|
Platinum Schedule of Benefits:
| Benefit |
IC Platinum |
| Overall Maximum Limit |
$5,000,000 Lifetime |
| Deductibles Available |
$250, $500, $1,000, $2,500 or $5,000 per Certificate Period |
| Family Deductible |
Maximum of 3 Deductibles per family per Certificate Period |
| Coinsurance -- Claims incurred in US or Canada |
80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit. The Coinsurance will be waived if expenses are incurred within the PPO |
| Coinsurance -- claims incurred outside US or Canada |
100% of Eligible Expenses after the Deductible to the Overall Maximum Limit |
| Hospital Room and Board -- In US or Canada |
Average Semi-private room rate |
| Hospital Room and Board -- Outside US or Canada |
Average Private room rate |
| Intensive Care Unit -- In US or Canada |
Usual, Reasonable and Customary |
| Intensive Care Unit -- Outside US or Canada |
Usual, Reasonable and Customary |
| Prescription Drugs |
Usual, Reasonable and Customary Subject to Deductible and Coinsurance |
| Mental Health Disorders |
$10,000 per Certificate Period, $25,000 Lifetime Maximum, $50 Maximum per visit per day for outpatient care (after 12 months of continuous coverage) |
| Maternity -- Normal Delivery |
After the Deductible, Underwriters will pay 50% of the next $100,000 of Eligible Medical Expenses, then 100% to a Lifetime Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery, and post-natal care (after 12 months of continuous coverage) |
| Maternity -- Complicated Delivery |
After the Deductible, Underwriters will pay 50% of the next $100,000 of Eligible Medical Expenses, then 100% to a Lifetime Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery, and post-natal care (after 12 months of continuous coverage) |
| Maximum for Maternity |
$250,000 Lifetime |
| Newborn Care |
Included as part of Maternity benefits for a maximum of 31 days |
| Pre-existing Conditions |
Same as any other Injury or Illness if disclosed on Application and not excluded or limited by Rider |
| Local Ambulance |
Usual, Reasonable and Customary |
| Physical Therapy |
$50 Maximum per visit per day |
| Wellness |
$50 per visit (including immunizations), maximum of three visits per year for children under the age of 19 (after 12 months of continuous coverage). $250 per Certificate Period (after 12 months of continuos coverage) for Members age 35 or older. Not Subject to Deductible |
| Human Organ/Tissue Transplants* |
Same as any other Illness for Covered Transplants |
| All Other Eligible Expenses |
Usual, Reasonable and Customary |
| Emergency Medical Evacuation |
$50,000 Lifetime Maximum |
| Repatriation of Remains |
$25,000 Limit |
| Emergency Reunion |
$10,000 Lifetime Maximum |
| Pre-notification Penalty |
50% |
| *Covered transplants include Heart/Lung, Lung, Kidney/Pancreas, Liver and Allogenic and Autologous Bone Marrow. |
Plan Features:
Wellness:
If you are insured under the Platinum Plan, after 12 months of continuous coverage, you may be eligible for Wellness benefits that are not subject to the deductible. If you are at least 35 years old, you will be entitled to the following Wellness benefit: $250 per Certificate Period for a routine physical exam, including mammogram and OB/GYN visits for females. If you are under the age of 19, you will be entitled to the following Wellness benefit: $50 per visit (including immunizations) with a maximum of three visits per Certificate Period.
Emergency Medical Evacuation:
If you are insured under the Platinum Plan, you are covered for Emergency Medical Evacuation to the nearest medical facility qualified to treat your life-threatening condition or potential loss of limb. All Emergency Medical Evacuations must be approved in advance and coordinated by MultiNational Underwriters®. Emergency Medical Evacuations provide you with access to care when you need it most. MultiNational Underwriters® is available 24 hours a day, 7 days a week, to approve and coordinate Emergency Medical Evacuations.
Emergency Reunion:
In the event of a covered Emergency Medical Evacuation, the Platinum Plan will provide the following benefits: the cost of an economy round-trip air and/or ground transportation ticket for one of your relatives (parent, spouse, sibling or child age 18 or older) for transportation to the area where you are hospitalized following Emergency Medical Evacuation, and reasonable expenses for lodging and meals for your relative for a period not to exceed 15 days.
Repatriation of Remains:
In the event of a covered Injury or Illness resulting in your death, the Platinum Plan will provide the following benefit: air or ground transportation of bodily remains or ashes to the area of your Principal Residence and reasonable cost of preparation of your remains necessary for transportation.
Optional Dental Insurance:
The Optional Dental Rider provides important benefits for families including Preventative care for children and Basic and Major Dental benefits for both children and adults. Preventative benefits include routine oral exams and x-rays, cleaning and fluoride treatments. Basic benefits include Periodontics, Endodontics, Extractions and Fillings. Major benefits include crowns, bridges and dentures. The International Citizen Optional Dental Rider is a must for families as well as individuals. Coverage is provided worldwide at your choice of dentists. The Optional Dental Insurance Rider is available with both the Platinum and Premier plans.
Optional Sports Rider:
The Optional Sports Rider is a must-have addition for your extreme sports lifestyle. Whether your interests include mountaineering, skydiving, or whitewater rafting, electing the Sports Rider option will add coverage up to a lifetime maximum of $25,000 for these activities excluded by the standard plan. Coverage for contact sports, such as soccer or hockey, is added up to a lifetime maximum of $5,000. The Sports Rider adds coverage for sports and athletics except those activities engaged in for wage, reward, or profit.
International Citizen Assistance Services:
All Assistance Services are available to you 24 hours a day, 7 days a week while your International Citizen Plan is in effect.
Pre-Trip Health and Safety Advisories (available after your purchase of the International Citizen Series and before your departure) - Call us for current passport, visa, inoculation and vaccine requirements, as well as up-to-date travel safety advisories.
Livetravel Services - We will make emergency travel and itinerary changes for you including rebooking flights, hotel reservations and ground transportation arrangements.
BagTrak - We are the industry leaders in tracking lost checked baggage. We will help you locate your lost checked baggage and deliver it to you anywhere in the world.
Emergency Message Relay - We will relay messages to your family, friends and co-workers, helping you to maintain contact during an emergency.
Emergency Cash Transfers - We will assist you in arranging and obtaining cash transfers anywhere in the world.
International Citizen Assistance Services also include:
- Medical referrals
- Up-to-the-minute travel medical advisories
- Assistance with prescription drug replacement
- Dispatch of a doctor or specialist
- Emergency travel arrangements for family members
- Lost passport or travel documents assistance
- Embassy and consulate referrals
- Legal and accounting referrals
- Bail bond assistance
- Translation and interpretation assistance
International Citizen Assistance Services are not insurance benefits, and provision of any International Citizen Assistance Services is not a guarantee of any other benefit under the International Citizen Series.
Optional Term Life and ADD Insurance:
Age |
Basic Life Principal Sum |
Supplemental Life Principal Sum |
19 to 59 |
$50,000 |
$50,000 |
60 to 64 |
$25,000 |
$25,000 |
65 to 69 |
$10,000 |
Not Available |
Dependent Child |
$5,000 |
Not Available |
Accidental Death |
Principal Sum |
Accidental Loss of Two Members |
Principal Sum |
Accidental Loss of One Member |
50% of Principal Sum |
The Benefit is based on your age at time of Death or Dismemberment. "Member" means hand, foot or eye.
Optional Dental Rider:
|
Year 1 |
Year 2 |
Year 3 |
Preventative Dental Benefits Children age 9 through 16 (after 3 months of continuous coverage) |
100% |
100% |
100% |
Basic Dental Benefits (after 6 months of continuous coverage) |
50% |
65% |
80% |
Major Dental Benefits (after 6 months of continuous coverage) |
30% |
40% |
50% |
Dental Deductible |
$100.00 per Certificate Period |
$100.00 per Certificate Period |
$100.00 per Certificate Period |
Maximum Dental Benefits |
$500.00 per Certificate Period |
$750.00 per Certificate Period |
$1,000.00 per Certificate Period |
|
International Citizens
