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MEDICARE BENEFITS
URC
= Usual , Reasonable Customary
= Habituel Raisonable Normalement
Subject to deductible
and
coinsurance
Coverage Area
Worldwide
Policy Maximum Per Individual
US$5,000,000 lifetime
Hospitalization
Semi-private room and board Nursing services Prescription medication Physician charges Diagnostic and laboratory testing X-rays Chemotherapy and radiation Durable medical equipment Treatment, services and supplies routinely provided
URC
Intensive Care Unit
URC
Surgery
Surgical care Second surgical opinion Anesthetics Physician charges for surgery Treatment, services and supplies routinely provided
URC
Transplants
Limited to certain transplants and covered only within designated transplant facilities that are members of IMG's independently-
contracted PPO network
US$1,000,000 lifetime
Outpatient
Emergency treatment of illness or injury Surgery Rehabilitative treatment Treatment, services or supplies routinely provided Prescription medication
URC
Emergency
Surgery or dental treatment following an accident Emergency room following an accident
URC
Emergency
Transportation by
Ground Ambulance
URC
Emergency Medical Evacuation
Included with Emergency Medical Evacuation is an Emergency Reunion benefit of US$10,000 lifetime
Up to policy maximum
Repatriation
US$25,000
Supplemental Accident
The first $300 will be covered for each accidental injury
US$300 per occurrence
Maternity
Available after 12 months of continuous coverage Pre and Post-natal care Normal delivery or C-section Well baby care and treatment of newborn for first 31 days
US$50,000 lifetime
Newborns
Eligible newborn children may be added without evidence of insurability under certain circumstances An application form must be submitted within 31 days of child's birth
URC
Child Wellness
Available for eligible children from 14 days to 18 years of age after 12 months of continuous coverage
US$50 maximum per visit; US$150 per policy period
Pre-existing Conditions
After 24 months of continuous coverage
US$50,000 lifetime
Mental/Nervous Care
Available after 12 months of continuous coverage Inpatient and outpatient care by a licensed psychiatrist
US$10,000 per period of coverage
Wellness
Females age 35 and over, after 12 months of continuous coverage Routine physicals Mammogram, ob/gyn visit, etc. (exams must be separated by 12 months) Males age 35 and over, after 12 months of continuous coverage Routine physicals (exams must be separated by 12 months)
US$250 per policy period
Complementary Medicine
(Each per policy period)
Acupuncture
US$150
Aroma Therapy
US$50
Herbal Therapy
US$75