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|Hospital room and board||Average semi-private room rate up to the maximum limit. Includes nursing service
|Intensive care||Up to the maximum limit|
|Pre-Certification||50% reduction of eligible medical expenses if pre-certification provisions are not met|
|Remote Transportation||$5,000 per period, $20,000 lifetime maximum|
|Sudden and Unexpected Recurrence of a Pre-existing Condition-Medical(For U.S. citizens)||
Up to age 65 with primary health plan - Usual Reasonable and Customary up to plan maximum.
Up to age 65 without primary health plan - $20,000 lifetime maximum.
Age 65+ with or without primary health plan - $2,500 lifetime maximum.
|Sudden and Unexpected Recurrence of a Pre-existing Condition-Medical(For Non U.S. citizens)||
Up to $50,000 lifetime maximum for age 65 and under.
Up to $2,500 for age 65+.
|Emergency room accident||Up to the maximum limit|
|Hospital Emergency Room(Inside the U.S.)||Injury: Not subject to Emergency Room
Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission
|Hospital Emergency Room(Outside the U.S.)||Up to the maximum limit|
|Emergency dental treatment||$300 maximum limit due to dental accident or unexpected pain to sound natural teeth. Subject to deductible and coinsurance|
|Hospital indemnity||$250 per overnight inpatient confinement, maximum limit of 10 overnights. Not subject to deductible|
|Supplemental Accident||$300 per covered accident|
|Emergency medical evacuation||Up to maximum limit|
For a maximum of 15 days
|Return of mortal remains or cremation/burial||Up to the maximum limit for return of mortal remains or ashes to country of residence, or $5,000 maximum limit for cremation or local burial at the place of death. Not subject to deductible|
|Return of minor children||$100,000 maximum limit|
|Natural disaster||$25,000 maximum limit. Not subject to deductible.|
|Urgent Care Clinic||$25 copay. Copay is not applicable when the $0 deductible is selected. Not subject to deductible.|
|Walk-In Clinic||$15 copay. Copay is not applicable when the $0 deductible is selected. Not subject to deductible|
|Trip Interruption||$10,000 maximum limit. Not subject to deductible|
|Bedside Visit||$1,500 maximum limit. Not subject to deductible.|
|Remote transportation||$5,000per certificate period
$20,000 lifetime maximum
|Identity theft assistance||Up to $500|
|Assistant Surgeon||20% of the primary surgeon’s eligible fee|
|Lost / Theft of luggage, valuables, personal papers||$50 per item, $500 maximum limit|
|Terrorism||$50,000 maximum limit|
|Interfacility Ambulance Transfer||Company pays 100%|
|Sports & leisure activities||Up to the maximum limit for basic sports|
|Incidental home country coverage||Up to cumulative of 2 weeks|
|End of trip home country coverage||One month for every four months of travel coverage, up to a maximum of three months|
|Common carrier accidental death||$25,000 per insured child, $100,000 per insured adult, $250,000 maximum limit per family.|
|Accidental death & dismemberment||$50,000 principal sum.|
|Small pet common carrier accidental death||$500 maximum limit.|