Deductibles
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$0, $100, $250, $500, $1,000 or $2,500 per Certificate Period
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Coinsurance – Claims incurred in US or Canada:
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For the Certificate Period, Underwriters will pay 80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit
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Coinsurance – Claims incurred outside US or Canada:
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For the Certificate Period, Underwriters will pay 100% of Eligible Expenses after the Deductible up to the Overall Maximum Limit
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Hospital Room and Board:
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Average Semi-private room rate, including nursing services
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Local Ambulance:
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Usual, Reasonable and Customary charges
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Hospital Indemnity:
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$100 per day (not subject to Deductible or Coinsurance)
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Intensive Care Unit:
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Usual, Reasonable and Customary charges
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Outpatient Treatment:
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Usual, Reasonable and Customary charges
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Acute Onset of Pre-existing Condition:
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$15,000 limit per Certificate Period for Eligible Medical Expenses; $25,000 limit per Certificate Period for Emergency Medical Evacuation (only available to members under age 70)
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Physical Therapy:
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$50 per visit
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All Other Eligible Medical Expenses:
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Usual, Reasonable and Customary charges
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Emergency Dental:
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Accident – Overall Maximum Limit Acute Onset of Pain – $100 limit per Certificate Period
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Emergency Medical Evacuation:
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$500,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing Condition (not subject to Deductible or Coinsurance)
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Emergency Reunion:
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$15,000 limit per Certificate Period
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Return of Minor Children:
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$5,000 limit per Certificate Period
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Terrorism:
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$50,000 Maximum Lifetime Limit, Medical Expenses only
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Accidental Death and Dismemberment:
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Principal Sum: $25,000 Adults age 18-69; $12,500 Adults age 70-74; $6,250 Adults age 75 and above;
$5,000 Children age 17 and below (not subject to Deductible or Coinsurance)
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Common Carrier Accidental Death:
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$50,000 per adult, $25,000 children under age 18; $250,000 Maximum per family (not subject to Deductible or Coinsurance)
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Repatriation of Remains:
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Overall Maximum Limit (not subject to Deductible or Coinsurance)
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Trip Interruption:
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$5,000 limit per Certificate Period (not subject to Deductible or Coinsurance)
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Lost Checked Luggage:
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$250 limit per Certificate Period (not subject to Deductible or Coinsurance) (not subject to Deductible or Coinsurance)or following a disaster strike
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Natural Disaster Benefit
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Up to $100 a day for 5 days when Displaced from planned, paid accommodations due to evacuation from forecasted disaster or following a disaster strike
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Hospital Pre-Notification Penalty:
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50% of Eligible Medical Expenses
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Optional Hazardous Sports Rider:
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Overall Maximum Limit
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Overall Maximum Limit per Certificate Period (includes all benefits except Accidental Death and Dismemberment and Common Carrier Accidental Death):
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Age 14 days to 69 – $50,000, $100,000, $500,000 or $1,000,000; Age 70 to 79 – $50,000; Age 80 or older – $10,000
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