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International Health Insurance > HCC Medical Insurance Services > CitizenSecureSM Economy

HCC Medical Insurance Services

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CitizenSecureSM Economy Benefit Schedule


Optional Term Life and AD&D Insurance
Dental Insurance Rider

Benefits Limits
Coverage Area Worldwide
Overall Policy Maximum $5,000,000 Lifetime
Deductibles Available $250, $500, $1,000, $2,500 or $5,000 per person per Certificate Period.
Coinsurance -- Claims incurred in US or Canada HCCMIS will pay 80% of the next $5,000 of Eligibile Medical Expenses after the Deductible, then 100% to the Overall Maximum Limit. The Coinsurance will be waived if expenses are incurred within the PPO and expenses are submitted to HCCMIS for review and payment directly to the provider
Coinsurance -- claims incurred outside US or Canada HCCMIS will pay 100% of Eligible Medical Expenses after the Deductible to the Overall Policy Maximum.
Acute Onset of Pre-existing Conditions $1,000 during the first Certificate Period and $2,500 during the second Certificate Period
Pre-existing Conditions $5,000 per Certificate Period subject to a Lifetime Maximum of $50,000 (including Acute Onset claims) after 24 months of continuous coverage hereunder
Maternity $5,000 per Pregnancy after 12 months of continuous coverage hereunder, including Inpatient, Outpatient and other benefits as herein provided. Not subject to Coinsurance
Newborn Care $15,000 per covered Pregnancy, including Inpatient, Outpatient and other benefits as herein provided, during the first 60 days of life
Organ Transplants $250,000 Lifetime maximum for covered transplants**
INPATIENT BENEFITS (All Subject to Deductible and Coinsurance)
Hospital Room and Board $600 per day, maximum of 240 days per Hospitalization (including ICU days)
Intensive Care Unit (ICU) $1,500 per day, maximum of 240 days per Hospitalization (including non ICU days)
Lab, x-rays and other covered Inpatient services & supplies Usual, Reasonable and Customary Charges (except as limited herein)
OUTPATIENT BENEFITS (All Subject to Deductible and Coinsurance)
Office Visits (Including Physician, Specialist Physician, Psychiatrist, Chiropractor, Surgical Consultant, Physical or Occupational Therapist) 25 visits per Certificate Period per person as provided herein
Physician $70 per visit
Specialist Physician $70 per visit
Psychiatrist $60 per visit, after 12 months of continuous coverage hereunder
Chiropractors $50 per visit (must be prescribed by another non-Chiropractor Physician)
Surgical Consultant $500 per consultation prior to Surgery
Physical or Occupational Therapy $50 per visit (must be prescribed by a Physician who is not affiliated with the Physical Therapy practice)
X-rays $250 per exam (includes Sonograms, Ultrasounds and diagnostic Mammograms)
Laboratory $300 per exam (includes all procedures carried out on one specimen)
Emergency Room Usual, Reasonable and Customary for covered Illnesses if hospitalized as Inpatient and for covered Injuries
Local Ambulance $1,500 per Certificate Period per person
INPATIENT or OUTPATIENT BENEFITS (All Subject to Deductible and Coinsurance)
Prescription Medications Usual, Reasonable and Customary
Surgery Usual, Reasonable and Customary
Assistant Surgeon 20% of Surgeon benefit
Anesthesiologist 20% of Surgeon benefit
Midwife Services $500 per covered Pregnancy
MRI, CAT Scan, Echocardiography, Endoscopy, Gastroscopy, Colonoscopy and Cystoscopy $600 per exam
Chemotherapy and Radiation Therapy Usual, Reasonable and Customary
WELLNESS BENEFITS (Not Subject to Deductible or Coinsurance)
Well Child (under age 19) $50 per visit for a maximum of 3 visits per Certificate Period (included in Office Visit limit), after 12 months of continuous coverage hereunder
Wellness (Adult 19+) $250 per Certificate Period, after 24 months of continuous coverage hereunder, including Office Visit for $70 and X-Ray and Lab for $180
OTHER BENEFITS (All Subject to Deductible and Coinsurance)
Durable Medical Equipment Usual, Reasonable and Customary charges for Wheelchair, Hospital Bed, and/or Toilet
Emergency Medical Evacuation $50,000 Per Certificate Period
Repatriation of Remains $25,000 Lifetime Maximum
Emergency Reunion $5,000 Lifetime Maximum

** Covered Transplants include Heart, Heart/Lung, Lung, Kidney, Kidney/Pancreas, Liver and Allogenic and Autologous Bone Marrow.

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Optional Term Life Insurance and Accidental Death and Dismemberment

Term Life Insurance
Age
Option 1 - Principal Sum
Option 2 - Principal Sum
19 to 59
$50,000
$100,000
60 to 64
$25,000
$50,000
65 to 69
$10,000
Not Available
Dependent Child
$5,000
Not Available

Accident Death and Dismemberment

Accidental Death Principal Sum to Beneficiary
Accidental Loss of Two Members Principal Sum to Member
Accidental Loss of One Member 50% of Principal Sum to Member

"Limb" means hand, foot, or eye. The Benefit is based on age at the time of death or dismemberment.

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Optional Dental Rider

Optional Dental Rider
  Certificate Period 1 Certificate Period 2 Certificate Period 3 and after
Preventative Dental Benefits Children age 9 through 16 (after 3 months of continuous coverage) 100% 100% 100%
Basic Dental Benefits (after 6 months of continuous coverage) 50% 65% 80%
Major Dental Benefits (after 6 months of continuous coverage) 30% 40% 50%
Dental Deductible $100.00 per Certificate Period per person $100.00 per Certificate Period per person $100.00 per Certificate Period per person
Maximum Dental Benefits $500.00 per Certificate Period per person $750.00 per Certificate Period per person $1,000.00 per Certificate Period per person

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