|
MEDICAL INSURANCE
|
BENEFIT
Subject to deductible and coinsurance |
|
Coverage Area |
Worldwide |
| Policy Maximum Per Individual | US$5,000,000 lifetime |
|
Hospitalization Semi-private room and board Nursing services Prescription medication Physician charges Diagnostic and laboratory testing X-rays Chemotherapy and radiation Durable medical equipment Treatment, services and supplies routinely provided |
URC |
| Intensive Care Unit | URC |
|
Surgery Surgical care Second surgical opinion Anesthetics Physician charges for surgery Treatment, services and supplies routinely provided |
URC |
|
Transplants
Limited to certain transplants and covered only within designated transplant facilities that are members of IMG's independently-contracted PPO network |
US$1,000,000 lifetime |
|
Outpatient Emergency treatment of illness or injury Surgery Rehabilitative treatment Treatment, services or supplies routinely provided Prescription medication |
URC |
|
Emergency Surgery or dental treatment following an accident • Emergency room following an accident • Charges incurred for the use of the Emergency Room for treatment of an illness are subject to an additional (extra) US$250 deductible if treatment does not require admittance to the hospital. |
URC |
|
Emergency Transportation by Ground Ambulance |
URC |
|
Emergency Medical Evacuation Included with Emergency Medical Evacuation is an Emergency Reunion benefit of US$10,000 lifetime |
Up to policy maximum |
| Repatriation | US$25,000 |
|
Supplemental Accident The first $300 will be covered for each accidental injury |
US$300 per occurrence (not subject to the deductible or coinsurance) |
|
Maternity Available after 12 months of continuous coverage Pre and Post-natal care Normal delivery or C-section Well baby care and treatment of newborn for first 31 days |
US$50,000 lifetime maximum of US$5,000 for normal delivery for each pregnancy; maximum of US$7,500 for C-Section delivery for each pregnancy |
|
Newborns Eligible newborn children may be added without evidence of insurability under certain circumstances An application form must be submitted within 31 days of child's birth |
URC |
|
Child Wellness Available for eligible children from 14 days to 18 years of age after 12 months of continuous coverage |
US$50 maximum per visit; US$200 per policy period (not subject to deductible or coinsurance) |
|
Pre-existing Conditions After 24 months of continuous coverage |
US$50,000 lifetime (maximum of US$5,000 per period of coverage) |
|
Mental/Nervous Care Available after 12 months of continuous coverage Inpatient and outpatient care by a licensed psychiatrist |
US$10,000 per period of coverage, US$25,000 lifetime |
|
Wellness Females age 30 and over, after 12 months of continuous coverage Routine physicals Mammogram, ob/gyn visit, etc. (exams must be separated by 12 months) Males age 30 and over, after 12 months of continuous coverage Routine physicals (exams must be separated by 12 months) |
US$250 per policy period (not subject to deductible or coinsurance) |
|
Dental Emergency
Necessary treatment of sudden, unexpected pain to sound natural teeth |
US$100 per period of coverage |
| Complementary Medicine | (Each per policy period) |
| Acupuncture | US$150 |
| Aroma Therapy | US$50 |
| Herbal Therapy | US$50 |
| Magnetic Therapy | US$75 |
| Massage Therapy | US$150 |
| Vitamin Therapy | US$100 |
|
Recreational SCUBA Coverage
Illness or injury while using safe diving practices as laid down by an Authoritative Diving Body |
URC |
|
Other Chiropractor when referred by a physician Radiation treatment Home nursing care Hospice care Physical therapy (maximum US$50 per visit) Prosthetic devices |
URC |
The foregoing list is only a summary of available benefits and coverages, and is subject to the specific
terms and conditions of the plan concerning eligible benefits, limitations, eligibility and
exclusions. Please refer to the certificate wording for a complete description, which is available
upon request.
