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Schedule of Benefits |
| Standard Furlough |
Up to 12 months |
| Coverage Area |
Worldwide |
| Overall Policy Maximum |
$5,000,000 Lifetime |
| Deductibles Available |
$250, $500, $1,000, $2,500 or $5,000 per Certificate Period. |
| Family Deductible |
Maximum of 3 Deductibles per family per Certificate Period |
| Coinsurance -- Claims incurred in US or Canada |
80% of the next $5,000 of Eligible Medical Expenses after the Deductible, then 100% to the Overall Policy Maximum. The Coinsurance will be waived
if expenses are incurred within the PPO. |
| Coinsurance -- claims
incurred outside US or Canada |
100% of Eligible Medical Expenses after the Deductible to the Overall
Policy Maximum. |
| Hospital Room and Board -- In US or Canada |
Average Semi-private room rate. |
| Hospital Room and Board
-- Outside US or Canada |
Average Private room rate. |
| Intensive Care Unit -- In US or Canada |
Usual, Reasonable and Customary. |
| Intensive Care Unit --
Outside US or Canada |
Usual, Reasonable and Customary. |
| Prescription Drugs |
Usual, reasonable and customary (subject to deductible and co-insurance) |
| Mental Health Disorders |
$10,000 per Certificate Period ; $25,000 Lifetime Maximum, $50 maximum per visit per day for outpatient care (after 12 months of continuous coverage). |
| Maternity -- Normal Delivery |
After the Deductible, Underwriters will pay 50% of the next $100,000
of Eligible Medical Expenses after the Deductible, then 100% to a Lifetime
Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery,
and post- natal care. (after 12 months of continuous coverage). |
| Maternity -- Complicated Delivery |
After the Deductible, Underwriters will pay 50% of the next $100,000
of Eligible Medical Expenses after the Deductible, then 100% to a Lifetime
Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery,
and post- natal care. (after 12 months of continuous coverage). |
| Maximum for Maternity |
$250,000 Lifetime |
| Newborn Care |
Included as part of Maternity benefits for maximum of 31 days. |
| Pre-existing Conditions |
Same as any other Injury or Illness if disclosed on Application and
not excluded or limited by Rider. |
| Local Ambulance |
Usual, Reasonable and Customary. |
| Physical Therapy |
$50 Maximum per visit. |
| Wellness |
$50 per visit (including immunizations), maximum of 3 visits per year
for children under the age of 19 (after 12 months of coninuous coverage).
$250 per Certificate Period (after 12 months of continuous coverage)
for Members age 35 or older. Not subject to Deductible. |
| Human Organ/Tissue Transplants* |
Same as any other Illness for Covered Transplants. |
| All Other Eligible Expenses |
Usual, Reasonable and Customary. |
| Emergency Medical Evacuation |
$50,000 Lifetime Maximum. |
| Repatriation of Remains |
$25,000 Limit |
| Emergency Reunion |
$10,000 Lifetime Maximum. |
| Pre-certification Penalty |
50% |
| * Covered transplants
include Heart, Heart/Lung, Lung, Kidney, Kidney/Pancreas, Liver, and Allogenic
and Autologous Bone Marrow |