Inbound Guest 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 M aximums
All coverages and plan costs listed in this brochure are in U.S. Dollar amounts.
Age 14 days to Age 69 Plan A Plan B Plan C Plan D
INPATIENT $45,000 Max per Injury/Sickness $65,000 Max per Injury/Sickness $85,000 Max per Injury/Sickness $120,000 Max per Injury/Sickness
Hospital Room & Board including miscellaneous Up to $1260/day, 30 day max Up to $1565/day, 30 day max Up to $1785/day, 30 day max Up to $2340/day, 30 day max
Hospital Intensive Care Unit Additional $595/day, 8 day max Additional $720/day, 8 day max Additional $790/day, 8 day max Additional $1020/day, 8 day max
Surgical Treatment Up to $2970 Up to $3960 Up to $4840 Up to $6600
Anesthetist Up to $740 Up to $990 Up to $1210 Up to $1650
Assistant Surgeon Up to $740 Up to $990 Up to $1210 Up to $1650
Physician’s Non-Surgical Visits Up to $50/visit, 1/day, 30 visits max Up to $65/visit,1/day, 30 visits max Up to $75/visit, 1/day, 30 visits max Up to $100/visit, 1/day, 30 visits max
A Consulting Physician, when requested by attending Physician Up to $405 Up to $465 Up to $485 Up to $600
Private Duty Nurse Up to $495 Up to $550 Up to $550 Up to $660
Pre-Admission Tests w/in 7 days before Hospital admission Up to $990 Up to $1100 Up to $1100 Up to $1100
OUTPATIENT        
Surgical Treatment Up to $2970 Up to $3960 Up to $4840 Up to $6600
Anesthetist Up to $740 Up to $990 Up to $1210 Up to $1650
Assistant Surgeon Up to $740 Up to $990 Up to $1210 Up to $1650
Physician’s Non-Surgical/Urgent Care Visits Up to $50/visit, 1/day, 10 visits max Up to $65/visit, 1/day, 10 visits max Up to $75/visit, 1/day, 10 visits max Up to $100/visit, 1/day, 10 visits max
Diagnostic X-rays & Lab Services Up to $405 - Additional $250 - One Cat scan, PET scan or MRI Up to $465 – additional $375 - One Cat scan, PET scan or MRI Up to $485 - Additional $450 - One Cat scan, PET scan or MRI Up to $600 - Additional $500 - One Cat scan, PET scan or MRI
Hospital Emergency Room (all expenses incurred therein) Up to $295 Up to $395 Up to $485 Up to $660
Prescription Drugs Up to $90 Up to $115 Up to $135 Up to $180
Outpatient Surgical Facility Up to $900 Up to $1030 Up to $1070 Up to $1320
OTHER TREATMENT & SERVICES        
Ambulance Services Up to $450 Up to $450 Up to $450 Up to $450
Initial Orthopedic Prosthesis/brace Up to $990 Up to $1160 Up to $1240 Up to $1560
Chemotherapy and/or radiation therapy Up to $990 Up to $1175 Up to $1275 Up to $1620
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
AD&D Principal Sum $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier $25,000 Common Carrier
If an insured person turn 70 years old during the purchased coverage period, the 70 and over benefit schedule becomes effective upon the day the insured turns 70. Individuals with the $85,000 or $120,000 per injury or sickness policy maximum will receive the $60,000 per injury or sickness schedule for age 70 and older. Individuals with the $45,000 or $65,000 per injury or sickness policy maximum will receive the $40,000 per injury or sickness schedule for age 70 and older.
Age 70 to Age 99 Plan J Plan K
INPATIENT $40,000 Max per Injury/Sickness $60,000 Max per Injury/Sickness
Hospital Room & Board including miscellaneous Up to $870/day, 30 day max Up to $1260/day, 30 day max
Hospital Intensive Care Unit Additional $380/day, 8 day max Additional $550/day, 8 day max
Surgical Treatment Up to $2285 Up to $3300
Anesthetist Up to $570 Up to $825
Assistant Surgeon Up to $570 Up to $825
Physician’s Non-Surgical Visits Up to $45/visit, 1/day, 30 visits max Up to $65/visit, 1/day, 30 visits max
A Consulting Physician, when requested by attending Physician Up to $330 Up to $480
Private Duty Nurse Up to $375 Up to $450
Pre-Admission Tests w/in 7 days before Hospital admission Up to $775 Up to $775
OUTPATIENT    
Surgical Treatment Up to $2285 Up to $3300
Anesthetist Up to $570 Up to $825
Assistant Surgeon Up to $570 Up to $825
Physician’s Non-Surgical / Urgent Care Visits Up to $45/visit, 1/day, 10 visits max Up to $65/visit, 1/day, 10 visits max
Diagnostic X-rays & Lab Services Up to $330 - Additional $250 - One Cat scan, PET scan or MRI Up to $480 – additional $300 - One Cat scan, PET scan or MRI
Hospital Emergency Room (all expenses incurred therein) Up to$208 Up to $300
Prescription Drugs Up to $65 Up to $95
Outpatient Surgical Facility Up to $705 Up to $1020
OTHER TREATMENT    
Ambulance Services Up to $450 Up to $450
Initial Orthopedic Prosthesis/brace Up to $705 Up to $1020
Chemotherapy and/or radiation therapy Up to $705 Up to $1020
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
AD&D Principal Sum $25,000 Common Carrier $25,000 Common Carrier