Eligibility
| Hospital Room (average semi-private) & Board, and Miscellaneous | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Hospital Intensive Care Unit | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Surgeon | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Anesthetist | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Assistance Surgeon | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Doctor’s Non-Surgical Visits | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Consultant Doctor, when requested by attending Doctor | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Pre-Admission Tests within 14 days before hospital admission | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Surgical Room & Supply Expenses | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Surgeon | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Anesthetist | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Assistance Surgeon | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Doctor’s Non-Surgical Visits | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Diagnostic X-rays & Lab Services | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| CAT Scan, PET Scan, or MRI | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Hospital Emergency Room | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Prescription Drugs | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Ambulance Services | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Rehabilitative Braces or Appliances | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Dental Treatment injury to Sound, Natural teeth (Due to Accident) | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Chemotherapy and/or Radiation Therapy | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Physical & Occupational Therapy | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Private Duty Nurse | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Emergency Medical Treatment of Pregnancy | 80% of Covered Network Charges up to the Overall Maximum Benefit |
| Medical Evacuation | $25,000 maximum |
| Repatriation of Remains | $20,000 maximum |
| Intercollegiate Sports | None |
| Accidental Death & Dismemberment | $25,000 maximum |
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