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Benefits
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Limits
|
|
Coverage Area
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Worldwide
|
|
Overall Policy Maximum
|
$5,000,000 Lifetime
|
|
Deductibles Available
|
$250, $500, $1,000, $2,500 or $5,000 per person per Certificate Period.
|
|
Coinsurance -- Claims incurred in US or Canada
|
Underwriters will pay 80% of the next $5,000 of Eligibile Medical Expenses after the
Deductible, then 100% to the Overall Maximum Limit. The Coinsurance will be waived if
expenses are incurred within the PPO and expenses are submitted to Underwriters for
review and payment directly to the provider |
|
Coinsurance -- claims incurred outside US or Canada
|
Underwriters will pay 100% of Eligible Medical Expenses after the Deductible to the Overall
Policy Maximum. |
|
Acute Onset of Pre-existing Conditions
|
$1,000 during the first Certificate Period and $2,500 during the second
Certificate Period
|
|
Pre-existing Conditions
|
$5,000 per Certificate Period subject to a Lifetime Maximum of $50,000
(including Acute Onset claims) after 24 months of continuous coverage
hereunder
|
|
Maternity
|
$5,000 per Pregnancy after 12 months of continuous coverage hereunder,
including Inpatient, Outpatient and other benefits as herein provided.
Not subject to Coinsurance
|
|
Newborn Care
|
$15,000 per covered Pregnancy, including Inpatient, Outpatient and other
benefits as herein provided, during the first 60 days of life
|
|
Organ Transplants
|
$250,000 Lifetime maximum for covered transplants**
|
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INPATIENT BENEFITS (All Subject to Deductible and Coinsurance)
|
|
Hospital Room and Board
|
$600 per day, maximum of 240 days per Hospitalization (including ICU
days)
|
|
Intensive Care Unit (ICU)
|
$1,500 per day, maximum of 240 days per Hospitalization (including non
ICU days)
|
|
Lab, x-rays and other covered Inpatient services & supplies
|
Usual, Reasonable and Customary Charges (except as limited herein)
|
|
OUTPATIENT BENEFITS (All Subject to Deductible and Coinsurance)
|
|
Office Visits (Including Physician, Specialist Physician, Psychiatrist,
Chiropractor, Surgical Consultant, Physical or Occupational Therapist)
|
25 visits per Certificate Period per person as provided herein
|
|
Physician
|
$70 per visit
|
|
Specialist Physician
|
$70 per visit
|
|
Psychiatrist
|
$60 per visit, after 12 months of continuous coverage hereunder
|
|
Chiropractors
|
$50 per visit (must be prescribed by another non-Chiropractor Physician)
|
|
Surgical Consultant
|
$500 per consultation prior to Surgery
|
|
Physical or Occupational Therapy
|
$50 per visit (must be prescribed by a Physician who is not affiliated
with the Physical Therapy practice)
|
|
X-rays
|
$250 per exam (includes Sonograms, Ultrasounds and diagnostic Mammograms)
|
|
Laboratory
|
$300 per exam (includes all procedures carried out on one specimen)
|
|
Emergency Room
|
Usual, Reasonable and Customary for covered Illnesses if hospitalized as Inpatient and
for covered Injuries |
|
Local Ambulance
|
$1,500 per Certificate Period per person
|
|
INPATIENT or OUTPATIENT BENEFITS (All Subject to Deductible and Coinsurance)
|
|
Prescription Medications
|
Usual, Reasonable and Customary
|
|
Surgery
|
Usual, Reasonable and Customary
|
|
Assistant Surgeon
|
20% of Surgeon benefit
|
|
Anesthesiologist
|
20% of Surgeon benefit
|
|
Midwife Services
|
$500 per covered Pregnancy
|
|
MRI, CAT Scan, Echocardiography, Endoscopy, Gastroscopy, Colonoscopy
and Cystoscopy
|
$600 per exam
|
|
Chemotherapy and Radiation Therapy
|
Usual, Reasonable and Customary
|
|
WELLNESS BENEFITS (Not Subject to Deductible or Coinsurance)
|
|
Well Child (under age 19)
|
$50 per visit for a maximum of 3 visits per Certificate Period (included
in Office Visit limit), after 12 months of continuous coverage hereunder
|
|
Wellness (Adult 19+)
|
$250 per Certificate Period, after 24 months of continuous coverage hereunder,
including Office Visit for $70 and X-Ray and Lab for $180
|
|
OTHER BENEFITS (All Subject to Deductible and Coinsurance)
|
|
Durable Medical Equipment
|
Usual, Reasonable and Customary charges for Wheelchair, Hospital Bed,
and/or Toilet
|
|
Emergency Medical Evacuation
|
$50,000 Per Certificate Period
|
|
Repatriation of Remains
|
$25,000 Lifetime Maximum
|
|
Emergency Reunion
|
$5,000 Lifetime Maximum
|
"Limb" means hand, foot, or eye. The Benefit is based on age at the time of death or dismemberment.
Atlas
