|
Medical |
|
Health and Sickness |
Covered |
 |
|
Accidents |
Covered |
 |
|
Out-Patient |
|
Surgical Treatment |
$50,000 Plan: $2,500 per Incident
$100,000 Plan: $4,250 per Incident
$250,000 Plan: $4,900 per Incident
Age 70 Over: $2,100 per Incident |
 |
|
Dr. / Physician Visit |
$50,000 Plan: $40 per visit
$100,000 Plan: $60 per visit
$250,000 Plan: $70 per visit
Age 70 Over: $40 per visit |
 |
|
Prescription Drugs / Medicines |
$50,000 Plan: $85 per visit
$100,000 Plan: $125 per visit
$250,000 Plan: $150 per visit
Age 70 Over: $70 per visit |
 |
|
Physical Therapy |
$30 per visit |
 |
|
Lab & X-rays |
$50,000 Plan: $350 per Incident
$100,000 Plan: $375 per Incident
$250,000 Plan: $400 per Incident
Age 70 Over: $300 per Incident |
 |
|
In-Patient |
|
Surgical Treatment |
$50,000 Plan: $2,500 per day
$100,000 Plan: $4,250 per day
$250,000 Plan: $4,900 per day
Age 70 Over: $2,100 per day |
 |
|
Hospital Intensive Care Unit |
$50,000 Plan: $450 per day
$100,000 Plan: $640 per day
$250,000 Plan: $740 per day
Age 70 Over: $350 per day |
 |
|
Hospital Room and Board |
$50,000 Plan: $1,075 per day
$100,000 Plan: $1,500 per day
$250,000 Plan: $1,725 per day
Age 70 Over: $800 per day |
 |
|
Emergency Services |
|
Ambulance Expenses |
$350 per Incident |
 |
|
Emergency Room(ER) |
$50,000 Plan: $250 per Incident
$100,000 Plan: $425 per Incident
$250,000 Plan: $490 per Incident
Age 70 Over: $200 per Incident |
 |
|
Dental |
|
Acute, spontaneous and unexpected pain |
Not covered |
 |
|
Accidental emergency |
$425 per Incident |
 |
|
Travel |
|
Emergency Medical Evacuation / Repatriation |
Up to $50,000 |
 |
|
Return of mortal Remains |
Up to $7,500 |
 |
|
Emergency Reunion |
Not covered |
 |
|
Return of minor Child(ren) |
Not covered |
 |
|
Trip Interruption |
Not Covered |
 |
|
Loss of checked Baggage |
Not Covered |
 |
|
Life |
|
AD&D |
Not Covered |
 |
|
Common Carrier Accidental Death |
Up to $25,000 |
 |
|
Other |
|
More Details |
Please check Policy Details |
 |
|
Plan Exclusions |
What is not covered |
 |
|
Pre-Existing Conditions |
Not Covered |
 |
|
Maternity |
Not covered |
 |
|
General Physical full Checkup |
Not covered |
 |
|
Terrorism Coverage |
Not covered |
 |
|
Support |
|
24-Hrs Emergency Assistance |
Yes. Contact number and details can be found on the ID card. |
 |
|
|
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Back  |
|
Note
: Plan features
listed here are high
level, provided for
your convenience and
information purpose
only. Please review
the Evidence of Coverage
and Plan Contract
(Policy) for a detailed
description of Coverage
Benefits, Limitations
and Exclusions. Must
read the Policy Brochure
and Plan Details for
complete and accurate
details. Only the
Terms and Conditions
of Coverage Benefits
listed in the policy
are binding. |
|