COVERED
SERVICES INJURY AND SICKNESS BENEFIT MAXIMUMS
| |
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 |
Up
to $1275/day, 30 day max |
Up
to $1750/day, 30 day max |
|
Up
to $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 |
Up
to $3000 |
Up
to $5000 |
|
Up
to $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 |
Up
to $50/visit, 1/day, 30 visits |
Up
to $75/day, 1/day, 30 visits |
|
Up
to $50/visit, 1/day, 30 visits |
|
Consultant Physician, when requested by attending Physician |
Up
to $400 |
Up
to $450 |
|
Up
to $350 |
|
Pre-Admission Tests within 7 days before Hospital admission |
Up
to $1000 |
Up
to $1000 |
|
Up
to $700 |
|
Private Duty Nurse |
Up
to $500 |
Up
to $500 |
|
Up
to $500 |
OUTPATIENT
|
OUTPATIENT |
Age
14 days to Age 69 |
Age
14 days to Age 69 |
|
Age 70 and over |
|
Surgical Treatment |
Up
to $3000 |
Up
to $5000 |
|
Up
to $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 / Urgent Care Visits |
Up
to $50/visit, 1/day, 10 visits |
Up
to $75/visit, 1/day, 10 visits |
|
Up
to $50/visit, 1/day, 10 visits |
|
Diagnostic X-rays & Lab Services |
Up
to $400
Additional $250 - One Cat scan, PET scan or MRI |
Up
to $450
Additional $500 - One Cat scan, PET scan or MRI |
|
Up
to $350
Additional $250 - One Cat scan, PET scan or MRI |
|
Hospital Emergency Room (all expenses incurred therein) |
75%
of U&C to $300 |
75%
of U&C to $500 |
|
75%
of U&C to $250 |
|
Prescription Drugs |
Up
to $100 |
Up
to $150 |
|
Up
to $80 |
|
Outpatient Surgical Facility |
Up
to $900 |
Up
to $1000 |
|
Up
to $800 |
OTHERS
|
OTHERS |
Age
14 days to Age 69 |
Age
14 days to Age 69 |
|
Age 70 and over |
|
Ambulance Services |
Up
to $400 |
Up
to $400 |
|
Up
to $400 |
|
Initial Orthopedic Prosthesis / brace |
Up
to $1000 |
Up
to $1200 |
|
Up
to $800 |
|
Chemotherapy and / or radiation therapy |
Up
to $1000 |
Up
to $1250 |
|
Up
to $800 |
|
Dental Treatment for Injury to Sound, Natural Teeth |
Up
to $500 |
Up
to $500 |
|
Up
to $500 |
|
Mental & Nervous Disorder & Substance Abuse |
Same as any Sickness |
Same as any Sickness |
|
Same as any Sickness |
|
Physiotherapy |
Up
to $35/visit, 1/day, 12 visits |
Up
to $35/visit, 1/day, 12 visits |
|
Up
to $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.
|