World Med - Including USA

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

$500,000 or $1,000,000

Maximum per Injury / Illness

$500,000, or $1,000,000

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 $250 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: $20,000

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 $250,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Repatriation of Remains

Up to $50,000 - not subject to deductible or coinsurance

Emergency Reunion

Up to $15,000, subject to a maximum of 15 days - not subject to deductible or coinsurance

Return of Minor Children

Up to $50,000 - 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

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
$250,000 maximum benefit any one family or group.
- not subject to deductible, coinsurance, or overall maximum limit

Optional Enhanced Accidental Death & Dismemberment Rider

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

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

*Benefit limits may apply to certain conditions. See the Description of Coverage for details.

*The maximum medical benefit limit for ages 70-79 is $50,000 and for ages 80+ is $15,000.

MEDICAL BENEFITS

When a covered Injury or Illness results, the Company will pay:

In Hospital Medical Services.....................................................................90%* of covered expenses
In Hospital Surgical Services....................................................................90%* of covered expenses
Out of Hospital Medical Expenses...........................................................90%* of covered expenses
 
*The policy will pay 90% of the first $20,000 annually for covered medical expenses incurred. Then the policy will pay 100% up to the policy maximum amount as stated in Limits of Coverage.
 
DEDUCTIBLE: The above medical expenses are excess of an annual deductible paid per Confirmation number. The Confirmation number will remain the same provided there is no lapse of coverage. The deductible amount consists of covered expenses which would otherwise be payable under the policy. These expenses must be borne by the Insured Person.
 
Illness must be contracted and manifest itself, or Injury must occur, during the Period of Coverage. Benefit period is 26 weeks.
 
Covered Expenses
 
For the purpose of this section, only such expenses incurred as the result of and within 26 weeks from a disablement, which are specifically enumerated in the following list of charges, and which are not excluded in the Exclusions Section, shall be considered covered expenses:
  1. Charges made by a Hospital for room and board, floor nursing and other services, including charges for professional services, except personal services of a non-medical nature; provided, however, that expenses do not exceed the Hospital’s average charge for semi-private room and board accommodation.
  2. Charges made for diagnosis, treatment and surgery by a Physician.
  3. Charges made for the cost and administration of anesthetics.
  4. Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood transfusions, iron lungs, and medical treatment.
  5. Charges for physiotherapy, if recommended by a Physician for the treatment of a specific disablement and administered
    by a licensed physiotherapist.
  6. Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physician or surgeon.
  7. Hotel room charge when the insured, otherwise necessarily confined in a hospital, shall be under the care of a duly qualified physician in a hotel room owing to unavailability of a hospital room by reason of capacity or distance or to any other circumstances beyond control of Insured.
  8. Coverage for eligible medical expenses incurred while an insured person is in their Home Country not to exceed $50,000 or 30 days, whichever is less. Eligible medical expenses are those eligible medical expenses associated with an accident or illness that has occurred during the insured’s stay inside their Home Country. Such coverage is subject to the deductibles and co-insurance as stated in the Accident and Sickness Medical Expense Benefit.
  9. If the insured receives medical care for the following conditions: tumor or related conditions, cancer or related conditions, stroke or cerebrovascular accident or event, cardiovascular accident or event, myocardial infarction or heart attack, coronary thrombosis, or aneurysm, the company will pay up to $300/day up to a maximum of $5,000 for an inpatient stay or a maximum of $5,000 as an outpatient. Eligible medical services for these conditions should not exceed the total aggregate amount of $5,000.
 
The charges enumerated above shall in no event include any amount of such charges which are in excess of reasonable and customary charges. A charge incurred by an Insured Person shall be deemed a reasonable and customary charge for the services and supplies for which the charge is made if it is not in excess of the average charge for such services and supplies in the locality where received, considering the nature and severity of the sickness or bodily Injury in connection with which such services and supplies are received. If the charge incurred is in excess of such average charge, such excess amount shall not be recognized as covered expenses.
 
Treatment of an Injury or Illness must occur during the period of coverage.
 
This Confirmation of Insurance is presented for general information purposes and is not intended to replace the Master Policy on file with Travel Insurance Services and The Insurance Company of the State of Pennsylvania. In the event of a conflict between this Confirmation and the Master Policy, the Master Policy will govern.