|
Medical |
|
Health and Sickness |
 Covered |
 |
|
Accidents |
Covered |
|
|
Out-Patient |
|
Surgical Treatment |
In-Network:100% covered
Out-of-Network:80%covered for first $5000
100% covered thereafter |
|
|
Dr. / Physician Visit |
In-Network:100% covered
Out-of-Network: 80%covered for first $5000
100% covered thereafter |
|
|
Prescription Drugs / Medicines |
80%covered for first $5000
100% covered thereafter
(pay first then file claim) |
|
|
Physical Therapy |
$50 per visit |
|
|
Lab & X-rays |
In-Network:100% covered
Out-of-Network: 80%covered for first $5000
100% covered thereafter |
|
|
In-Patient |
|
Hospital Intensive Care Unit |
In-Network:100% covered
Out-of-Network: 80%covered for first $5000
100% covered thereafter |
|
|
Surgical Treatment |
In-Network:100% covered
Out-of-Network: 80%covered for first $5000
100% covered thereafter |
|
|
Hospital Room and Board |
In-Network:100% covered
Out-of-Network: 80%covered for first $5000
100% covered thereafter |
|
|
Emergency Services |
|
Ambulance Expenses |
In-Network:100% covered
Out-of-Network: 80%covered for first $5000
100% covered thereafter |
|
|
Emergency Room(ER) |
In-Network:100% covered
Out-of-Network: 80%covered for first $5000
100% covered thereafter for injuries
(Emergency Room cost not covered for general illness unless hospitalized. Prefer going to an urgent care facility or make an appointment directly with doctor for general illness related conditions.) |
|
|
Dental |
|
Acute, spontaneous and unexpected pain |
Up to $100 |
|
|
Accidental emergency |
In-Network:100% covered
Out-of-Network: 80%covered for first $5000
100% covered thereafter |
|
|
Travel |
|
Emergency Medical Evacuation / Repatriation |
Emergency air and/or ground transportation to the nearest hospital that is qualified to provide the Medically Necessary treatment.$500,000 Maximum Lifetime Limit. |
|
|
Return of mortal Remains |
Air and/or ground transportation of bodily remains or ashes to the area of your Principal Residence, and reasonable costs of preparation of your remains necessary for transportation. |
|
|
Emergency Reunion |
$15,000 |
|
|
Return of minor Child(ren) |
The cost of a one-way economy air and/or ground transportation ticket for each covered child to the terminal serving the area of Principal Residence of each covered child. |
|
|
Trip Interruption |
The cost of a one-way economy air and/or ground transportation ticket for each covered child to the terminal serving the area of Principal Residence. |
|
|
Loss of checked Baggage |
$50 per item, $250 max |
|
|
Life |
|
AD&D |
Up to $25,000
(Benefit Limits apply for ages 70 & over)
(Dependents: $5,000) |
|
|
Common Carrier Accidental Death |
Up to $50,000
(Dependents $25,000 each; $250,000 Max for Family) |
|
|
Other |
|
Plan Exclusions |
What is not covered |
|
|
More Details |
Please check Policy Details  |
|
|
Pre-Existing Conditions |
If you are under age 70, you are covered for an Acute Onset of a Pre-existing Condition. Coverage is available up to $15,000 Maximum for Eligible Medical Expenses and up to $25,000 for Emergency Medical Evacuation. An Acute Onset of a Pre-existing Condition is a sudden and unexpected outbreak or recurrence of a Pre-existing Condition which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. |
|
|
Maternity |
 Not covered |
|
|
General Physical full Checkup |
Not covered |
|
|
Terrorism Coverage |
Up to $50,000 |
|
|
Support |
|
24-Hrs Emergency Assistance |
Yes. Contact Number and details can be found on the ID card. |
|
|
|
|
|
<<
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. |
|
Show
Similar Plans
