Disciple Missionary Medical Insurance Benefits

Schedule of Benefits

All amounts listed are in U.S. dollars. Click the titles to see further information.

Covered Services - Injury and Sickness Benefit Maximums

Age 14 days to Age 69 Plan A Plan B Plan C Plan D
INPATIENT $50,000 Max per Injury/Sickness $75,000 Max per Injury/Sickness $100,000 Max per Injury/Sickness $130,000 Max per Injury/Sickness
Hospital Room & Board including
Laboratory Tests, X-Rays,
Prescription Medical and
other miscellaneous
Up to $1400/day, 30 day max Up to $1675/day, 30 day max Up to $1950/day, 30 day max Up to $2535/day, 30 day max
Hospital Intensive Care Unit Additional $660/day, 8 day max Additional $755/day, 8 day max Additional $850/day, 8 day max Additional $1105/day, 8 day max
Surgical Treatment Up to $3300 Up to $4400 Up to $5500 Up to $7150
Anesthetist Up to $825 Up to $1100 Up to $1375 Up to $1775
Assistant Surgeon Up to $825 Up to $1100 Up to $1375 Up to $1775
Physician’s Non-Surgical Visits Up to $55/visit, 1/day, 30 visits max Up to $70/visit, 1/day, 30 visits max Up to $85/visit, 1/day, 30 visits max Up to $110/visit, 1/day, 30 visits max
A Consulting Physician, when requested by attending Physician Up to $450 Up to $475 Up to $500 Up to $650
Private Duty Nurse Up to $550 Up to $550 Up to $550 Up to $700
Pre-Admission Tests w/in 7 days before Hospital admission Up to $1,100 Up to $1,100 Up to $1,100 Up to $1,450
OUTPATIENT        
Surgical Treatment Up to $3300 Up to $4400 Up to $5500 Up to $7150
Anesthetist Up to $825 Up to $1100 Up to $1375 Up to $1775
Assistant Surgeon Up to $825 Up to $1100 Up to $1375 Up to $1775
Physician’s Non-Surgical/Urgent Care Visits Up to $55/visit, 1/day, 10 visits max Up to $70/visit, 1/day, 10 visits max Up to $85/visit, 1/day, 10 visits max Up to $110/visit, 1/day, 10 visits max
Diagnostic X-rays & Lab Services Up to $450 - Additional $250 - One Cat scan, PET scan or MRI Up to $475 - Additional $375 - One Cat scan, PET scan or MRI Up to $500 - Additional $500 - One Cat scan, PET scan or MRI Up to $650 - Additional $600 - One Cat scan, PET scan or MRI
Hospital Emergency Room (all expenses incurred therein) Up to a maximum of $330 Up to a maximum of $440 Up to a maximum of $550 Up to a maximum of $700
Prescription Drugs Up to $100 Up to $125 Up to $150 Up to $200
Outpatient Surgical Facility Up to $1,000 Up to $1,050 Up to $1,100 Up to $1,400
OTHER TREATMENT AND SERVICES        
Ambulance Services Up to $450 Up to $450 Up to $450 Up to $450
Initial Orthopedic Prosthesis/brace Up to $1,100 Up to $1,200 Up to $1,300 Up to $1,700
Chemotherapy and/or radiation therapy Up to $1,100 Up to $1,225 Up to $1,350 Up to $1,750
Dental Treatment for Injury to Sound, Natural Teeth Up to $550 Up to $550 Up to $550 Up to $550
Mental & Nervous Disorder & Substance Abuse Same as any Sickness Same as any Sickness Same as any Sickness Same as any Sickness
Physiotherapy Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max
Emergency Evacuation $50,000 $50,000 $50,000 $50,000
Repatriation of Remains $7,500 $7,500 $7,500 $7,500
Political Evacuation and Repatriation $10,000 $10,000 $10,000 $10,000
Emergency Reunion Up to $10,000 Up to $10,000 Up to $10,000 Up to $10,000
Return of Minor Children Up to $10,000 Up to $10,000 Up to $10,000 Up to $10,000
Felonious Assault Benefit Up to $10,000 Up to $10,000 Up to $10,000 Up to $10,000
Coma Benefit Up to $10,000 Up to $10,000 Up to $10,000 Up to $10,000
Furlough Coverage Up to 90 days per 12 months Up to 90 days per 12 months Up to 90 days per 12 months Up to 90 days per 12 months
Terrorism Same as any Sickness Same as any Sickness Same as any Sickness Same as any Sickness
AD&D Principal Sum $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier
OPTIONAL PRE-EX BENEFIT Plan A Plan B Plan C Plan D
PRE-EXISTING CONDITIONSf
(the above maximum schedule still
applies)
Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke
Age 70 to Age 99 Plan J Plan K
INPATIENT $50,000 Max per Injury/Sickness $70,000 Max per Injury/Sickness
Hospital Room & Board including
Laboratory Tests, X-Rays,
Prescription Medical and
other miscellaneous
Up to $1,050/day, 30 day max Up to $1,470/day, 30 day max
Hospital Intensive Care Unit Additional $460/day, 8 day max Additional $640/day, 8 day max
Surgical Treatment Up to $2,750 Up to $3,850
Anesthetist Up to $685 Up to $960
Assistant Surgeon Up to $685 Up to $960
Physician’s Non-Surgical Visits Up to $55/visit, 1/day, 30 visits max Up to $75/visit, 1/day, 30 visits max
A Consulting Physician, when requested by attending Physician Up to $400 Up to $560
Private Duty Nurse Up to $450 Up to $450
Pre-Admission Tests w/in 7 days before Hospital admission Up to $775 Up to $1,085
OUTPATIENT    
Surgical Treatment Up to $2,750 Up to $3,850
Anesthetist Up to $685 Up to $960
Assistant Surgeon Up to $685 Up to $960
Physician’s Non-Surgical/Urgent Care Visits Up to $55/visit, 1/day, 10 visits max Up to $75/visit, 1/day, 10 visits max
Diagnostic X-rays & Lab Services Up to $400 - Additional $250 - One Cat scan, PET scan or MRI Up to $560 - Additional $300 - One Cat scan, PET scan or MRI
Hospital Emergency Room (all expenses incurred therein) Up to a maximum of $250 Up to a maximum of $350
Prescription Drugs Up to $80 Up to $350
Outpatient Surgical Facility Up to $850 Up to $1,190
OTHER TREATMENT AND SERVICES    
Ambulance Services Up to $450 Up to $450
Initial Orthopedic Prosthesis/brace Up to $850 Up to $1,190
Chemotherapy and/or radiation therapy Up to $850 Up to $1,190
Dental Treatment for Injury to Sound, Natural Teeth Up to $550 Up to $550
Mental & Nervous Disorder & Substance Abuse Same as any Sickness Same as any Sickness
Physiotherapy Up to $40/visit, 1/day, 12 visits max Up to $40/visit, 1/day, 12 visits max
Emergency Evacuation $50,000 $50,000
Repatriation of Remains $7,500 $7,500
Political Evacuation and Repatriation $10,000 $10,000
Emergency Reunion Up to $10,000 Up to $10,000
Return of Minor Children Up to $10,000 Up to $10,000
Felonious Assault Benefit Up to $10,000 Up to $10,000
Coma Benefit Up to $10,000 Up to $10,000
Furlough Coverage Up to 90 days per 12 months Up to 90 days per 12 months
Terrorism Same as any Sickness Same as any Sickness
AD&D Principal Sum $25,000 Common Carrier $25,000 Common Carrier
OPTIONAL PRE-EX BENEFIT Plan A Plan B
PRE-EXISTING CONDITIONSf
(the above maximum schedule still
applies)
Up to $3,000 in coverage for Myocardial Infarction (heart attack) or Stroke Up to $3,000 in coverage for Myocardial Infarction (heart attack) or Stroke