COVERED SERVICES INJURY AND SICKNESS BENEFIT LIMITS
| Age 14 days to Age 69 | Age 14 days to Age 69 | Age 70 and over | ||
| Maximum Limit | $50,000 Max per Injury / Sickness | $100,000 Max per Injury / Sickness | $50,000 Max per Injury / Sickness |
INPATIENT
| INPATIENT | Age 14 days to Age 69 | Age 14 days to Age 69 | Age 70 and over | |
| Hospital Room & Board including miscellaneous | $1275/day, 30 day max | $1750/day, 30 day max | $950/day, 30 day max | |
| Hospital Intensive Care Unit | Additional $525/day, 8 day max | Additional $750/day, 8 day max | Additional $425/day, 8 day max | |
| Surgical Treatment | $3000 | $5000 | $2500 | |
| Anesthetist | 25% of surgical benefit | 25% of surgical benefit | 25% of surgical benefit | |
| Assistant Surgeon | 25% of surgical benefit | 25% of surgical benefit | 25% of surgical benefit | |
| Physician's Non-Surgical Visits | $50/visit, 1/day, 30 visits | $75/day, 1/day, 30 visits | $50/visit, 1/day, 30 visits | |
| Consultant Physician, when requested by attending Physician | $400 | $450 | $350 | |
| Pre-Admission Tests within 7 days before Hospital admission | $1000 | $1000 | $700 | |
| Private Duty Nurse | $500 | $500 | $500 |
OUTPATIENT
| OUTPATIENT | Age 14 days to Age 69 | Age 14 days to Age 69 | Age 70 and over | |
| Surgical Treatment | $3000 | $5000 | $2500 | |
| Anesthetist | 25% of surgical benefit | 25% of surgical benefit | 25% of surgical benefit | |
| Assistant Surgeon | 25% of surgical benefit | 25% of surgical benefit | 25% of surgical benefit | |
| Physician's Non-Surgical Visits | $50/visit, 1/day, 10 visits | $75/visit, 1/day, 10 visits | $50/visit, 1/day, 10 visits | |
| Diagnostic X-rays & Lab Services | $400 Additional $250 - One Cat scan, PET scan or MRI |
$450 Additional $750 - One Cat scan, PET scan or MRI |
$350 Additional $250 - One Cat scan, PET scan or MRI |
|
| Hospital Emergency Room | 75% of U&C to $300 | 75% of U&C to $500 | 75% of U&C to $250 | |
| Prescription Drugs | $100 | $150 | $80 | |
| Day surgery miscellaneous, related to outpatient scheduled surgery performed at a Hospital or licensed outpatient surgery center; including the cost of operating room, anesthesia, drugs and medicines and medical supplies. | $900 | $1000 | $800 |
OTHERS
| OTHERS | Age 14 days to Age 69 | Age 14 days to Age 69 | Age 70 and over | |
| Ambulance Services | $400 | $400 | $400 | |
| Initial Orthopedic Prosthesis / brace | $1000 | $1200 | $800 | |
| Chemotherapy and / or radiation therapy | $1000 | $1250 | $800 | |
| Dental Treatment for Injury to Sound, Natural Teeth | $500 | $500 | $500 | |
| Mental & Nervous Disorder & Substance Abuse | Same as any Sickness | Same as any Sickness | Same as any Sickness | |
| Physiotherapy | $35/visit, 1/day, 12 visits | $35/visit, 1/day, 12 visits | $35/visit, 1/day, 12 visits | |
| Emergency Evacuation | $10,000 | $10,000 | $10,000 | |
| Repatriation of Remains | $7,500 | $7,500 | $7,500 | |
| AD&D Principal Sum | $25,000 Common Carrier | $25,000 Common Carrier | $25,000 Common Carrier |
Should an insured person
turn 70 during the purchased coverage period, the 70 and over benefit schedule
becomes effective upon the day the insured turns 70.