Total Plus Schedule of Benefits Below is a brief summary of benefits offered to eligible insureds under the IMG Maestro SM Total Plus plan option.
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1 Total Plus Schedule of s Below is a brief summary of benefits offered to eligible insureds under the IMG Maestro SM Total Plus plan option. Limit/Other Maximum Limit $8,000,000 per period of coverage Area of Coverage Deductible Coinsurance (Percent insured is responsible after Deductible is met) Hospital Room & Board Worldwide $800, $1,800, $2,800, $4,000, or $9,000 per insured per Period of Coverage. NOTE: Deductible reduced by 50% up to $2,500 for treatment outside the USA For treatment outside USA/Canada. 0% For treatment within the USA/Canada within PPO Network 0% For treatment within USA/Canada outside PPO Network 20% of eligible medical expenses up to $5,000, then 0% Inpatient s 100% private or semi-private room rate Intensive Care 100% Anesthetist s Charges Associated with Diagnostic Procedures 100% Prescription Medication 100% Transplant Expense Parental Hospital Accommodations $2,000,000 lifetime maximum. $35,000 lifetime maximum for donor preparation for eligible covered transplants $500 per night, maximum 10 nights Physical Therapy and Rehabilitation 100% Outpatient s Physician and Specialist visits 100% Diagnostic Procedures 100% Prescription Medication Physical Therapy and Rehabilitation Wellness 100% if outside the U.S.A, 80% if within the U.S.A. 100%. Maximum 60 daily visits $500 per period of coverage. $250 allowed during initial 6-months of coverage. Not subject to deductible Maternity s Maternity Complications of Pregnancy Cord Bank (i.e. Stem Cells) Coverage For Newborns $10,000 maximum per pregnancy after 12 months of continuous coverage. Not subject to deductible $1,000,000 lifetime maximum after 12 months of continuous coverage $2,000 maximum per covered pregnancy Included during the first 31 days after birth and covered pregnancy after 12 months of mother s continuous coverage
2 Evacuation s Emergency Medical Evacuation Return of Mortal Remains/ Cremation Political Evacuation Congenital and/or Hereditary Conditions Other s Limit $50,000 lifetime maximum. Not subject to deductible $10,000 lifetime maximum. Not subject to deductible $500,000 lifetime maximum limit when diagnosed prior to age % when diagnosed at age 18 or older Chemotherapy and Radiation Therapy 100% Dialysis Mental and Nervous Local Ambulance Hospice Care 100% for acute renal failure only $100,000 lifetime maximum after 12 months of continuous coverage. Inpatient: $25,000 maximum per period of coverage. Outpatient: 30 visits maximum per period of coverage $15,000 lifetime maximum Durable Medical Equipment 100% Adventure Sports & non-collision Sports Complementary Medicine HIV/AIDS 100%. Additional $250 deductible for orthopedic injuries 100%. Maximum 20 visits $500,000 lifetime maximum after 24 months of continuous coverage Home Nursing Care 100% Terrorism Emergency Room Extended Coverage For Dependents when Primary Insured Dies $50,000 lifetime maximum. Not subject to deductible or coinsurance 100%. Additional $250 deductible if in the U.S.A. and not admitted as inpatient to the hospital as a result of illness Premium waived for existing dependent coverage for 2 years Dental s Limit/Amount for Eligible Expenses Dental Emergency (Accident only) 100% $750 after 6 months of continuous coverage. Dental deductible: $50 Dental Care Expenses Class I Services Class II Services Class III Service 90%. Deductible waived 70% after deductible 50% after deductible This invitation to inquire allows eligible applicants an opportunity to inquire further about the insurance offered and is limited to a brief description of any loss for which benefits may be payable. Coverage is issued and underwritten by International Medical Insurance Company, Ltd. s are offered as described in the insurance contract. s are subject to all deductibles, coinsurance, provisions, terms, conditions, limitations, and exclusions in the insurance contract. The contract does contain a pre-existing condition exclusion and does not cover losses or expenses related to a pre-existing condition. If disclosed in the application and no treatment is received or symptoms are experienced within 5 years prior to effective date, charges are excluded until after 30 days of coverage. If disclosed in the application and treatment was received and/or symptoms were experienced within 5 years prior to effective date, charges are excluded until after 24 months of coverage.
3 Total Schedule of s Below is a brief summary of benefits offered to eligible insureds under the IMG Maestro SM Total plan option. Limit/Other Maximum Limit Area of Coverage Deductible Coinsurance (Percent insured is responsible after Deductible is met) $4,000,000 per period of coverage Worldwide $800, $1,800, $2,800, $4,000, or $9,000 per insured per Period of Coverage. NOTE: Deductible reduced by 50% up to $2,500 for treatment outside the USA For treatment outside USA/Canada. 0% For treatment within the USA/Canada within PPO Network 0% For treatment within USA/Canada outside PPO Network 20% of eligible medical expenses up to $5,000, then 0% Hospital Room & Board Inpatient s 100% private or semi-private room rate Intensive Care 100% Anesthetist s Charges Associated with Diagnostic Procedures 100% Prescription Medication 100% Transplant Expense Parental Hospital Accommodations $250,000 lifetime maximum. $35,000 lifetime maximum for donor preparation for eligible covered transplants $200 per night, maximum 10 nights Physical Therapy and Rehabilitation 100% Outpatient s Physician and Specialist visits 100% Diagnostic procedures 100% Prescription Medication $7,000 maximum. 100% if outside the U.S.A., 80% if within the USA Physical Therapy and Rehabilitation Wellness $75 per daily visit, maximum 60 visits $500 maximum per period of coverage. $250 allowed during initial 6-months of coverage. Not subject to deductible Maternity s Maternity Complications of Pregnancy Coverage For Newborns Available after 12 months of continuous coverage. $50,000 lifetime maximum. $5,000 per normal pregnancy, $7,500 for C-section. $250,000 lifetime maximum after 12 months of continuous coverage Included during the first 31 days after birth and covered pregnancy after 12 months of mother s continuous coverage Evacuation s Emergency Medical Evacuation Return of Mortal Remains/ Cremation Limit $150,000 lifetime maximum. Not subject to deductible $25,000 lifetime maximum. Not subject to deductible
4 Other s Congenital and/or Hereditary Conditions $250,000 lifetime maximum limit when diagnosed prior to age 18. $1,000,000 lifetime maximum when diagnosed at age 18 or older Chemotherapy and Radiation Therapy 100% Dialysis Mental and Nervous Local Ambulance Hospice Care 100% for acute renal failure only $50,000 lifetime maximum after 12 months of continuous coverage. Inpatient: $10,000 maximum per period of coverage. Outpatient: $50 maximum per visit, 10 visits maximum per period of coverage $10,000 lifetime maximum Durable Medical Equipment 100% Adventure Sports and non-collision sports Complementary Medicine HIV/AIDS Home Nursing Care Emergency Room Extended Coverage For Dependents when Primary Insured Dies 100%. Additional $750 deductible for orthopedic injuries 100%. Maximum 10 visits $100,000 lifetime maximum after 24 months of continuous coverage 100%. 60 days maximum 100%. Additional $250 deductible if in the U.S.A. and not admitted inpatient to the hospital as a result of illness Premium waived for existing dependent coverage for 1 year Dental s Dental Emergency (Accident only) 100% This invitation to inquire allows eligible applicants an opportunity to inquire further about the insurance offered and is limited to a brief description of any loss for which benefits may be payable. Coverage is issued and underwritten by International Medical Insurance Company, Ltd. s are offered as described in the insurance contract. s are subject to all deductibles, coinsurance, provisions, terms, conditions, limitations, and exclusions in the insurance contract. The contract does contain a pre-existing condition exclusion and does not cover losses or expenses related to a pre-existing condition. If disclosed in the application and no treatment is received or symptoms are experienced within 5 years prior to effective date, charges are excluded until after 30 days of coverage. If disclosed in the application and treatment was received and/or symptoms were experienced within 5 years prior to effective date, charges are excluded until after 24 months of coverage.
5 Vital Schedule of s Below is a brief summary of benefits offered to eligible insureds under the IMG Maestro SM Vital plan option. Limit/Other Maximum Limit Area of Coverage Deductible Coinsurance (Percent insured is responsible after Deductible is met) Hospital Room & Board $8,000,000 per period of coverage Worldwide $1,800, $2,800, $4,000, $9,000 or $18,000 per insured per Period of Coverage. NOTE: Deductible reduced by 50% up to $2,500 for treatment outside the USA For treatment outside USA/Canada. 0% For treatment within the USA/Canada within PPO Network 0% For treatment within USA/Canada outside PPO Network 20% of eligible medical expenses up to $5,000, then 0% Inpatient s 100% private or semi-private room rate Intensive Care 100% Anesthetist s Charges Associated with Prescription Medication Transplant Expense Parental Hospital Accommodations 100%. Maximum 30 day supply per prescription $2,000,000 lifetime maximum. $35,000 lifetime maximum for donor preparation for eligible Covered Transplants $500 per night, maximum 10 nights Physical Therapy and Rehabilitation 100% Chemotherapy and Radiation Therapy 100% Durable Medical Equipment 100% Diagnostic Treatment 100% Dialysis Hospice Care HIV/AIDS 100% for acute renal failure only $15,000 lifetime maximum $500,000 lifetime maximum after 24 months of continuous coverage Adventure Sports & non-collision Sports 100% Emergency Room 100% if admitted as Inpatient Outpatient s Continuing Treatment of Illness or Injury when Inpatient Treatment was Received $2,000 maximum per period of coverage. Limited to 90 days of Outpatient Treatment immediately before and after related Inpatient Treatment.
6 Evacuation s Emergency Medical Evacuation Return of Mortal Remains/ Cremation Political Evacuation Limit $50,000 lifetime maximum. Not subject to deductible $10,000 lifetime maximum. Not subject to deductible Other s Local Ambulance Terrorism Extended Coverage For Dependents when Primary Insured Dies $50,000 lifetime maximum. Not subject to deductible or coinsurance Premium waived for existing dependent coverage for 2 years This invitation to inquire allows eligible applicants an opportunity to inquire further about the insurance offered and is limited to a brief description of any loss for which benefits may be payable. Coverage is issued and underwritten by International Medical Insurance Company, Ltd. s are offered as described in the insurance contract. s are subject to all deductibles, coinsurance, provisions, terms, conditions, limitations, and exclusions in the insurance contract. The contract does contain a pre-existing condition exclusion and does not cover losses or expenses related to a pre-existing condition. If disclosed in the application and no treatment is received or symptoms are experienced within 5 years prior to effective date, charges are excluded until after 30 days of coverage. If disclosed in the application and treatment was received and/or symptoms were experienced within 5 years prior to effective date, charges are excluded until after 24 months of coverage.
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