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, 50% 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) |
