Highest level of coverage with free-choice of hospitals and physicians worldwide, including the richest maternity and organ transplant benefits.

Transcription

1 Highest level of coverage with free-choice of hospitals and physicians worldwide, including the richest maternity and organ transplant benefits.

2 Global Superior is tailored exclusively for individuals and families residing in Latin America and the Caribbean who seek the highest level of comprehensive international health insurance with an open medical provider network. The plan offers a range of deductibles for members and provides coverage for inpatient care, outpatient care, emergencies, preventive care, plus a pharmacy benefit and more. As with all GBG plans, Global Superior includes the world-class services of GBG Assist for case management and evacuations, if necessary, anywhere in the world any time of day. GBG Assist services include a vast network of medical facilities that will bill GBG directly, eliminating the need for a member to pay up-front for services. When a claim does need to be filed, GBG offers state-of-the-art claims submission and reimbursement options through its website, This process makes claims reimbursement simple, fast and easy. Global Superior also includes the GBG Personal Medical Advisor, one of the world s leading Medical Second Opinion services. Geographic Coverage Areas Global Superior provides worldwide coverage with an open network, including access to a U.S. Preferred Provider Network containing more than 5,000 hospitals and 550,000 providers. This extensive geographic coverage area and use of provider networks allow GBG to provide first-class worldwide coverage while maintaining affordable rates.

3 Worldwide: Free choice of providers. Private/Semi-private room Intensive Care Unit (medically necessary) Global Superior Schedule of Benefits Medical treatment, medicines, laboratory and diagnostic tests (including cancer treatment, chemotherapy/radiotherapy) HOSPITALIZATION BENEFITS, U.S. Out-of-Network: $2,000 Maximum/day U.S. Out-of-Network: $4,000 Maximum/day Inpatient Consultation by a Physician or Specialist Inpatient Surgery/Inpatient Surgeon Extended Care / Inpatient Rehabilitation (Must be confined to facility immediately following a Hospital stay) Private Duty Nursing Accommodation charges for companion of a hospitalized child Guest Meals $500 per day/ Maximum 10 days $50 per day/ Maximum 10 days Inpatient Psychiatric and Psychotherapist Consultation OUTPATIENT BENEFITS Outpatient Physician/Specialist Visit ; Policy Year Maximum 60 visits Echocardiography, Ultrasound, CAT Scan, PET Scan, MRI, Endoscopy (e.g., gastroscopy, colonoscopy, cystoscopy), X-rays and Laboratory PROVIDER NETWORK MAXIMUM BENEFIT Policy Year Maximum of $10,000,000 ANNUAL DEDUCTIBLES Plan In Country of Residence Out of Country of Residence Plan In Country of Residence Out of Country of Residence Plan 1 N/A N/A Plan 4 $5,000 $5,000 Plan 2 $1,000 $2,000 Plan 5 $10,000 $10,000 Plan 3 $2,000 $3,000 Plan 6 $20,000 $20,000 Family Maximum Deductible: 2 x Individual Deductible Outpatient Surgery, medical and nursing fees Outpatient Dialysis Physical Therapy and Rehabilitation Services Complementary Therapy: Osteopathic, Chiropractic, Podiatric, Psychiatric, Short Term Speech and Homeopathic Preventive Care, Annual Exams & Immunizations for children (six months or older) and adults ; Policy Year Maximum 80 visits, all therapies combined $600 maximum per Insured, per Policy Year; Deductible waived Prescribed medication following a covered hospitalization or outpatient surgery Prescribed medication following a covered outpatient treatment EMERGENCIES ; Deductible waived for period Serious Accident Hospitalization (24 hours or more) of first hospitalization only Ground Ambulance This is only a brief summary of key Plan provisions. Please refer to the Policy for complete details. Benefits are per person per policy year and are based upon medical necessity and Usual, Customary and Reasonable (UCR) charges, after Annual Deductible. Currency: USD.

4 EMERGENCIES (CONTINUED) Air Ambulance Per Event Maximum $175,000 Non-Emergency Use of the Emergency Room in the U.S. 50% Emergency Room Emergency Medical Services Emergency Dental Care - Limited to accidental injury of sound, natural teeth. Services must be completed within 120 days of accident. CATASTROPHIC CONDITIONS Cancer Treatment (including chemotherapy/radiotherapy) Congenital and Hereditary Conditions Transplant Procedures (in the U.S. Institutes of Excellence facilities approved by GBG only) OTHER BENEFITS ; $2,000,000 Lifetime Maximum per diagnosis including Donor expenses and Donor procurement expenses up to $60,000 Repatriation of Mortal Remains Maximum Per Insured $75,000 Home Health Care; Private Duty Nursing, Skilled Nursing, Visiting Nurse, Home Health Nursing Special Treatments (prosthesis, implants, appliances, and orthotic devices, durable medical equipment, radiation therapy, chemotherapy, and highly specialized drugs) Hospice Care Durable Medical Equipment Prosthetic limbs Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC). 24 month waiting period applies. Benefit is not covered if condition was diagnosed a pre-existing condition. $50,000 Policy Year Maximum; $200,000 Lifetime Maximum ; $50,000 Lifetime Maximum War and Terrorism Benefit Professional Sports Term Life Insurance/Mortal Benefit - Coverage terminates at the end of the Policy period following attainment of age % Deductible Reduction Benefit (on the 4th Policy Year after 3 consecutive years without paid claims and no change in policy deductible) MATERNITY BENEFITS (INCLUDED UNDER PLANS 2 & 3 ONLY) $30,000 Policyholder; $7,500 Spouse; $1,000 per Dependent Plans 2, 3 and 4 only Benefit for Insured, including prenatal care and postnatal care. Any fertility/infertility services, tests, treatments, drugs and/or procedures, including the resulting pregnancy, complications of that pregnancy, prenatal and postpartum care are excluded from coverage, but the delivery (Normal Delivery or C-Section) is covered up to the benefit limit. A 10 month waiting period applies; no maternity related treatment for the mother or newborn is covered during this period If only the mother is covered in the policy: Normal Delivery or C-Section If both the mother and the father are covered in the policy: Normal Delivery or C-Section Complications of Pregnancy and Premature birth (provided the child was born under a pregnancy covered through the maternity benefit) $10,000 Benefit Maximum per Pregnancy $15,000 Benefit Maximum per Pregnancy up to $10,000,000 Lifetime Maximum This is only a brief summary of key Plan provisions. Please refer to the Policy for complete details. Benefits are per person per policy year and are based upon medical necessity and Usual, Customary and Reasonable (UCR) charges, after Annual Deductible. Currency: USD.

5 MATERNITY BENEFITS (INCLUDED UNDER PLANS 2 & 3 ONLY) (CONTINUED) Optional Rider for Complications of Pregnancy and Premature Birth (Plans 4, 5 & 6 only). Coverage for primary or spouse only. Infant Examinations (immunizations & routine medical exams) (provided the child was born under a pregnancy covered by the maternity benefit) Provisional coverage for Newborn children (for a maximum of 90 days); Covered Pregnancies only Blood Cord Storage $500,000 Lifetime Maximum ; Up to 6 months of age; Maximum 7 visits; Deductible waived $50,000 Benefit Maximum per Pregnancy as part of the Complications of Pregnancy Benefit Maximum $2,000 Lifetime Maximum per covered pregnancy Key Benefits The Highest Level of Worldwide Health Insurance Coverage No Lifetime Maximum Free choice of Hospitals Worldwide Inpatient and Outpatient Coverage Worldwide Direct-bill Network Online Claims Filing Live Customer Service parents are covered on the same plan Worldwide Portability Pre-authorization is recommended for these services: Hospitalization Outpatient Surgery Any condition that is expected to accumulate over $5,000 of medical treatment per policy year. Inpatient Private Duty Nursing Pre-Authorization is required for the following benefits: Organ, Bone Marrow, Stem Cell Transplants, and other similar procedures Air Ambulance Air ambulance service will be coordinated by Insurer s air ambulance provider. All Cancer Treatment (Including Chemotherapy and Radiation) Specialty Treatments and Highly Specialized drugs and Exams (MRIs, CT, etc,) Physical Therapy and Rehabilitation Services (after 60 visits combined) Note: Failure to pre-authorize a procedure that requires pre-authorization will result in a 30% penalty. This is only a brief summary of key Plan provisions. Please refer to the Policy for complete details. Benefits are per person per policy year and are based upon medical necessity and Usual, Customary and Reasonable (UCR) charges, after Annual Deductible. Currency: USD.

6 LATAM_GSUPERIOR_ENG_17JUN16 Global Benefits Group Portola Parkway, Suite 110 Foothill Ranch, CA USA GBG Latin America 7600 Corporate Center Drive, Suite 500 Miami, FL USA