|
Benefit Description
Subject to deductible and
coinsurance unless otherwise noted
|
Global Medical Insurance - Gold
|
|
Coverage Area
|
Two
options: worldwide or worldwide
excluding the U.S. and Canada |
|
Policy Maximum
|
$5,000,000
lifetime per individual |
|
Deductible
|
Ranges from $250
to $10,000 per period of coverage, 50%
reduction within PPO, Carry forward deductible - last 30 days of
certificate year |
|
Family
Deductible
|
3x the single |
|
Coinsurance within the U.S. and Canada
|
80% of the next
$5,000 of eligible expenses after the deductible, then 100% to
the overall maximum per period of coverage |
|
Coinsurance within the PPO network and
outside the U.S. and Canada
|
100% |
|
Hospitalization / Room & Board
|
Average semi-private room rate |
|
Intensive Care
Unit
|
Usual,
Reasonable and Customary (URC) |
|
Surgery
|
URC |
|
Anesthetist's Charges Associated with
Surgery
|
URC |
|
Transplants
|
$1,000,000
lifetime maximum |
|
Outpatient
|
URC |
|
Rx Coverage
|
URC |
|
Emergency Room Illness
|
URC -
subject to an additional $250 deductible if not admitted |
|
Emergency Room Accident
|
URC |
|
Local Ambulance
|
URC |
|
Emergency
Evacuation
|
Limited to
policy maximum - not subject to deductible or coinsurance |
|
Emergency
Reunion
|
$10,000
lifetime maximum |
|
Return of Mortal Remains
|
$25,000
lifetime maximum per insured -not
subject to deductible or coinsurance |
|
Maternity
|
Optional Rider - $50,000 lifetime
maximum, maximum of $5,000 for normal delivery, $7,500 for
C-section, $200 child wellness benefit for first 12 months - not
subject to deductible or coinsurance. Available after 10 months of
coverage benefits reduced by 50% for births that occur in11th or
12th month of continuous coverage |
|
Supplemental
Accident
|
$300
per occurrence
not subject to
deductible or coinsurance
|
|
Mental/Nervous
|
$10,000
per period of coverage
up to a $50,000 lifetime maximum. Available after 12
months of continuous coverage |
|
Adult Wellness
|
$250 per period
of coverage - not subject to deductible or coinsurance
Available for those 30 years of
age and over after 12 months of continuous coverage |
|
Child Wellness
|
$200 maximum per
period of coverage -not subject to deductible or coinsurance
Available for children
under 18 years of age after 12 months of continuous coverage |
|
Other Services
|
URC |
|
Physical
Therapy
|
Maximum $50 per visit |
|
High School
Sports Injury
|
NA |
|
Recreational
SCUBA
|
URC |
|
Remote
Transportation
|
NA |
|
Political Evacuation and Repatriation
|
NA |
|
Complementary Medicine
|
Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period
of coverage
|
|
Non-emergency
Dental
|
NA |
|
Emergency Dental due to
Accident |
URC |
|
Emergency Dental due to Sudden
Unexpected Pain
|
$100 per period of coverage |
|
Vision
|
NA |
|
Global Concierge & Assistance Services
|
NA |
|
Pre-existing
Conditions
|
$5,000 per
period of coverage up to a $50,000 lifetime maximum.
Available after 24 months of
continuous coverage |
|
NA (Not Applicable) /
URC (Usual, Reasonable and Customary) / SAAI (Same As Any Illness) |
