Benefit Description
Subject to deductible and
coinsurance unless otherwise noted |
Silver |
Gold |
Platinum |
| Coverage Area |
Two options: worldwide or worldwide excluding the U.S. and Canada
|
Two options: worldwide or worldwide excluding the U.S. and Canada
|
Two options: worldwide or worldwide excluding the U.S. and Canada
|
| Policy Maximum |
$5,000,000
lifetime per individual |
$5,000,000
lifetime per individual |
$8,000,000
lifetime per individual |
| Deductible |
Ranges from $250
to $10,000 per period of coverage, 50% reduction within PPO
|
Ranges from $250
to $10,000 per period of coverage, 5 0% reduction within PPO, Carry forward deductible
- last 30 days of certificate year
|
Ranges from $100
to $10,000 per period of coverage, 50% reduction within PPO,
Carry forward deductible - last 30 days of certificate year
|
| Family Deductible |
3x the single
|
3x the single
|
2x the single
|
| Coinsurance within the U.S. and Canada |
80% of the next
$5,000 of eligible expenses after the deductible, then 100% to
the overall maximum per period of coverage
|
80% of the next
$5,000 of eligible expenses after the deductible, then 100% to
the overall maximum per period of coverage
|
90% of the next
$5,000 of eligible expenses after the deductible, then 100% to
the overall maximum per period of coverage
|
| Coinsurance within the PPO network and
outside the U.S. and Canada |
100%
|
100%
|
100%
|
| Hospitalization / Room & Board |
$600 per day
(maximum of 240 consecutive days per covered event)
|
Average semi-private room rate
|
Private room rate
|
| Intensive Care Unit |
$1,500 per day
(maximum of 180 consecutive days per covered event)
|
Usual,
Reasonable and Customary (URC)
|
Usual,
Reasonable and Customary (URC)
|
| Surgery |
URC
|
URC
|
URC
|
| Anesthetist's Charges Associated with
Surgery |
20% of surgery benefit
|
URC |
URC |
| Transplants |
$250,000
per transplant
|
$1,000,000
lifetime maximum
|
$2,000,000
lifetime maximum
|
| Outpatient |
Visits/Exams - 25 visits per insured
person per period of coverage to the maximum limit as outlined: physician $70; specialist $70; psychiatrist $60; chiropractor $50; surgical intervention consultation $500; X-rays - $250 per exam maximum limit; Lab Tests - $300 per exam maximum limit |
URC
|
URC
|
| Rx Coverage |
URC
|
URC
|
URC
|
| Emergency Room Illness |
URC -
subject to an additional $250 deductible if not admitted
|
URC -
subject to an additional $250 deductible if not admitted
|
URC -
subject to an additional $250 deductible if not admitted
|
| Emergency Room Accident |
URC
|
URC
|
URC
|
| Local Ambulance |
$1,500
per covered event - not subject to deductible or coinsurance
|
URC
|
URC
|
| Emergency Evacuation |
$50,000
per period of coverage - not subject to deductible or
coinsurance
|
Limited to
policy maximum - not subject to deductible or coinsurance
|
Limited to
policy maximum - not subject to deductible or coinsurance
|
| Emergency Reunion |
NA
(Not Applicable)
|
$10,000
lifetime maximum
|
$10,000
lifetime maximum
|
| Return of Mortal Remains |
$25,000
lifetime maximum per insured - not subject to deductible or
coinsurance
|
$25,000
lifetime maximum per insured -not
subject to deductible or coinsurance
|
$50,000
lifetime maximum per insured -not subject to deductible or
coinsurance
|
| Maternity |
Optional Rider - $50,000 lifetime
maximum, maximum of $5,000 for normal delivery, $7,500 for
C-section, $200 child wellness benefit for first 12 months - not
subject to deductible or coinsurance. Available after 10 months of
coverage benefits reduced by 50% for births that occur in11th or
12th month of continuous coverage
|
Optional Rider - $50,000 lifetime
maximum, maximum of $5,000 for normal delivery, $7,500 for
C-section, $200 child wellness benefit for first 12 months - not
subject to deductible or coinsurance. Available after 10 months of
coverage benefits reduced by 50% for births that occur in11th or
12th month of continuous coverage
|
Same As Any
Illness (SAAI) $1,000 additional deductible, $50,000 lifetime
maximum, $200 child wellness benefit for first 12 months. Available after 10 months of
coverage
|
| Supplemental
Accident |
NA
|
$300
per occurrence - not subject to
deductible or coinsurance
|
$500
per occurrence - not subject to deductible or coinsurance
|
| Mental/Nervous |
Outpatient only
- (see Outpatient) Available after 12 months of continuous coverage |
$10,000
per period of coverage up to a $50,000 lifetime maximum. Available after 12
months of continuous coverage
|
SAAI
$50,000 lifetime maximum. Available after 12 months of
continuous coverage
|
| Adult Wellness |
NA
|
$250 per period
of coverage - not subject to deductible or coinsurance Available for those 30 years of
age and over after 12 months of continuous coverage
|
$500 per period
of coverage - not subject to deductible or coinsurance Available for those 18 years of
age and over after 12 months of continuous coverage
|
| Child Wellness |
Three visits per
period of coverage -maximum $70 per visit. Available for children under 18
years of age after 12 months of continuous coverage
|
$200 maximum per
period of coverage -not subject to deductible or coinsurance Available for children
under 18 years of age after 12 months of continuous coverage
|
$400 maximum per
period of coverage - not subject to deductible or coinsurance Available for children
under 18 years of age after 12 months of continuous coverage
|
| Other Services |
Extended Care - limited to first 30
days of confinement
Radiation
Treatment - URC
Home Nursing Care
- limited 30 days per
covered event
Hospice Care - limited 30 days per
covered event
Prosthetic
Devices - all URC
|
URC
|
URC
|
| Physical
Therapy |
Maximum $40 per
visit 30 visit maximum per period of coverage
|
Maximum $50 per visit
|
Maximum $50 per visit
|
| High School
Sports Injury |
NA
|
NA
|
Up to $5,000 maximum
|
| Recreational
SCUBA |
NA
|
URC
|
URC
|
| Remote
Transportation |
NA
|
NA
|
Limited to
$5,000 per certificate period up to a $20,000 lifetime maximum
|
| Political Evacuation and Repatriation |
NA
|
NA
|
Limited to $10,000 lifetime
maximum
|
| Complementary Medicine |
NA
|
Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period
of coverage
|
Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period
of coverage
|
| Non-emergency
Dental |
NA
|
NA
|
Calendar year
maximum - $750
Individual deductible - $50
Schedule of benefits -
Class I: 90% Class II: 70%
Class III: 50% Ortho 0%
(6 month waiting period)
|
|
Emergency Dental due to
Accident
|
$1,000 per period of coverage
|
URC
|
URC
|
| Emergency Dental due to Sudden
Unexpected Pain |
NA
|
$100 per period of coverage
|
See non-emergency dental
benefits
|
| Vision |
NA
|
NA
|
Exams - up to
$100 per 24 months
Materials - up to $150 per 24 months
|
| Global Concierge & Assistance Services |
NA
|
NA
|
Included
|
| Pre-existing
Conditions |
$5,000 per
period of coverage up to a $50,000 lifetime maximum. Available after 24 months of
continuous coverage
|
$5,000 per
period of coverage up to a $50,000 lifetime maximum. Available after 24 months of
continuous coverage
|
SAAI
|
|
NA (Not Applicable) /
URC (Usual, Reasonable and Customary) / SAAI (Same As Any Illness)
|
