|
Plan
|
Visitors Care Plan A $75 Deductable
|
Visitors Care Plan A $150 Deductable
|
|
Deductible
|
|
Deductible Amount
|
$150
|
$75
|
|
General
|
|
Common Carrier Accidental Death
|
US$25,000 to Beneficiary
|
US$25,000 to Beneficiary
|
|
Emergency Evacuation
|
To US$50,000 when coordinated through IMG (not to exceed plan maximum)
|
To US$50,000 when coordinated through IMG (not to exceed plan maximum)
|
|
Repatriation
|
To US$7,500 when coordinated through IMG
|
To US$7,500 when coordinated through IMG
|
|
Inpatient Treatment
|
|
Consult physician
|
US$350 per period of coverage
|
US$350 per period of coverage
|
|
Hospital room & board
|
Up to US US$825 per day, 30 day maximum per period of coverage
|
Up to US US$825 per day, 30 day maximum per period of coverage
|
|
Intensive Care
|
Additional US$400 per day, 8 day maximum per period of coverage
|
Additional US$400 per day, 8 day maximum per period of coverage
|
|
Physician visits
|
US$40 allowable charge per visit, 30 visits per period of coverage
|
US$40 allowable charge per visit, 30 visits per period of coverage
|
|
Pre-admission tests
|
US$750 per period of coverage
|
US$750 per period of coverage
|
|
Private duty nurse
|
US$400 per period of coverage
|
US$400 per period of coverage
|
|
Surgical Treatment
|
US$2,000 per surgical session
|
US$2,000 per surgical session
|
|
Outpatient Treatment
|
|
Diagnostic x-ray & lab
|
US$650 per period of coverage, (US$325 allowable charge per procedure)
|
US$650 per period of coverage, (US$325 allowable charge per procedure)
|
|
Hospital emergency room
|
US$200 allowable charge per visit
|
US$200 allowable charge per visit
|
|
Physician visits
|
US$50 allowable charge per visit, 10 visits per period of coverage
|
US$50 allowable charge per visit, 10 visits per period of coverage
|
|
Prescription drugs
|
US$150 per period of coverage
|
US$150 per period of coverage
|
|
Surgical treatment
|
US$2,000 per surgical session
|
US$2,000 per surgical session
|
|
Miscellaneous
|
|
Anesthetist
|
US$450 per surgical session
|
US$450 per surgical session
|
|
Assistant surgeon
|
US$450 per surgical session
|
US$450 per surgical session
|
|
Other
|
|
Ambulance
|
US$250 per period of coverage
|
US$250 per period of coverage
|
|
Dental for accident to sound natural teeth
|
US$350 per period of coverage
|
US$350 per period of coverage
|
|
Physiotherapy
|
US$25 per visit per day, 12 visits per period of coverage
|
US$25 per visit per day, 12 visits per period of coverage
|
