Table of Benefits
Table of Benefits
| Maximum plan benefit per Insureance Year USD | $1 000 000 |
| Life time Maximum (reinstatements included) | $1 500 000 |
| Deductible per Insurance Year (inside & out of network) | $400 |
| Hospitalization +24 hrs.: $750 | |
| Outpatient surgeries: $750 | |
| Chemotherapy: $1,500 | |
| Higher deductible applies for related ailments | |
| Co-insurance | 15% |
| Maximum individual co-insurance per year | Max. $600 |
In-Patient
| Benefits | Annual deductible In the Network | Annual deductible Out of Network Network | Co-payment (only applies for treatment in the USA) | Inside or Out of Network Coverage Up to |
| Hospital Accomodation – Private room | $750 | $750 | No | 85% refund |
| Intensive Care | Yes | Yes | No | 85% refund |
| Prescription Drugs when have a doctor’s prescription only | Yes | Yes | No | 85% refund |
| Surgical fees, including anesthesia, material & appliances | Yes | Yes | No | 85% refund |
| Physician and Therapist fees (in the U.S) | Yes | Yes | $20 per visit | 85% refund |
| Physician and Therapist fees (Out of the U.S & Canadá) | N/A | N/A | N/A | 0 % refund |
| Diagnostic tests (in the U.S.) | Yes | Yes | $20 per visit | 85% refund |
| Diagnostic tests (Out of the U.S. & Canadá) | N/A | N/A | N/A | 0 % refund |
| Maternity (multiple pregnancies, prenatal care, complications, childbirth, nurseries, pediatrician fees, congenital conditions) | Yes | Yes | No | 85% refund **OUT OF NETWORK PENALTY 15% COINSURENCE WITHOUT LIMIT*** |
| Congenital Diseases (in the U.S.) | No | No | No | 100% refund |
| Congenital Diseases (Canada) | Yes | Yes | No | 100% refund |
| Psychiatry and psycotherapy | Yes | Yes | No | 85% refund $100,000 per lifetime, Max. 60 days |
| Prescribed treatment for alcoholism and drug abuse (in a Rehab. Center) | Yes | Yes | No | 80% refund Max $50,000 Max. 30 days |
Out-Patient
| Benefits | Annual deductible In the Network | Co-payment (only applies for treatment in the USA) | Inside or Out of Network Coverage Up to | |
| Medical practitioner fees (in the U.S. & Canadá) | Yes | $20 per visit | 85% refund | |
| Medical practitioner fees (Out of the U.S.) | N/A | N/A | 0% refund | |
| Diagnostic tests (in the U.S.& Canadá) | Yes | Yes | $20 per visit | 85% refund |
| Diagnostic tests (Out of the U.S.) | N/A | N/A | 0% refund | |
| Prescription Drugs (In the U.S. & Canadá ) | Yes | $15 per generic drug $20 per branded drugs $25 per specialist/high cost | 100% refund | |
| Prescription Drugs (Out of the U.S.) | N/A | N/A | 0% refund | |
| House Call Visits | Yes | No | 80% refund per year Max. 60 visits | |
| Specialist Fees (in the U.S. & Canadá) | Yes | $20 per visit | 85% refund | |
| Specialist Fees (out of the U.S.) | N/A | N/A | 0% refund | |
| Presribed medical aids | Yes | No | 85% refund | |
| Orthopedic devices & prosthetics (inudes sleep apnea, manual chair) | Yes | No | 80% refund | |
| Psychiatry and psychotherapy | Yes | No | 85% refund Max. 60 visits | |
| Prescribed treatment for alcoholism and drug abuse (out-patient) | Yes | No | 80% refund Max. $10,000 | |
| Emergency out-patient treatment (In the U.S.) | Yes | Yes | 85% refund | |
| Use of emergency room | $50 per emergency | |||
| Emergency consultation, diagnostic tests and readings | $30 per visit | |||
| Emergency out-patient treatment (Out of the U.S.) | No | |||
| Rehabilitation therapies (Rehab. Centers) | Yes | No | 85% refund Max. 60 sessions | |
| Check-ups | No | No | 100% refund Max. $500 per contractual year | |
| Gynecological exams for women limited to: (In the U.S.) Annual papanicolau smear Mammogram & other tests | Yes | $15 per visit | 85% refund per year Max. 2 exams per year | |
| Gynecological exams for women limited to: (Out of the U.S.) Annual papanicolau smear Mammogram & other tests | N/A | N/A | 0% refund | |
| Vaccintation (Mandatory in the U.S. & Canadá) | Yes | $15 per visit | 85% refund | |
| Vaccintation (Mandatory out of the U.S. ) | N/A | N/A | 0% refund | |
| Ground or air ambulance (Nearest medical facility) | No | No | 95% refund |
| Benefits | Annual deductible In the Network | Co-payment (only applies for treatment in the USA) | Inside or Out of Network Coverage Up to |
| COVID Vaccine coverage (dispensing fee) | Yes | $20 per visit | 85% refund |
| COVID Antiviral | Yes | $15 per generic drug $20 per branded drugs $25 per specialist/high cost | 100% refund |
| COVID Test (OTC) covered | |||
| Broad Vaccination Network (BVN) – Seasonal & non seasonal vaccinations are not covered |