Covered Services Injury & Sickness Benefit limits

When your covered Injury or Sickness requires treatment by a physician, this program will provide benefits for the Usual and Customary (U&C) charges scheduled below which exceed the chosen Per Person Deductible (either $0, $50 or $100, and $200 deductible options for age 70 and over) for each Injury and each Sickness and which are incurred within the 52 weeks following the Injury or Sickness (within 32 weeks for those insureds age 70 and over). Payment for any covered service will be no more than the Benefit Limit shown for it. The total payable by all Benefits will be no more than $50,000, $75,000, $100,000 or $130,000 for each Injury and each Sickness.

For persons age 70 and over, the maximum benefit limit is $75,000, the period in which covered expenses must be incurred is 32 weeks following the Injury or Sickness, and a separate schedule applies.

Inbound Immigrant Benefits
Age 14 days to Age 69
Plan A
Age 14 days to Age 69
Plan B
Age 14 days to Age 69
Plan C
Age 14 days to Age 69
Plan D
Age 70 and over
Plan J
Maximum Limit $50,000 Max per Injury / Sickness $75,000 Max per Injury / Sickness $100,000 Max per Injury / Sickness $130,000 Max per Injury / Sickness $75,000 Max per Injury / Sickness
INPATIENT
Hospital Room & Board including miscellaneous Up to $1,500/day, 30 day max Up to $2,000/day, 30 day max Up to $2,500/day, 30 day max Up to $3,000/day, 30 day max Up to $1,250/day, 30 day max
Hospital Intensive Care Unit Additional $500/day, 8 day max Additional $500/day, 8 day max Additional $500/day, 8 day max Additional $500/day, 8 day max Additional $525/day, 8 day max
Surgical Treatment Up to $2,100 Up to $4,800 Up to $5,800 Up to $7,200 Up to $3,350
Anesthetist Up to $500 Up to $750 Up to $1,000 Up to $1,650 Up to $800
Assistant Surgeon Up to $500 Up to $750 Up to $1,000 Up to $1,650 Up to $800
Physician's Non-Surgical Visits Up to $38/visit, 1/day, 30 visits Up to $56/visit, 1/day, 30 visits Up to $75/day, 1/day, 30 visits Up to $100/day, 1/day, 30 visits Up to $65/visit, 1/day, 30 visits
Consultant Physician, when requested by attending Physician Up to $250 Up to $325 Up to $500 Up to $575 Up to $450
Pre-Admission Tests within 7 days before Hospital admission Up to $650 Up to $975 Up to $1,300 Up to $1,300 Up to $900
Private Duty Nurse Up to $650 Up to $650 Up to $650 Up to $650 Up to $450
OUTPATIENT
Surgical Treatment Up to $2,100 Up to $4,800 Up to $5,800 Up to $7,200 Up to $3,350
Anesthetist Up to $500 Up to $750 Up to $1,000 Up to $1,650 Up to $800
Assistant Surgeon Up to $500 Up to $750 Up to $1,000 Up to $1,650 Up to $800
Physician's Non-Surgical Visits Up to $38/visit, 1/day, 30 visits Up to $56/visit, 1/day, 30 visits Up to $75/day, 1/day, 30 visits Up to $100/day, 1/day, 30 visits Up to $65/visit, 1/day, 30 visits
Diagnostic X-rays & Lab Services Up to $250
Additional $325 -
One Cat scan, PET scan or MRI
Up to $375
Additional $325 -
One Cat scan, PET scan or MRI
Up to $500
Additional $975 -
One Cat scan, PET scan or MRI
Up to $575
Additional $975 -
One Cat scan, PET scan or MRI
Up to $450
Additional $325 -
One Cat scan, PET scan or MRI
Hospital Emergency Room Up to $200 max Up to $300 max Up to $400 max Up to $650 max Up to $325 max
Prescription Drugs Up to $68 Up to $101 Up to $135 Up to $200 Up to $100
Outpatient Surgical Facility Up to $600 Up to $600 Up to $1,200 Up to $1,400 Up to $1,050
OTHERS
Ambulance Services Up to $500 Up to $500 Up to $500 Up to $500 Up to $500
Initial Orthopedic Prosthesis / brace Up to $663 Up to $994 Up to $1,600 Up to $1,600 Up to $1,000
Chemotherapy and / or radiation therapy Up to $663 Up to $994 Up to $1,600 Up to $1,600 Up to $1,000
Dental Treatment for Injury to Sound, Natural Teeth Up to $650 Up to $650 Up to $650 Up to $650 Up to $650
Mental & Nervous Disorder & Substance Abuse Same as any Sickness Same as any Sickness Same as any Sickness Same as any Sickness Same as any Sickness
Maternity (conception occurs at least 90 days after your effective date) Up to $2,800 Up to $2,800 Up to $2,800 Up to $2,800 N/A
Physiotherapy Up to $45/visit, 1/day, 12 visits Up to $45/visit, 1/day, 12 visits Up to $45/visit, 1/day, 12 visits Up to $45/visit, 1/day, 12 visits Up to $45/visit, 1/day, 12 visits
Emergency Evacuation $50,000 $50,000 $50,000 $50,000 $50,000
Repatriation of Remains $7,500 $7,500 $7,500 $7,500 $7,500
AD&D Principal Sum $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier
Acute Onset of a Pre-existing Condition(s) $50,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation. $75,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation. $100,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation. $130,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation. N/A

Should an insured person turn 70 during the purchased coverage period, the 70 and over benefit schedule becomes effective upon the day the insured turns 70.

Repatriation of Mortal Remains Expenses

If Injury or Sickness commencing during the Period of Coverage results in death, all reasonable expenses incurred for preparation and return of the remains to the Country of Residence are covered up to a maximum of $7,500 provided that all arrangements are coordinated by the Assistance Provider.

Common Carrier Accidental Death and Dismemberment (AD&D)

Accidental Death and Dismemberment shall apply to covered accidents sustained by an insured person while riding as a passenger in or on any land, water or air conveyance operated under a license for the transportation of passengers for hire. A loss must occur within 365 days after the date of accident causing the loss:

AD & D Benefits
For Loss of: Indemnity
Life Principal Sum
Both Hands or Both Feet or Sight of Both Eyes Principal Sum
One Hand and One Foot Principal Sum
Either Hand or Foot and Sight of One Eye Principal Sum
Either Hand or Foot One-Half the Principal Sum
Sight of One Eye One-Half the Principal Sum

Patient Protection and Affordable Care Act (“PPACA”): This insurance is not subject to, and does not provide certain of the insurance benefits required by, the United States PPACA. PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney or tax professional to determine if PPACA’s requirements are applicable to you. The policy contains the plan benefits, including a lifetime maximum that you have selected. Please review your choices to ensure that you have sufficient coverage to meet your medical needs.