VisitorsCoverage - Inbound USA Schedule of Benefits

Inbound USA Schedule of Benefits

Inbound USA is a Limited Coverage Plan, its benefits are in the form of a specific fixed amount rather then percentage. The following schedule are benefits per injury/sickness. The amount listed is what the insurance company pays and anything beyond this amount is the insured's responsibility.

Medical Coverage Age:	Plan A 14 Days-69 Yrs	Plan B 14 Days-69 Yrs	Plan C 14 Days-69 Yrs	Plan D 14 Days-69 Yrs	Plan J 70 - 99 Yrs	Plan K 70 - 99 Yrs
Maximum Limit	$50,000 per Injury/Sickness	$75,000 per Injury/Sickness	$100,000 per Injury/Sickness	$130,000 per Injury/Sickness	$50,000 per Injury/Sickness	$70,000 per Injury/Sickness
Outpatient
Dr. / Physician Visit	Up to $55/visit, 10 visits max	Up to $70/visit, 10 visits max	Up to $85/visit, 10 visits max	Up to $110/visit, 10 visits max	Up to $55/visit, 10 visits max	Up to $75/visit, 10 visits max
Prescription Drugs / Medicines	Up to $100	Up to $125	Up to $150	Up to $200	Up to $80	Up to $110
Lab & X-rays	Up to $450 Plus $250 for 1 Cat scan, PET scan or MRI	Up to $475 Plus $375 for 1 Cat scan, PET scan or MRI	Up to $500 Plus $500 for 1 Cat scan, PET scan or MRI	Up to $650 Plus $600 for 1 Cat scan, PET scan or MRI	Up to $400 Plus $250 for 1 Cat scan, PET scan or MRI	Up to $560 Plus $300 for 1 Cat scan, PET scan or MRI
Surgical Treatment	Up to $3,300	Up to $4,400	Up to $5,500	Up to $7,150	Up to $2,750	Up to $3,850
Anesthetist	Up to $825	Up to $1,100	Up to $1,375	Up to $1,775	Up to $685	Up to $960
Assistant Surgeon	Up to $825	Up to $1,100	Up to $1,375	Up to $1,775	Up to $685	Up to $960
Outpatient Surgical Facility	Up to $1000	Up to $1050	Up to $1100	Up to $1400	Up to $850	Up to $1,190
Inpatient
Hospital Room and Board	Up to $1400/day, 30 day max	Up to $1675 per day, 30 day max	Up to $1950 per day, 30 day max	Up to $2535 per day, 30 day max	Up to $1050 per day, 30 day max	Up to $1470/day, 30 day max
Hospital Intensive Care Unit	Additional $660/day, 8 day max	Additional $755/day, 8 day max	Additional $850/day, 8 day max	Additional $1105/day, 8 day max	Additional $460/day, 8 day max	Additional $640/day, 8 day max
Private Duty Nurse	Up to $550	Up to $550	Up to $550	Up to $700	Up to $450	Up to $450
Pre-Admission Tests w/in 7 days before Hospital admission	Up to $1,100	Up to $1,100	Up to $1,100	Up to $1,450	Up to $775	Up to $1,085
Surgical Treatment	Up to $3,300	Up to $4,400	Up to $5,500	Up to $7,150	Up to $2,750	Up to $3,850
Anesthetist	Up to $825	Up to $1,100	Up to $1,375	Up to $1,775	Up to $685	Up to $960
Assistant Surgeon	Up to $825	Up to $1,100	Up to $1,375	Up to $1,775	Up to $685	Up to $960
Physician's Non-Surgical Visits	Up to $55/visit, 30 visits max	Up to $70/visit, 30 visits max	Up to $85/visit, 30 visits max	Up to $110/visit, 30 visits max	Up to $55/visit, 30 visits max	Up to $75/visit, 30 visits max
A Consulting Physician, when requested by attending Physician	Up to $450	Up to $475	Up to $500	Up to $650	Up to $400	Up to $560
Emergency Services
Emergency Room (ER)	75% of U&C* to a max of $330	75% of U&C* to a max of $440	75% of U&C* to a max of $550	75% of U&C* to a max of $700	75% of U&C* to a max of $250	75% of U&C* to a max of $350
Ambulance Expenses	Up to $450	Up to $450	Up to $450	Up to $450	Up to $450	Up to $450
Other Treatments & Services
Initial Orthopedic Prosthesis/brace	Up to $1,100	Up to $1,200	Up to $1,300	Up to $1,700	Up to $850	Up to $1,190
Chemotherapy and/or radiation therapy	Up to $1,100	Up to $1,225	Up to $1,350	Up to $1,750	Up to $850	Up to $1,190
Mental & Nervous Disorder & Substance Abuse	Same as any Sickness	Same as any Sickness	Same as any Sickness	Same as any Sickness	Same as any Sickness	Same as any Sickness
Physical Therapy	Up to $40/visit, 12 visits max	Up to $40/visit, 12 visits max	Up to $40/visit, 12 visits max	Up to $40/visit, 12 visits max	Up to $40/visit, 12 visits max	Up to $40/visit, 12 visits max
Pre-Existing Conditions	Up to $5,000 in coverage forMyocardial Infarction (heart attack)or Stroke	Up to $5,000 in coverage forMyocardial Infarction (heart attack)or Stroke	Up to $5,000 in coverage forMyocardial Infarction (heart attack)or Stroke	Up to $5,000 in coverage forMyocardial Infarction (heart attack)or Stroke	Up to $3,000 in coverage for Myocardial Infarction (heart attack) or Stroke	Up to $3,000 in coverage for Myocardial Infarction (heart attack) or Stroke
Maternity	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered
General Physical Checkup	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered

Dental Coverage Age:	Plan A 14 Days-69 Yrs	Plan B 14 Days-69 Yrs	Plan C 14 Days-69 Yrs	Plan D 14 Days-69 Yrs	Plan J 70 - 99 Yrs	Plan K 70 - 99 Yrs
Dental - Acute, unexpected pain	Not covered	Not covered	Not covered	Not covered	Not covered	Not covered
Dental - Accident related emergency	Up to $550	Up to $550	Up to $550	Up to $550	Up to $550	Up to $550

Travel/Life Coverage Age:	Plan A 14 Days-69 Yrs	Plan B 14 Days-69 Yrs	Plan C 14 Days-69 Yrs	Plan D 14 Days-69 Yrs	Plan J 70 - 99 Yrs	Plan K 70 - 99 Yrs
Emergency Medical Evacuation / Repatriation	$50,000	$50,000	$50,000	$50,000	$50,000	$50,000
Return of mortal Remains	$7,500	$7,500	$7,500	$7,500	$7,500	$7,500
AD&D (accidental death & dismemberment)	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000
Emergency Reunion	Not covered	Not covered	Not covered	Not covered	Not covered	Not covered
Return of minor Child(ren)	Not covered	Not covered	Not covered	Not covered	Not covered	Not covered
Trip Interruption	Not covered	Not covered	Not covered	Not covered	Not covered	Not covered
Loss of checked Baggage	Not covered	Not covered	Not covered	Not covered	Not covered	Not covered
Terrorism Coverage	Not covered	Not covered	Not covered	Not covered	Not covered	Not covered

*U&C: usual, reasonable and customary charges

Note: If an insured person turns 70 years old during the purchased coverage period, the 70 and over benefit schedule becomes effective upon the day the insured turns 70. Individuals with the $100,000 or $130,000 per injury or sickness policy maximum will recieve the $70,000 per injury or sickness schedule for age 70 and older. Individuals with the $75,000 or $50,000 per injury or sickness policy maximum will receive the $50,000 per injury or sickness schedule for age 70 and older.

Other
More Plan Details	Please Check Policy Details
Plan Exclusions	What is not covered
24-Hrs Emergency Assistance	Yes. Contact Number and details can be found on the ID card.

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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.

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