International Citizens Benefits and Policy Limits

International Citizens Benefits and Policy Limits

Platinum
Premier
Optional Term Life and AD&D Insurance

BENEFIT	PLATINUM
Coverage Area	Worldwide
Overall Policy Maximum	$5,000,000 Lifetime
Deductibles Available	$250, $500, $1,000 or $2,500 per Certificate Period.
Coinsurance -- Claims incurred in US or Canada	After the dedutible, Underwriters will pay 80% of Eligible Medical Expenses up to $5,000, then 100% to the Overall Policy Maximum. The Coinsurance will be waived if expenses are incurred within the PPO.
Coinsurance -- claims incurred outside US or Canada	100% of Eligible Medical Expenses after the Deductible to the Overall Policy Maximum.
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.
Mental Health Disorders	$10,000 per Certificate Period (after 12 months of continuous coverage); $25,000 Lifetime Maximum.
Maternity -- Normal Delivery	Same as any other Illness (after 12 months of continuous coverage) including pre-natal, Delivery and post-natal care.
Maternity -- Complicated Delivery	Same as any other Illness (after 12 months of continuous coverage).
Maximum for Maternity	$50,000 Lifetime
Newborn Care	$25,000 Maximum Limit for 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.
Wellness	$50 per visit (including immunizations), maximum of 3 visits per year for children under the age of 19 (after 12 months of continuous coverage). $150 per Certificate Period (after 12 months of continuous 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.
Emergency Reunion	$10,000 Lifetime Maximum
Repatriation of Remains	$25,000 Limit
Prescription Drugs	Usual, reasonable and Customary charges. Subject to Deductible and Co-insurance
Pre-certification Penalty	50%

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Premier

BENEFIT	PREMIER
Coverage Area	Worldwide, except US and Canada
Overall Policy Maximum	$1,000,000 Lifetime
Deductibles Available	$250, $500, $1,000 or $2,500 per Certificate Period.
Coinsurance–Claims incurred in US or Canada	No coverage in US or Canada.
Coinsurance–claims incurred outside US or Canada	100% of Eligible Medical Expenses after the Deductible to the Overall Policy Maximum.
Hospital Room and Board–In US or Canada	No coverage in US or Canada.
Hospital Room and Board–Outside US or Canada	Average Private room rate.
Intensive Care Unit–In US or Canada	No coverage in US or Canada.
Intensive Care Unit–Outside US or Canada	3 times the Average Private room rate.
Mental or Nervous Disorders	$5,000 per Certificate Period (after 24 months of continuous coverage); $10,000 Lifetime Maximum.
Maternity–Normal Delivery	$3,500 per Pregnancy (after 24 months of continuous coverage) including pre-natal, Delivery and post-natal care.
Maternity–Complicated Delivery	$6,000 per Pregnancy (after 24 months of continuous coverage) including pre-natal, Delivery and post-natal care.
Maximum for Maternity	$10,000 Lifetime
Newborn Care	$5,000 Maximum Limit for maximum of 31 days.
Pre-existing Conditions	$25,000 Lifetime Maximum (after 24 months of continuous coverage).
Local Ambulance	$1,000 Lifetime Maximum.
Physical Therapy	No coverage.
Wellness	No coverage.
Human Organ/Tissue Transplants	Same as any other Illness for Covered Transplants.
All Other Eligible Expenses	Usual, Reasonable and Customary.
Emergency Medical Evacuation	No coverage.
Pre-certification Penalty	50%

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Optional Term Life Insurance and Accidental Death and Dismemberment

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.

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