| BENEFIT |
Limit - all limits are per Certificate Period except as specifically indicated otherwise |
| Overall Maximum Limit |
$5,000,000 Lifetime |
| Coverage Area |
Option 1 - Including the US and Canada
Option 2 - Excluding the US and Canada |
| Deductibles Available |
$250, $500, $1,000, $2,500 or $5,000 per Member per Certificate Period |
| Family Deductible |
Maximum of 3 Deductibles per Family per Certificate Period |
| Coinsurance -- Claims Incurred in US or Canada* |
After the Deductible, Underwriters will pay 80% of the next $5,000 of Eligible Expenses per Member per Certificate Period, then 100% to the Overall Maximum Limit. The Coinsurance will be waived if expenses are incurred within the PPO and expenses are submitted to Underwriters for review and payment directly to the provider |
| Coinsurance -- Claims Incurred outside US or Canada |
After the Deductible, Underwriters will pay 100% of Eligible Expenses per Member per Certificate Period to the Overall Maximum Limit |
| Family Coinsurance |
After $3,000 of Coinsurance has been paid per Family per Certificate Period, Underwriters will pay 100% of Eligible Expenses to the Overall Maximum Limit |
| Hospital Room and Board -- In US or Canada* |
Average Semi-private room rate |
| Hospital Room and Board -- Outside US or Canada |
Average Private room rate |
| Intensive Care Unit |
Usual, Reasonable and Customary |
| Prescription Drugs |
Usual, Reasonable and Customary Subject to Deductible and Coinsurance |
| Mental Health Disorders |
$10,000 per Certificate Period, $25,000 Lifetime Maximum, $50 Maximum per visit per day for outpatient care (after 12 months of continuous coverage) |
| Maternity -- Normal or Complicated Delivery |
After the Deductible, Underwriters will pay 50% of the next $100,000 of Eligible Medical Expenses, then 100% to a Lifetime Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery, and post-natal care (after 12 months of continuous coverage) |
| Maternity -- Complicated Delivery |
After the Deductible, Underwriters will pay 50% of the next $100,000 of Eligible Medical Expenses, then 100% to a Lifetime Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery, and post-natal care (after 12 months of continuous coverage) |
| Maximum for Maternity |
$250,000 Lifetime |
| Newborn Care |
Included as part of Maternity benefits for a maximum of 60 days |
| Pre-existing Conditions |
Same as any other Injury or Illness if disclosed on Application and not excluded or limited by Rider |
| Local Ambulance |
Usual, Reasonable and Customary |
| Physical Therapy |
$50 Maximum per visit per day |
| Wellness |
All Wellness benefits are available after 12 months of continuous coverage and are not subject to Deductible. Members under age 19: $50 per visit (including immunizations), maximum of three visits per Certificate Period. Members age 30 and over: $250 per Member per Certificate Period. Female Members age 40 and over (or qualifying Woman at Risk): $100 per Member per Certificate Period for a screening mammogram |
| Human Organ/Tissue Transplants |
Same as any other Illness for Covered Transplants** |
| All Other Eligible Expenses |
Usual, Reasonable and Customary |
| Emergency Medical Evacuation |
$50,000 Lifetime Maximum |
| Repatriation of Remains |
$25,000 Limit |
| Emergency Reunion |
$10,000 Lifetime Maximum |
| Pre-certification Penalty |
50% |
* Benefits within the US and Canada are not available to applicants electing Option 2 as their Coverage Area.
**Covered Transplants include Heart/Lung, Lung, Kidney/Pancreas, Liver and Allogenic and Autologous Bone Marrow. |
