Inbound USA Visitor Medical Insurance from SevenCorners

If 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 ($0, $50 or $100) for each Injury and each Sickness and which are incurred within the 26 weeks following the Injury or Sickness.  Payment for any covered service will not exceed the Benefit Maximum shown.  The maximum amount payable for all benefits will be no more than $50,000, $75,000, $100,000, or $130,000 for each Injury and each Sickness.

Injury & Sickness Benefit Limits
Age 14 days to Age 69 Plan A Plan B Plan C Plan D
$50,000 Max per Injury/Sickness $75,000 Max per Injury/Sickness $100,000 Max per Injury/Sickness $130,000 Max per Injury/Sickness
INPATIENT
Hospital Room & Board including miscellaneous Up to $1,400/day, 30 day max Up to $1,725/day, 30 day max Up to $2,000/day, 30 day max Up to $2,585/day, 30 day max
Hospital Intensive Care Unit Additional $660/day, 8 day max Additional $755/day, 8 day max Additional $850/day, 8 day max Additional $1,105/day, 8 day max
Surgical Treatment Up to $3,300 Up to $4,400 Up to $5,500 Up to $7,150
Anesthetist Up to $825 Up to $1,100 Up to $1,375 Up to $1,775
Assistant Surgeon Up to $825 Up to $1,100 Up to $1,375 Up to $1,775
Physician’s Non-Surgical Visits Up to $60/visit, 1/day, 30 visits max Up to $75/visit, 1/day, 30 visits max Up to $85/visit, 1/day, 30 visits max Up to $115/visit, 1/day, 30 visits max
A Consulting Physician, when requested by attending Physician Up to $450 Up to $475 Up to $500 Up to $650
Private Duty Nurse Up to $550 Up to $550 Up to $550 Up to $700
Pre-Admission Tests w/in 7 days before Hospital admission Up to $1,100 Up to $1,100 Up to $1,100 Up to $1,450
OUTPATIENT
Surgical Treatment Up to $3,300 Up to $4,400 Up to $5,500 Up to $7,150
Anesthetist Up to $825 Up to $1,100 Up to $1,375 Up to $1,775
Assistant Surgeon Up to $825 Up to $1,100 Up to $1,375 Up to $1,775
Physician’s Non-Surgical / Urgent Care Visits Up to $60/visit, 1/day, 10 visits max Up to $75/visit, 1/day, 10 visits max Up to $85/visit, 1/day, 10 visits max Up to $115/visit, 1/day, 10 visits max
Diagnostic X-rays & Lab Services Up to $450
Additional $250 - One Cat scan, PET scan or MRI
Up to $475
Additional $375 – One Cat scan PET or MRI
Up to $500
Additional $500 - One Cat scan, PET scan or MRI
Up to $650 -
Additional $600 - One Cat scan, PET scan or MRI
Hospital Emergency Room (all expenses incurred therein) Up to $330 Up to $465 Up to $550 Up to $750
Prescription Drugs Up to $250 Up to $250 Up to $250 Up to $350
Outpatient Surgical Facility Up to $1,000 Up to $1,050 Up to $1,100 Up to $1,400
OTHER TREATMENT AND SERVICES
Ambulance Services Up to $475 Up to $475 Up to $475 Up to $475
Initial Orthopedic Prosthesis/brace Up to $1,100 Up to $1,200 Up to $1,300 Up to $1,700
Chemotherapy and/or radiation therapy Up to $1,100 Up to $1,225 Up to $1,350 Up to $1,750
Dental Treatment for Injury to Sound, Natural Teeth Up to $550 Up to $550 Up to $550 Up to $550
Mental & Nervous Disorder & Substance Abuse Same as any Sickness Same as any Sickness Same as any Sickness Same as any Sickness
Physiotherapy Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max
Emergency Evacuation $50,000 $50,000 $50,000 $50,000
Repatriation of Remains $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
OPTIONAL PRE-EX BENEFIT
Pre-existing Conditions
(the above maximum schedule still applies)
Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke

If an insured person turns seventy (70) years old during the purchased coverage period, the seventy (70) and over benefit schedule becomes effective upon the day the insured turns seventy (70). Individuals with the $100,000 or $130,000 per injury or sickness policy maximum will receive the $70,000 per injury or sickness schedule for age seventy (70) and older. Individuals with the $75,000 or $50,000 per injury or sickness policy maximum will receive the $50,000 per injury or sickness schedule for age seventy (70) and older.

Emergency Medical Evacuation Expenses

The program will pay up to $50,000 in Covered Expenses incurred if any covered Injury or Sickness originating during the Period of Coverage results in the Medically Necessary Emergency Medical Evacuation or Repatriation of the Insured Person (the Insured Person's medical condition warrants immediate transportation from the medical facility where the Insured Person is located to the nearest adequate medical facility where medical treatment can be obtained).  The benefit must be ordered by the Assistance Company in consultation with the Insured Person’s local attending Physician. *

Repatriation of Mortal Remains Expenses

The program will pay the reasonable Covered Expenses incurred up to a maximum of $7,500 to return the Insured Person's remains to his/her Home Country, if he or she dies.*

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:

Common Carrier Accidental Death and Dismemberment 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

* NOTE: In the event of an Emergency Medical Evacuation or Repatriation of Mortal Remains benefit is needed or utilized, arrangements must be made by the Assistance Service Provider.

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.