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 |
