Coverage, limited to $475 allowable charge per procedure |
Hospital Emergency Room |
Up to $200 allowable charge per v |
75% of URC to a maximum of $330 allowable charge per visit |
75% of URC to a maximum of $550 allowable charge per visit |
Prescription Drugs |
Up to $150 per Period of Coverage |
Up to $250 per Period of Coverage |
Up to $250 per Period of Coverage |
Emergency Local Ambulance |
Up to $250 per Period of Coverage |
Up to $450 per Period of Coverage |
Up to $450 per Period of Coverage |
Physical Therapy |
Up to $25 allowable charge per visit and 1 visit per day, limited to 12 visits per Period of Coverage |
Up to $40 allowable charge per visit and 1 visit per day, limited to 12 visits per Period of Coverage |
Up to $40 allowable charge per visit and 1 visit per day, limited to 12 visits per Period of Coverage |
Dental Accident |
Up to $350 per Period of Coverage |
Up to $550 per Period of Coverage |
Up to $550 per Period of Coverage |
Extended Care Facility |
Up to $150 per day, limited to 15 days per Period of Coverage |
Up to $200 per day, limited to 15 days per Period of Coverage |
Up to $250 per day, limited to 15 days per Period of Coverage |
Common Carrier Accidental Death Benefit |
$25,000 |
$25,000 |
$25,000 |
Emergency Medical Evacuation Expenses |
Up to $25,000 per evacuation, must be approved in advance and coordinated by the Company |
Up to $50,000 per evacuation, must be approved in advance and coordinated by the Company |
Up to $50,000 per evacuation, must be approved in advance and coordinated by the Company |
Return of Mortal Remains |
Up to $7,500, or up to US$5,000 for local burial or cremation, must be approved in advance and coordinated by the Company |
Up to $7,500, or up to US$5,000 for local burial or cremation, must be approved in advance and coordinated by the Company |
Up to $7,500, or up to US$5,000 for local burial or cremation. Must be approved in advance and coordinated by the Company |
Incidental Trip Coverage |
Up to 14 days per Period of Coverage |
Up to 14 days per Period of Coverage |
Up to 14 days per Period of Coverage |