INF Standard Plan Insurance

Hospital Room (average semi-private) & Board, and Miscellaneous	Plan 50k: Charges up to $1,300 a day maximum Up to 30 days Plan 100k: Charges up to $1,750 a day maximum Up to 30 days Plan 150k: Charges up to $1,900 a day maximum Up to 30 days
Hospital Intensive Care Unit	Plan 50k: Charges up to $525 maximum additional a day \| Up to 8 Days Plan 100k: Charges up to $750 maximum additional a day \| Up to 8 Days Plan 150k: Charges up to $850 maximum additional a day \| Up to 8 Days
Surgeon	Plan 50k: Up to $3,000 maximum Plan 100k: Up to $5,000 maximum Plan 150k: Up to $6,000 maximum
Anesthetist	Plan 50k: Up to $750 maximum Plan 100k: Up to $1,250 maximum Plan 150k: Up to $1,500 maximum
Assistance Surgeon	Plan 50k: Up to $750 maximum Plan 100k: Up to $1,250 maximum Plan 150k: Up to $1,500 maximum
Doctor’s Non-Surgical Visits	Plan 50k: Up to $60 a visit maximum \| 1 visit a day Up to 10 visits Plan 100k: Up to $100 a visit maximum \| 1 visit a day Up to 10 visits Plan 150k: Up to $125 a visit maximum \| 1 visit a day Up to 10 visits
Consultant Doctor, when requested by attending Doctor	Plan 50k: Up to $400maximum Plan 100k: Up to $450 maximum Plan 150k: Up to $500 maximum
Pre-Admission Tests within 14 days before hospital admission	Plan 50k: Up to $1,000 maximum Plan 100k: Up to $1,100 maximum Plan 150k: Up to $1,200 maximum

Surgical Room & Supply Expenses	Plan 50k: Up to $1,000 maximum Plan 100k: Up to $1,100 maximum Plan 150k: Up to $1,200 maximum
Surgeon	Plan 50k: Up to $3,000 maximum Plan 100k: Up to $5,000 maximum Plan 150k: Up to $6,000 maximum
Anesthetist	Plan 50k: Up to $750 maximum Plan 100k: Up to $1,250 maximum Plan 150k: Up to $1,500 maximum
Assistance Surgeon	Plan 50k: Up to $750 maximum Plan 100k: Up to $1,250 maximum Plan 150k: Up to $1,500 maximum
Doctor’s Non-Surgical Visits	Plan 50k: Up to $60 a visit maximum \| 1 visit a day Up to 10 visits Plan 100k: Up to $100 a visit maximum \| 1 visit a day Up to 10 visits Plan 150k: Up to $125 a visit maximum \| 1 visit a day Up to 10 visits
Diagnostic X-rays & Lab Services	Plan 50k: Up to $400 maximum Plan 100k: Up to $650 maximum Plan 150k: Up to $750 maximum
CAT Scan, PET Scan, or MRI	Plan 50k: Up to $400 additional Plan 100k: Up to $650 additionalbr> Plan 150k: Up to $1,000 additional

Ambulance Services	Plan 50k: Up to $400 additional Plan 100k: Up to $450 maximum Plan 150k: Up to $500 maximum
Rehabilitative Braces or Appliances	Plan 50k: Up to $1,200 maximum Plan 100k: Up to $1,100 maximum Plan 150k: Up to $1,200 maximum
Dental Treatment injury to Sound, Natural teeth (Due to Accident)	Plan 50k: Up to $450. There are no benefits for dental services for immediate relief of pain. Plan 100k: Up to $500. There are no benefits for dental services for immediate relief of pain. Plan 150k: Up to $550. There are no benefits for dental services for immediate relief of pain.
Chemotherapy and/or Radiation Therapy	Plan 50k: Up to $1,000 maximum Plan 100k: Up to $1,150 maximum Plan 150k: Up to $1,250 maximum
Physical & Occupational Therapy	Plan 50k: Up to $1,000 maximum Plan 100k: Up to $1,150 maximum Plan 150k: Up to $1,250 maximum
Private Duty Nurse	Plan 50k: Up to $400 maximum Plan 100k: Up to $500 maximum Plan 150k:Up to $550 maximum
Emergency Medical Treatment of Pregnancy	Plan 50k: Up to $4,500 maximum Plan 100k: Up to $5,000 maximum Plan 150k: Up to $5,500 maximum
Medical Evacuation	Plan 50k:$15,000 maximum Plan 100k: $20,000 maximum Plan 150k: $25,000 maximum
Repatriation of Remains	Plan 50k: $10,000 maximum Plan 100k: $15,000 maximum Plan 150k: $20,000 maximum
Accidental Death & Dismemberment	Plan 50k: $25,000 Principal Sum Plan 100k: $25,000 Principal Sum Plan 150k: $25,000 Principal Sum