|
| MEDICAL INSURANCE | BENEFIT
Subject to deductible and coinsurance |
| Coverage Area | Worldwide |
| Policy Maximum Per Individual | US$5,000,000 lifetime |
| Hospitalization |
URC |
| Intensive Care Unit | |
| Surgery Surgical care l Second surgical opinion l Anesthetics l Physician charges for surgery l 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 l Surgery l Rehabilitative treatment l Treatment, services or supplies routinely provided l Prescription medication |
URC |
| Emergency Surgery or dental treatment following an accident l Emergency room following an accident |
URC |
| Emergency
Transportation by Ground Ambulance |
URC |
| Emergency
Medical Evacuation Included with the 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 US$300 will be covered fop each accidental injury |
US$300
per occurance (not subject to deductible or coinsurance) |
| Maternity Available after 12 months of coverage | Pre and Post-natal care l Normal delivery or C-section l Well baby care and treatment of newborn for first 31 days |
US$50,000
lifetime (maximum of US$5,000 for each normal delivery for each pregnancy; maximum of US$7,500 for C-section delivery for each pregnancy) |
| Newborns Eligible newborn children may be added without evidence of insurability under certain circumstances | An application form must be submitted within 31 days of birth |
URC |
| Mental/Nervous
Care Inpatient and outpatient care by a licensed psychiatrist |
US$10,000
per period, US$25,000 lifetime (after 12 months of coverage) |
|
Wellness Females age 35 and over after 12 months of continuous coverage. Routine physicals l 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 period of coverage |
| Complementary
Medicine Acupuncture Aroma Therapy Herbal Therapy Magnetic Therapy Massage Therapy Vitamin Therapy |
(Each
per period of coverage) US$150 US$50 US$50 US$75 US$150 US$100 |
| Pre-existing
Conditions After 24 months of continuous coverage |
US$50,000
lifetime (maximum of $5,000 per period of coverage) |
|
Other Chiropractor when referred by a physician l Radiation treatment l Home nursing care l Hospice care l Physical therapy (maximum US$50 per visit) l Prosthetic devices |
URC |
This is a summary of benefits. Please refer to the certificate wording for a
complete description, which is available upon request.
Underwritten By: Sirius
International Insurance Corporation
Global Medical
InsuranceSM Rates
(Includes 2 ½% surplus lines tax.)
| $250 Deductible |
$500 Deductible |
$1,000 Deductible |
$2,500 Deductible |
$5,000 Deductible |
$10,000 Deductible |
|||||||
| Age | Male | Female | Male | Female | Male | Female | Male | Female | Male | Female | Male | Female |
| 14 days to 9* | First 2 Free, Then 450 | First 2 Free, Then 380 | First 2 Free, Then 290 | First 2 Free, Then 260 | First 2 Free, Then 250 | First 2 Free, Then 220 | ||||||
| 10-18* | 490 | 400 | 310 | 280 | 270 | 240 | ||||||
| First two Dependent Children free between the ages of 14 days to 9 years only when both parents or guardians are insured under the Global Medical Insurancesm plan. Dependent child rate only available when parent or guardian is insured under the Global Medical InsuranceSM plan. Children applying with no parent or guardian insured by Global Medical InsuranceSM use the Male 19 - 24 rates. | ||||||||||||
| 19 - 24 | 1,075 | 1,785 | 925 | 1,585 | 720 | 1,140 | 635 | 1,010 | 520 | 830 | 410 | 650 |
| 25 - 29 | 1,175 | 1,950 | 1,025 | 1,750 | 795 | 1,260 | 700 | 1,115 | 575 | 910 | 450 | 710 |
| 30 - 34 | 1,230 | 2,140 | 1,080 | 1,940 | 840 | 1,445 | 745 | 1,280 | 610 | 1,050 | 480 | 820 |
| 35 - 39 | 1,345 | 2,290 | 1,195 | 2,090 | 925 | 1,600 | 820 | 1,415 | 670 | 1,135 | 525 | 890 |
| 40 - 44 | 1,505 | 1,875 | 1,330 | 1,675 | 1,030 | 1,300 | 915 | 1,155 | 745 | 945 | 590 | 740 |
| 45 - 49 | 1,645 | 2,045 | 1,470 | 1,845 | 1,140 | 1,435 | 1,010 | 1,270 | 825 | 980 | 650 | 770 |
| 50 - 54 | 2,000 | 2,220 | 1,800 | 2,020 | 1,400 | 1,575 | 1,275 | 1,430 | 1,045 | 1,170 | 820 | 920 |
| 55 - 59 | 2,532 | 2,532 | 2,321 | 2,321 | 1,812 | 1,812 | 1,644 | 1,644 | 1,345 | 1,345 | 1,050 | 1,050 |
| 60 - 64 | 3,493 | 3,293 | 3,230 | 3,030 | 2,705 | 2,505 | 2,469 | 2,284 | 2,048 | 1,812 | 1,681 | 1,497 |
| 65 - 69 | 7,213 | 6,291 | 6,950 | 6,027 | 6,425 | 5,500 | 4,996 | 4,514 | 4,334 | 3,902 | 3,572 | 3,217 |
| 70 - 74 | Please contact IMG or your agent for premium information | |||||||||||