AZURE HEALTH INSURANCE

Transcription

1 AZURE HEALTH INSURANCE ELIGIBILITY DEDUCTIBLE Any person who resides in Latin America or the Caribbean up to 70 years of age, with guaranteed renewals Dependent children up to their 18 th birthday may remain as dependents if they are single and residing with the policyholder up to their 30 th birthday. In the event that the dependents are studying full-time outside their country of residence they may remain as a dependent until their 24 th birthday. Medical Exam is required for all proposed insureds age 65 and over. Applies per insured, per policy year, up to a maximum of two (2) deductibles per family. In case of an accident in country of residence in which the family members suffer injury only one deductible will apply. Expenses incurred during the last 90 days of the policy year not exceeding the deductible will be applied to the next policy year period. TABLE OF DEDUCTIBLES I II III IV V VI US$ 500 US$ 1,000 US$ 2,500 US$ 5,000 US$ 10,000 US$ 20,000 CO-INSURANCE ONLY APPLIES IN THE USA WAITING PERIOD TRAVEL ASSISTANCE (OPTIONAL) BENEFITS Once the deductible has been satisfied, BMI will cover up to 90% of the first US$ 5,000 per person, per policy year and of the remaining balance. coverage for accidents and infectious diseases upon effective date of the policy with a waiting period of 90 days for any other covered illness. coverage for medical emergencies or accidents incurred while outside country of residence. Insureds with deductibles of US$ 500 up to US$ 5,000: Will have a US$ 100 copay and the remaining balance will be paid at by BMI up to the policy limit. Insureds with deductibles of US$ 10,000 or US$ 20,000: Will have a US$ 100 copay up to the first US$ 5,000 of medical expenses. Expenses exceeding US$ 5,000 will be covered based on policy benefits (Deductible applies) Air ambulance Travel expenses for a companion Accommodation expenses for a companion Medical repatriation Return of minors Repatriation of mortal remains Rev. 07/2014. Available for regions 1, 2, 3, 5, 6 and 7. The information contained in this brochure is for informative purposes; please refer to policy contract for detailed benefit coverage.

2 AZURE HEALTH INSURANCE BENEFITS Maximum Coverage per Person (Per policy year) Medical and Surgical Charges Physician Fees Hospital Room and Board Intensive Care Unit Ambulatory Surgery Chemotherapy, Radiotherapy and Dialysis Laboratory Tests, X-Ray, MRI, CT Scans and Ultrasound Outpatient Services Hazardous Sports Emergency Room Physical Therapy Emergency Dental Treatment (Deductible does not apply) Local Ambulance Prescription Drugs during Hospitalization Prescription Drugs after Hospitalization/Ambulatory Surgery (90 days) Outpatient Prescription Drugs in Country of Residence Organ Transplantation (Lifetime) Living Donor Medical Benefit for Organ Resection Maternity (Deductible does not apply, Available for dependents, Available for options I, II & III) Maternity Complications, with Covered Maternity Newborn Coverage/Complications, with Covered Maternity (Lifetime) Umbilical Cord Stem Cells Preservation (Deductible does not apply, Per newborn) Congenital Conditions (Diagnosed after 90 days of birth) Permanent & Total Disability of Policyholder Medical Equipment, Prostheses and Orthopedic Devices Routine Medical Check-Up (Deductible does not apply, Policyholder and Spouse) Hospital Room Charges for Companion of Hospitalized Dependent under 18 years old (Per day, max. 10 days) Home Nursing Waiver of Premium upon Death or for Permanent & Total Disability of Policyholder Medical Treament for Accident or Emergency outside USA Network US$ 2,000,000 US$ 2,000 US$ 1,000,000 US$ 10,000 US$ 5,000 US$ 100,000 US$ 250,000 US$ 1,500 US$ 50,000 US$ 2,000 US$ 250 US$ days 2 years US$ 25,000 ADDITIONAL COVERAGE RIDERS (OPTIONAL) Travel Assistance Term Life Insurance (US$ 50,000 or US$ 100,000) The Protector (Permanent and Total Disability) Hospital Income Benefit Accidental Death and Dismemberment Insurance (AD&D) TEMPORARY EMERGENCY COVERAGE US$ 25,000 for covered medical expenses resulting from an accidental bodily injury from the date in which the application and full premium are received, until: (a) the effective date of the policy or (b) sixty (60) days from the date in which such application was received in BMI. WORLDWIDE COVERAGE AND GUARANTEED RENEWALS

3 ARIZONA ARIZONA HEART HOSPITAL BANNER DEL E. WEBB MEDICAL CENTER BANNER DESERT MEDICAL CENTER JOHN C. LINCOLN HOSP. DEER VALLEY NORTHWEST MEDICAL CENTER PHOENIX CHILDRENS HOSPITAL SIERRA VISTA REGIONAL HEALTH CTR ST JOSEPHS HOSPITAL & MED CTR TUCSON MEDICAL CENTER UNIVERSITY MEDICAL CENTER CALIFORNIA ALTA BATES SUMMIT MED CTR BROTMAN MEDICAL CENTER CALIF PACIFIC MEDICAL CENTER CHILDRENS HOSPITAL OAKLAND CHILDRENS HOSPITAL ORANGE CITY DOMINICAN SANTA CRUZ HOSPITAL EL CENTRO REGIONAL MEDICAL CTR EL CAMINO HOSPITAL ENCINO TARZANA REGIONAL FALLBROOK HOSPITAL GOOD SAMARITAN HOSPITAL HENRY MAYO NEWHALL MEMORIAL HOLLYWOOD PRESBYTERIAN MED CTR IRVINE MEDICAL CENTER LITTLE COMPANY OF MARY HOSPITAL LOMA LINDA UNIVERSITY MED CTR LONG BEACH MEMORIAL MED CTR MERCY HOSPITAL MISSION HOSPITAL REGIONAL MED CTR NORTHRIDGE HOSPITAL MED CTR ROSCOE O CONNOR HOSPITAL PACKARD CHILDRENS HOSPITAL PROVIDENCE ST. JOSEPH MED CTR PROVIDENCE TARZANA MED CTR REGIONAL MEDICAL CENTER OF SAN JOSE SAN ANTONIO COMMUNITY HOSPITAL SCRIPPS GREEN HOSPITAL SETON MEDICAL CENTER SIMI VALLEY HOSP AND HEALTHCARE SERVICE ST. AGNES MEDICAL CENTER ST. JOHNS HOSPITAL AND HEALTH CTR ST. ROSE HOSPITAL ST VINCENT MEDICAL CENTER STANFORD MEDICAL CENTER SUTTER MEMORIAL HOSPITAL TRI CITY MEDICAL CENTER TORRENCE MEMORIAL MEDICAL CENTER UCLA MEDICAL CENTER UCSF MEDICAL CENTER UNIVERSITY OF CALIF. IRVINE MEDICAL CTR USC UNIVERSITY HOSPITAL 1

4 FLORIDA ARNOLD PALMER HOSPITAL FOR CHILDREN AVENTURA HOSPITAL AND MEDICAL CTR BAPTIST MED CTR BEACHES JACKSONVILLE BAYFRONT MEDICAL CENTER BETHESDA MEMORIAL HOSPITAL BLAKE MEDICAL CENTER BOCA RATON COMMUNITY HOSPITAL BRANDON REGIONAL HOSPITAL BROWARD GENERAL MEDICAL CENTER CAPE CORAL HOSPITAL CENTRAL FLORIDA REGIONAL HOSPITAL CLEVELAND CLINIC FLORIDA HEALTH SYS CORAL GABLES HOSPITAL CORAL SPRINGS MEDICAL CENTER DELRAY MEDICAL CENTER DOCTORS HOSPITAL OF SARASOTA ENGLEWOOD COMMUNITY HOSPITAL FLORIDA HOSPITAL OCEANSIDE FLORIDA MEDICAL CENTER GOOD SAMARITAN MEDICAL CENTER HEART OF FLORIDA REGIONAL MED CTR HIGHLANDS REGIONAL MED CTR HOLMES REGIONAL MED CENTAR IMPERIAL POINT MEDICAL CENTER INDIAN RIVER MEMORIAL HOSPITAL JACKSON MEMORIAL HOSPITAL JFK MEDICAL CENTER JUPITER MEDICAL CENTER KENDALL REGIONAL MEDICAL CENTER MANATEE MEMORIAL HOSPITAL MARTIN MEMORIAL MEDICAL CTR MEMORIAL HOSPITAL PEMBROKE METROPOLITAN HOSPITAL OF MIAMI MIAMI CHILDRENS HOSPITAL MOUNT SINAI MED CTR/ MIAMI HEART NORTH BROWARD MEDICAL CENTER NORTH FLORIDA REGIONAL MED CTR NORTH RIDGE MEDICAL CENTER ORLANDO REGIONAL MEDICAL CTR PALM BEACH GARDENS MED CTR PALMS OF PASADENA HOSPITAL PALMETTO GENERAL HOSPITAL PEACE RIVER REGIONAL MED CTR PLANTATION GENERAL HOSPITAL SARASOTA MEMORIAL HOSPITAL SHANDS AT AGH SHANDS AT THE UNIVERSITY OF FLORIDA SHANDS JACKSONVILLE MED CTR SUN COAST HOSPITAL UNIVERSITY COMMUNITY HOSPITAL UNIVERSITY COMMUNITY HOSP CARROLLWOOD UNIVERSITY OF MIAMI CLINIC SYLVESTER UNIVERSITY OF MIAMI HOSPITAL WELLINGTON REGIONAL MEDICAL CTR WEST BOCA MEDICAL CENTER WESTSIDE REGIONAL MEDICAL CENTER 2

5 IOWA MERCY HOSPITAL ST. LUKES HOSPITAL UNIVERSITY OF IOWA HOSPITAL MARYLAND UNIVERSITY OF MARYLAND MED CTR MASSACHUSETTS BOSTON MEDICAL CENTER LAHEY CLINIC HOSPITAL LAWRENCE GENERAL HOSPITAL NEW ENGLAND MEDICAL CENTER TUFTS MEDICAL CENTER HOSPITAL UMASS MEMORIAL MEDICAL CENTER MINNESOTA REGIONS HOSPITAL MINNEAPOLIS REGIONS HOSPITAL ST. PAUL NEVADA BATTLE MOUNTAIN HOSPITAL NORTHEAST NEVADA REGIONAL HOSP NEW YORK ALBANY MEDICAL CENTER HOSPITAL CITY HOSPITAL CENTER ELMHURST CROUSE HOSPITAL LENOX HILL HOSPITAL LONG ISLAND JEWISH MEDICAL CTR NEW YORK DOWNTOWN HOSPITAL NEW YORK METHODIST HOSPITAL NYP WEILL CORNELL NYU HOSPITAL CENTER NYU HOSPITAL CENTER TISCH PARKWAY HOSPITAL ST LUKES ROOSEVELT HOSPTAL CTR ST VINCENT MEDICAL CENTER UNIVERSITY HOSP OF BROOKLYN WESTCHESTER MEDICAL CENTER NORTH CAROLINA DUKE UNIVERSITY HOSPITAL LESINGTON MEMORIAL HOSPITAL REX HOSPITAL OREGON LEGACY EMANUEL HOSPITAL PROVIDENCE PORTLAND MEDICAL CTR TUALITY COMMUNITY HOSPITAL 3

6 SOUTH CAROLINA BON SECOURS ST FRANCIS XAVIER MEDICAL UNIVERSITY OF SO. CAROLINA PROVIDENCE HOSPITAL TENNESSEE BAPTIST HOSPITAL GATEWAY MEDICAL CENTER NASHVILLE GENERAL HOSPITAL TEXAS APEX HOSPITAL KATY BAPTIST MEDICAL CENTER CHCA WOMENS HOSPITAL OF TEXAS CHRISTUS ST CATHERINE HOSPITAL CHRISTUS ST MICHAEL HEALTH CARE CLEAR LAKE REGIONAL MEDICAL CTR COLLEGE STATION MEDICAL CENTER CORPUS CHRISTI MED CTR / BAY AREA CORPUS CHRISTI / DOCTORS REGIONAL CYPRESS FAIRBANKS MEDICAL CTR DOCTORS HOSPITAL AT RENAISSANCE FOUNDATION SURGICAL HOSPITAL HOUSTON NORTHWEST MED CTR KINGWOOD MEDICAL CENTER LAS PALMAS MEDICAL CENTER MD ANDERSON CANCER CENTER MEDICAL CENTER OF ARLINGTON MEDICAL CENTER OF PLANO MEDICAL CITY DALLAS HOSPITAL METHODIST HEALTH CTR SUGARLAND METHODIST HOSPITAL MHHS KATY HOSPITAL NORTH AUSTIN MEDICAL CENTER NORTH CENTRAL BAPTIST HOSPITAL OAKBEND MEDICAL CENTER PARK PLAZA HOSPITAL PROVIDENCE MEMORIAL HOSPITAL RIO GRANDE REGIONAL HOSPITAL SCOTT & WHITE MEMORIAL HOSPITAL SIERRA MEDICAL CENTER SIERRA PROVIDENCE EAST MED CTR ST DAVIDS HOSPITAL ST JOSEPH MEDICAL CENTER ST JOSEPH REGIONAL HEALTH CENTER ST LUKES BAPTIST HOSPITAL ST LUKES COMMUNITY MED CTR THE WOODLANDS ST LUKES EPISCOPAL HOSPITAL ST LUKES THE WOODLANDS TEXAS CHILDRENS HOSPITAL TEXAS HEALTH DALLAS TEXAS HEALTH PRESBYTERIAN HOSPITAL PLANO TEXAS ORTHPEDIC HOSPITAL TEXSAN HEART HOSPITAL THOMASON GENERAL HOSPITAL 4

7 TEXAS UNIVERSITY HEALTH SYSTEM UT SOUTHWESTERN ST PAUL HOSPITAL UT SOUTHWESTERN ZALE LIPSHY HOSPITAL VALLEY BAPTIST MED CTR BROWNSVILLE WEST HOUSTON MEDICAL CENTER WOMANS HOSPITAL OF TEXAS UTAH MCKAY-DEE HOSPITAL CENTER WASHINGTON OVERLAKE HOSPITAL MEDICAL CENTER HARBOR VIEW MEDICAL CENTER UNIVERSITY OF WASHINGTON MEDICAL CTR * This provider list is modified periodically, for an updated list please see the options under Network on our webpage For those states not included on this list, the insured can visit any hospital within the United Healthcare Network. 5