VisitorSecure

Plan Detail

Plan Administrator: Tokio Marine HCC Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's

Benefits


SCHEDULE OF BENEFITS AND LIMITS
 
All benefits, except Emergency Medical Evacuation; Repatriation of Remains; and Common Carrier Accidental Death and Dismemberment, are subject to deductible and are the maximum per certificate period unless stated otherwise.
 
Penalty for Failure to Pre-Certify: 50% of Eligible Medical Expenses
 
All benefits are per sickness and per injury.
 
Benefit Plan A Plan B Plan C Plan D
Maximum per Injury / Illness
Ages 14 days through 69 years
$50,000 $75,000 $100,000 $130,000
Overall Policy Maximum
Ages 70-79
$50,000 $75,000 Not available Not available
Overall Policy Maximum
Ages 80 and above
$10,000 Not available Not available Not available
Deductible
Ages 14 days through 69 years
$0, $50, or $100 per Injury or Illness $0, $50, or $100 per Injury or Illness $0, $50, or $100 per Injury or Illness $0, $50, or $100 per Injury or Illness
Deductible
Ages 70 and above
$100 or $200 per Injury or Illness $100 or $200 per Injury or Illness Not available Not available
Penalty for failure to Pre-certify 50% of Eligible Medical Expenses 50% of Eligible Medical Expenses 50% of Eligible Medical Expenses 50% of Eligible Medical Expenses
Inpatient Treatment
Hospital Room and Board, including miscellaneous $1,450 per day, maximum 30 days $1,725 per day, maximum 30 days $2,000 per day, maximum 30 days $2,585 per day, maximum 30 days
Intensive Care Unit, including miscellaneous $2,110 per day, maximum 8 days max $2,480 per day, maximum 8 days max $2,850 per day, maximum 8 days max $3,690 per day, maximum 8 days max
Surgery $3,300 per session $4,400 per session $5,500 per session $7,150 per session
Consultant physician $450 $475 $500 $650
Private duty nurse $550 $550 $550 $700
Physician visits $60 per visit, 30 visits max $75 per visit, 30 visits max $90 per visit, 30 visits max $115 per visit, 30 visits max
Outpatient Treatment
Surgery $3,300 per session $4,400 per session $5,500 per session $7,150 per session
Outpatient Surgical Facility $1,000 $1,050 $1,100 $1,400
Pre-admission Testing $1,100 $1,100 $1,100 $1,450
Diagnostic X-ray and Labs $450, plus $250 for one CAT Scan, MRI or PET $475, plus $375 for one CAT Scan, MRI or PET $500, plus $500 for one CAT Scan, MRI or PET $650, plus $600 for one CAT Scan, MRI or PET
Emergency Room (all expenses incurred therein) $355 $465 $575 $750
Outpatient Prescription Drugs $100 $125 $150 $200
Office Visits, including Urgent Care $60 per visit, 10 visits max $75 per visit, 10 visits max $90 per visit, 10 visits max $115 per visit, 10 visits max
Miscellaneous Inpatient & Outpatient Treatment
Anesthesiologist $825 $1,110 $1,375 $1,775
Assistant Surgeon $825 $1,110 $1,375 $1,775
Local Ambulance $475 $475 $475 $475
Dental Accident $550 $550 $550 $550
Physical Therapy $40 per visit, 1 visit per day, maximum 12 visits $40 per visit, 1 visit per day, maximum 12 visits $40 per visit, 1 visit per day, maximum 12 visits $40 per visit, 1 visit per day, maximum 12 visits
Durable Medical Equipment $1,100 $1,200 $1,300 $1,700
Acute Onset of Pre-existing Condition (only available to Memvers under age 70)
$50,000 Lifetime Maximum for Eligible Medical Expenses.
$25,000 Lifetime Maximum for Emergency Medical Evacuation.
$75,000 Lifetime Maximum for Eligible Medical Expenses.
$25,000 Lifetime Maximum for Emergency Medical Evacuation.
$100,000 Lifetime Maximum for Eligible Medical Expenses.
$25,000 Lifetime Maximum for Emergency Medical Evacuation.
$100,000 Lifetime Maximum for Eligible Medical Expenses.
$25,000 Lifetime Maximum for Emergency Medical Evacuation.
Other Benefits
Emergency Medical Evacuation

$50,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing Condition. Available only to Members under age 70


If recommended by your attending Physician, who certifies that Evacuation is necessary to safeguard your life and that Medically Necessary treatment is not available locally, and if approved in advance and coordinated by MNU, the plan will provide the following benefits: Emergency air and/or ground transportation to the nearest Hospital that is qualified to provide the Medically Necessary treatment.

$50,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing Condition. Available only to Members under age 70


If recommended by your attending Physician, who certifies that Evacuation is necessary to safeguard your life and that Medically Necessary treatment is not available locally, and if approved in advance and coordinated by MNU, the plan will provide the following benefits: Emergency air and/or ground transportation to the nearest Hospital that is qualified to provide the Medically Necessary treatment.

$50,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing Condition. Available only to Members under age 70


If recommended by your attending Physician, who certifies that Evacuation is necessary to safeguard your life and that Medically Necessary treatment is not available locally, and if approved in advance and coordinated by MNU, the plan will provide the following benefits: Emergency air and/or ground transportation to the nearest Hospital that is qualified to provide the Medically Necessary treatment.

$50,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing Condition. Available only to Members under age 70


If recommended by your attending Physician, who certifies that Evacuation is necessary to safeguard your life and that Medically Necessary treatment is not available locally, and if approved in advance and coordinated by MNU, the plan will provide the following benefits: Emergency air and/or ground transportation to the nearest Hospital that is qualified to provide the Medically Necessary treatment.

Repatriation of Remains $7,500 per Member

In the event of a covered Injury or Illness resulting in your death, VisitorSecureSM will provide the following benefit: Air and/or ground transportation of bodily remains or ashes to the area of your Principal Residence, and reasonable costs of preparation of your remains necessary for transportation.
$7,500 per Member

In the event of a covered Injury or Illness resulting in your death, VisitorSecureSM will provide the following benefit: Air and/or ground transportation of bodily remains or ashes to the area of your Principal Residence, and reasonable costs of preparation of your remains necessary for transportation.
$7,500 per Member

In the event of a covered Injury or Illness resulting in your death, VisitorSecureSM will provide the following benefit: Air and/or ground transportation of bodily remains or ashes to the area of your Principal Residence, and reasonable costs of preparation of your remains necessary for transportation.
$7,500 per Member

In the event of a covered Injury or Illness resulting in your death, VisitorSecureSM will provide the following benefit: Air and/or ground transportation of bodily remains or ashes to the area of your Principal Residence, and reasonable costs of preparation of your remains necessary for transportation.
Common Carrier Accidental Death & Dismemberment $25,000 Lifetime Maximum Principal Sum per Member
Death or Loss of Two Limbs – Principal Sum
Loss of One Limb – One-half the Principal Sum

In the event of your Accidental Death or Dismemberment while traveling on board a commercial common carrier (airplane or cruiseline), VisitorSecureSM will provide the following benefit, subject to a maximum of $125,000 per family:
Accidental Death – $25,000 to the Beneficiary designated on your Application
Loss of 2 eyes or 2 or more limbs – $25,000 to you
Loss of 1 eye or 1 limb – $12,500 to you
$25,000 Lifetime Maximum Principal Sum per Member
Death or Loss of Two Limbs – Principal Sum
Loss of One Limb – One-half the Principal Sum

In the event of your Accidental Death or Dismemberment while traveling on board a commercial common carrier (airplane or cruiseline), VisitorSecureSM will provide the following benefit, subject to a maximum of $125,000 per family:
Accidental Death – $25,000 to the Beneficiary designated on your Application
Loss of 2 eyes or 2 or more limbs – $25,000 to you
Loss of 1 eye or 1 limb – $12,500 to you
$25,000 Lifetime Maximum Principal Sum per Member
Death or Loss of Two Limbs – Principal Sum
Loss of One Limb – One-half the Principal Sum

In the event of your Accidental Death or Dismemberment while traveling on board a commercial common carrier (airplane or cruiseline), VisitorSecureSM will provide the following benefit, subject to a maximum of $125,000 per family:
Accidental Death – $25,000 to the Beneficiary designated on your Application
Loss of 2 eyes or 2 or more limbs – $25,000 to you
Loss of 1 eye or 1 limb – $12,500 to you
$25,000 Lifetime Maximum Principal Sum per Member
Death or Loss of Two Limbs – Principal Sum
Loss of One Limb – One-half the Principal Sum

In the event of your Accidental Death or Dismemberment while traveling on board a commercial common carrier (airplane or cruiseline), VisitorSecureSM will provide the following benefit, subject to a maximum of $125,000 per family:
Accidental Death – $25,000 to the Beneficiary designated on your Application
Loss of 2 eyes or 2 or more limbs – $25,000 to you
Loss of 1 eye or 1 limb – $12,500 to you