Benefits | Coverage |
---|---|
Medical Maximum Options (per person per disablement) |
Ages 14 days to 64 years:$50,000; $100,000; $250,000; $500,0000 Ages 60 to 64 years:$50,000; $100,000; $250,000 |
Hospital Room & Board | URC to medical maximum |
COVID-19 Treatment | Usual, Reasonable, and Customary up to Medical Maximum or $100,000; whichever is less. |
Emergency Room Services | $50 copay |
Doctor’s Office Visits | $10 copay |
Urgent Care Visits | $20 copay |
Prescription Drugs | $10 copay |
Vaccinations | $150 per 364 days of continuous coverage |
Physiotherapy | $50 per visit, 60 visits maximum |
Spinal Manipulation | $50 per visit, 60 visits maximum |
Local Ambulance Benefit | $500 |
Coma | $25,000 separate from the medical maximum |
Felonious Assault | $15,000 separate from the medical maximum |
Extension of Benefits to Home Country | $5,000 |
Incidental Trips to Home Country | $5,000 |
Waiver of Pre-existing Conditions | Up to medical maximum |
Acute Onset of Pre-existing Conditions | $10,000 |
Mental Illness including Alcohol and Substance Abuse | Inpatient:$10,000, 45-day limit Outpatient:80% up to $1,000 |
Motor Vehicle Accident Inside the United States |
75% up to $100,000 |
Motor Vehicle Accident Outside the United States |
Up to medical maximum |
Non-contact Amateur Sports | $5,000 |
Maternity Care Inside the United States |
In PPO Network:80% up to $10,000 Out of PPO Network:60% up to $10,000 |
Maternity Care Outside the United States |
80% up to $10,00 |
Routine Newborn Care | $500 per newborn child |
Dental — Sudden Relief of Pain | $250 |
Dental — Accident | $1,000 |
Emergency Medical Evacuation and Repatriation | $250,000 |
Emergency Medical Reunion | $200 per day, 10-day limit $25,000 maximum |
Return of Children | $40,000 |
Return of Mortal Remains | $50,000 |
Local Cremation or Burial | $5,000 |
Natural Disaster Evacuation | $10,000 |
Natural Disaster Daily Benefit | $50 per day, 5-day limit |
Political Evacuation and Repatriation | $10,000 |
Terrorist Activity | $50,000 |
24/7 Travel Assistance Services | Included |
Pre-certification — 25% penalty | Required inside the United States for specific types of treatment. Penalty does not apply to emergencies. |
Hazardous Sports | Up to medical maximum |
Accidental Death and Dismemberment (AD&D) | Primary Insured: $25,000 Principal Sum Eligible Spouse: $10,000 Principal Sum Eligible Child(ren): $5,000 Principal Sum |
Personal Liability | $50,000 |
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