Benefit | Coverage |
Inpatient hospital expenses | Average semi-private room & board; usual, reasonable, & customary physician charges; prescription medications; durable medical equipment; nursing; & x-rays to the policy maximum |
Intensive care | Intensive Care room & board; usual, reasonable, & customary physician charges; prescription medications; durable medical equipment; nursing; & x-rays to the policy maximum. |
Surgery | Usual, reasonable, & customary charges for surgery, physician & anesthetics to the policy maximum. |
Hospital daily indemnity benefit | $50 per day ($1,000 maximum per policy period) while hospitalized outside of the U.S. & Canada. This payment is not related to the hospital charges & is paid in addition to other eligible benefits. |
Outpatient treatment | Usual, reasonable, & customary charges for emergency treatment; surgery; physician's office; & prescription medication to the policy maximum. |
Physiotherapy, chiropractic | Up to $75 per visit, when referred in advance by a physician. Lifetime maximum of $10,000. |
Medical supplies | Usual, reasonable, & customary charges to the policy maximum. |
Ambulance | Usual, reasonable, & customary charges to the policy maximum. |
Well child care (under age 19) | Up to $200 per policy period for checkups & routine visits after a 180-day waiting period. Not subject to deductible or coinsurance |
Maternity | Usual, reasonable, & customary to the limits below per pregnancy. You must pre-notify within the first 90 days of pregnancy. Waiting period of 364 days. After completion of 1 continuous policy period: $1,000 After completion of 2 continuous and consecutive policy periods: $2,000 After completion of 3 continuous and consecutive policy periods: $3,000 After completion of 4 continuous and consecutive policy periods: $4,000 After completion of 5 continuous and consecutive policy periods: $5,000 |
Newborn benefit | Maximums listed below per pregnancy for the first 31 days after birth. After completion of 2 continuous and consecutive policy periods: $2,000 After completion of 3 continuous and consecutive policy periods: $3,000 After completion of 4 continuous and consecutive policy periods: $4,000 After completion of 5 continuous and consecutive policy periods: $5,000 |
Mental & nervous | Usual, reasonable, & customary to $10,000 per policy period after a 364-day waiting period. Inpatient limited to 45 days per policy period. Outpatient limited to 40 visits per policy period at 70% of eligible expenses. Lifetime maximum of $30,000. |
Dental | $500 per policy period for usual, reasonable, & customary charges for repair & replacement of sound, natural teeth damaged in an accident. An optional Dental Rider may be purchased. | Emergency medical evacuation | $250,000 per person per policy period, when adequate medical facilities or treatment are not available |
Repatriation/return of remains | $25,000 per person |
Emergency medical reunion | $10,000 per person per ocurrence |
Preventive benefits (age 19 and over) | $175 per policy period for checkups & routine physical exams for all members & female preventative exams & mammograms after a 180-day waiting period. Not subject to deductible or coinsurance. |
Accidental death & dismemberment (ad&d) | 24-Hour AD&D: Principal Sum: $10,000 for insured & spouse, $2,000 for dependent children. Common Carrier AD&D: Principal Sum: $40,000 for insured & spouse, $8,000 for dependent children. |
Lifetime transplant benefit | Up to $1,000,000 per insured person |
Dental RiderOptional Worldwide dental coverage
AD & D Principal Sum Rider$100,000, $200,000, $300,000, $400,000 or $500,000 for the insured; $100,000 for the spouse and $10,000 for each child
Sports Rider$25,000 lifetime maximum for mountaineering up to 4500 meters where ropes or guides are normally used, hang gliding, parachuting & bungee jumping and $7,500 lifetime maximum for amateur sports or interscholastic athletics sponsored by a school or organization when not engaged for wage or profit
Hospital daily indemnity rider$150 per night when you are hospitalized outside US and Canada