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Inbound USA Travel Insurance Benefits (A to D)
Plan Overview | Benefits (A to D) | Benefits (J & K)
| Exclusions | Providers
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Rates: Plan A | Plan B | Plan C | Plan D | Plan J | Plan K
If your covered Injury or Sickness requires treatment by a physician, this program will provide benefits for the Usual and Customary (U&C) charges scheduled below which exceed the chosen Per Person Deductible ($0, $50 or $100) for each Injury and each Sickness and which are incurred within the 26 weeks following the Injury or Sickness. Payment for any covered service will not exceed the Benefit Maximum shown. The maximum amount payable for all benefits will be no more than $50,000, $75,000, $100,000, or $130,000 for each Injury and each Sickness.
Covered Services Injury & Sickness Benefit Limits
| 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 miscellaneous |
Up to $1,400/day, 30 day max |
Up to $1,675/day, 30 day max |
Up to $1,950/day, 30 day max |
Up to $2,535/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 $3,300 |
Up to $4,400 |
Up to $5,500 |
Up to $7,150 |
| Anesthetist |
Up to $825 |
Up to $1,100 |
Up to $1,375 |
Up to $1,775 |
| Assistant Surgeon |
Up to $825 |
Up to $1,100 |
Up to $1,375 |
Up to $1,775 |
| 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 $3,300 |
Up to $4,400 |
Up to $5,500 |
Up to $7,150 |
| Anesthetist |
Up to $825 |
Up to $1,100 |
Up to $1,375 |
Up to $1,775 |
| Assistant Surgeon |
Up to $825 |
Up to $1,100 |
Up to $1,375 |
Up to $1,775 |
| 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 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) |
75% of U&C to a maximum of $330 |
75% of U&C to a maximum of $440 |
75% of U&C to a maximum of $550 |
75% of U&C 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 |
| AD&D Principal Sum |
$25,000 Common Carrier |
$25,000 Common Carrier |
$25,000 Common Carrier |
$25,000 Common Carrier |
Should an insured person turn 70 during the purchased coverage period, the
70 and over benefit schedule becomes effective upon the day the insured turns
70.
Emergency Medical Evacuation Expenses
The program will pay up to $50,000 in Covered Expenses incurred if any covered Injury or Sickness originating during the Period of Coverage results in the Medically Necessary Emergency Medical Evacuation or Repatriation of the Insured Person (the Insured Person's medical condition warrants immediate transportation from the medical facility where the Insured Person is located to the nearest adequate medical facility where medical treatment can be obtained). The benefit must be ordered by the Assistance Company in consultation with the Insured Person’s local attending Physician. *
Repatriation of Mortal Remains Expenses
The program will pay the reasonable Covered Expenses incurred up to a maximum
of $7,500 to return the Insured Person's remains to his/her Home Country, if
he or she dies.*
Common Carrier Accidental Death and Dismemberment (AD&D)
Accidental Death and Dismemberment shall apply to covered accidents sustained
by an insured person while riding as a passenger in or on any land, water or
air conveyance operated under a license for the transportation of passengers
for hire. A loss must occur within 365 days after the date of accident causing
the loss:
| For Loss of: |
Indemnity
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| Life |
Principal Sum
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| Both Hands or Both Feet or Sight of Both
Eyes |
Principal Sum
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| One Hand and One Foot |
Principal Sum
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| Either Hand or Foot and Sight of One Eye |
Principal Sum
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| Either Hand or Foot |
One-Half the Principal Sum
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| Sight of One Eye |
One-Half the Principal Sum
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* NOTE: In the event of an Emergency Medical Evacuation or Repatriation of
Mortal Remains benefit is needed or utilized, arrangements must be made by the
Assistance Service Provider.
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