GLOC Nemwil Extended Plan – Caribbean Insurers Limited

Schedule of Benefits

IMPORTANT: This Policy is to be used as Secondary Insurance to the Virgin Islands National Health Insurance (NHI).

IMPORTANT: This Schedule of Benefits should be read in conjunction with the Individual Health Policy and is subject to the definitions, benefit limitations, exclusions and to all other provisions of the Individual Health Policy.Covered medical expenses are based on the usual customary and reasonable charges incurred by you or your Dependents while insured hereunder for Medically Necessary treatment of an Illness or Injury.

IMPORTANT: The Per Insured and Per Family Deductibles are applied to the covered medical expenses before the Coinsurance factors.The resulting net amount (after applications of Deductibles and Coinsurance) is always subject to any stipulated maximum dollar limit payable by Underwriters for the applicable medical treatment or condition. Family includes the Covered Insured, Spouse and any Dependents.

IMPORTANT: Once the Underwriters limit has been exhausted in respect of a specific treatment or condition then any further expenses relating to that treatment or condition are no longer covered, irrespective of any maximum out of pocket cap.

	NEMWIL EXTENDED (NHI MUST BE USED AS PRIMARY PLAN)
	BVI		OVERSEAS
MAJOR MEDICAL LIFETIME MAXIMUM	$2,000,000
Deductible, per Insured per policy year	$ –		$250
Deductible, per family per policy year (2 family members to satisfy)	$ –		$500
Maximum out of pocket cap per individual per policy year for covered medical treatment	No Cap		$4,000
Maximum out of pocket cap per family per policy year	No Cap		$8,000
Pre-certification penalty	35%		35%
Hospital Treatment including: Semi-Private Room – after 60 days of confinement, the Extended Care Facility Benefit applies Surgeon’s/Physicians fees Assistant Surgeon’s fee (20% of Surgeons fee) Anaesthesiologist (25% of Surgeons fee)	100%		90%
Extended Care Facility After a period of confinement, a maximum of $50 payable per day up to a maximum of 120 days	100% 90% Subject to a lifetime maximum of $6,000
Rehabilitation Facility Maximum of $250 payable per day up to 30 days per policy year Pre-certification Required	100% 90%
Home Health Care/Hospice Care After a period of confinement, a maximum of $50 payable per day up to a maximum of 120 days	100% 90% Subject to a lifetime maximum of $6,000
	NEMWIL EXTENDED (NHI MUST BE USED AS PRIMARY PLAN)
	BVI		OVERSEAS
Emergency Room including non-emergency treatment in emergency room	100% 90%
Out Patient Diagnostic Testing benefit MRI, CT Scans, Endoscopy, Cardiovascular Studies and any other Diagnostic Procedures Pre-certification Required	100% 90%
Prescription per item	100% 80% Annual Maximum – $2,500
Doctors and Specialist Visits	100% 80%
Second Surgical Opinion (No Deductible)	100% 90%
Preventative Care Services – subject to an overall maximum of $1,000 per policy year for the following services: Annual Routine Medical Exam Screening Mammogram Prostate Cancer Screening Annual Pap Smear Routine Diagnostic Lab Test & Other Routine Screening Exams Vaccinations/Immunizations up to age 5 oldyears	Annual Maximum of $1,000 100% 100%
Chiropractic Services, maximum of 10 treatments per policy year Maximum of $50 per visit	100% 90% Annual Maximum of $500
Private Duty Nursing – maximum of 30 days per policy year Maximum of $50 per visit Pre-certification Required	100% 90% Annual Maximum of $1,500
Hearing Test/Examination Consultation/Office Visit Hearing Test	100% 90%
Organ Transplants including Pre and Post-Operative Treatments Pre-certification Required	100% 90% Lifetime Maximum of $250,000
Air Ambulance Pre-certification Required	100% 100% Annual Maximum of $20,000
Ground Ambulance	100% 100% Annual Maximum of $500
Birth Abnormalities, Congenital Conditions, Premature Birth, or other defects in newborn children	100% 90% Lifetime Maximum of $100,000 per child
	NEMWIL EXTENDED (NHI MUST BE USED AS PRIMARY PLAN)
	BVI		OVERSEAS
All treatment for AIDS, HIV, ARC Pre-certification Required	100% 90% Annual Maximum of $5,000 Lifetime Maximum of $15,000
Chemotherapy Pre-certification Required	100% 90% Annual Maximum of $100,000
Radiotherapy Pre-certification Required	100% 90% Annual Maximum of $100,000
Dialysis	100% 90%
Physical Therapy – up to 20 one hour sessions per policy year Maximum of $50 per visit	100% 90% Annual Maximum of $1,000
Psychiatric Care – Limited to 20 visits per policy year Maximum of $100 per visit	100% 90% Annual Maximum of $2,000 Lifetime Maximum of $25,000
Durable Medical Equipment By Prescription Only	90% 90%
Alcoholism and Substance Abuse	100% 90% Annual Maximum $2,500 – Lifetime Maximum $25,000
Dental Care Benefits Diagnostic/Preventative Basic Restorative Major Replacement	100% 80% Annual Maximum of $1,500
Orthodontic	100% 80% Lifetime Maximum of $1,500
Vision Care Benefits Eye Examination – one per year Lenses (All types) – one pair per year Frames – one pair per year Contact Lenses	Annual Maximum of $500 100% 100%
	NEMWIL EXTENDED (NHI MUST BE USED AS PRIMARY PLAN)
	BVI		OVERSEAS
Maternity Benefits Pre-Natal Care Office visits Post-Natal Care Office visits Doctors’ Fees: Normal delivery Pre-certification Required Caesarean Section Pre-certification Required Ectopic or other complications Pre-certification required Hospital Fees: Maternity Pre-certification Required	90%	90%
	Subject to a maximum of $6,000 per pregnancy