Schedule of Benefits
IMPORTANT: This Plan will not cover medical expenses incurred in the British Virgin Islands.
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: Failure to pre-certify in accordance with the Pre-certification requirement will result in an additional 35% penalty for Preferred Providers, and 50% for Non-Preferred Providers.pThis penalty is in addition to any other Co-insurance or Deductible stipulated in the Schedule of Benefits and applies in full notwithstanding any applicable Maximum Out of Pocket Expenses Cap.
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.
| Non – Preferred Provider | Preferred Provider USA Worldwide | Preferred ProviderPuerto Rico | |
| Lifetime Maximum | $1,000,000.00 | ||
| Per Insured per year Deductible | $2,000 | $1,000 | $500 Waived |
| Family Year Deductible
(2 Family members to satisfy) |
$4,000 | $2,000 | $1,000 |
| Dental Services per Insured Person per Annual Insurance Period Deductible, if applicable | $200 | $200 | $200 |
| Dental Services per insured family per Annual Insurance Period Deductible (2 Family members to satisfy) if applicable | $400 | $400 | $400 |
| Co-Insurance factor BVI and Puerto Rico |
See Below | ||
| Co-Insurance factor USA Worldwide |
See Below | See Below | |
| Maximum out of pocket cap per individual each year for covered medical treatment | No Cap | $2,000 | $1,000 |
| Maximum out of pocket cap per Family | No Cap | $4,000 | $2,000 |
| Non pre-certification penalty | 50% | 35% | 35% |
Covered Medical Expenses and Coinsurance Factors
| Percentage of Covered Expenses payable by Underwriters | |||
| Non-Preferred Provider | Preferred Provider – USA & Worldwide | Preferred Provider -Puerto Rico | |
| Hospital Treatment including:
Semi-private room – after 60 days of confinement, the Extended Care Facility Benefit applies Pre-certification Required |
50% | 80% | 80% |
| Extended Care Facility After a period of confinement, a maximum of $50 payable per day up to a maximum of 120 days |
50% | 80% | 80% |
| Subject to a lifetime maximum of $6,000 | |||
| Rehabilitation Facility
Pre-certification Required |
50% | 80% | 80% |
| Home Health Care/Hospice Care
After a period of confinement, a maximum of $50 payable per day up to a maximum of 120 days |
50% | 80% | 80% |
| Subject to a lifetime maximum of $6,000 | |||
| Emergency Room including non-emergency treatment in emergency room | 50% | 80% | 80% |
| Out Patient Diagnostic Testing benefit MRI, CT Scans, Endoscopy, Cardiovascular Studies and any other Diagnostic Procedures Pre-certification Required | 50% | 80% | 80% |
| Prescription per item | 50% | 60% | 60% |
| Subject to a maximum amount of $1,500 per policy year | |||
| Doctors and Specialist Visits | 50% | 60% | 60% |
| Subject to a maximum amount of $1,500 per policy year | |||
| Second Surgical Opinion (no deductible) | 50% | 80% | 80% |
Preventative Care Services-subject to an overall maximum of $1,000 per policy year for the following services:
|
100% |
100% |
100% |
| Subject to a maximum amount of $150 per policy year | |||
| 100% | 100% | 100% | |
| Subject to a maximum amount of $300 per policy year | |||
| 100% | 100% | 100% | |
| Subject to a maximum amount of $50 per policy year | |||
| 100% | 100% | 100% | |
| Subject to a maximum amount of $70 per policy year | |||
| 80% | 80% | 80% | |
| 100% | 100% | 100% | |
| Non-Preferred Provider | Preferred Provider – USA & Worldwide | Preferred Provider -Puerto Rico | |
| Chiropractic Services, maximum of 20 treatments per year. | 50% | 80% | 80% |
| Subject to a maximum amount of $320 per policy year | |||
| Private Duty Nursing – $50 per day, maximum of 30 days per year | 50% | 80% | 80% |
| Pre-certification Required | Subject to a maximum amount of $1,500 per policy year | ||
| Hearing Test/Examination
Consultation/Office Visit Hearing Test Hearing Aid |
50%
50% 50% |
60%
80% 80% |
60%
80% 80% |
| Organ Transplants including Pre and Post Operative Treatments | 50% | 80% | 80% |
| Pre-certification Required | Subject to a lifetime maximum amount of $250,000 | ||
| Air Ambulance | 100% | 100% | 100% |
| Pre-certification Required | Subject to a maximum amount of $15,000 per policy year | ||
| Ground Ambulance @ $75 per trip | 100% | 100% | 100% |
| Subject to a maximum amount of $150 per policy year | |||
| Birth Abnormalities, Congenital Conditions, Premature Birth, or Other Defects in newborn children | 50% | 80% | 80% |
| Subject to a maximum amount for any insured child of $50,000 | |||
| All Treatment for AIDS, HIV, ARC | 50% | 50% | 80% |
| Pre-certification Required | Subject to a maximum amount of $5,000 per policy year and lifetime maximum of $15,000 | ||
| Chemotherapy
Pre-certification Required |
50% | 80% | 80% |
| Subject to a maximum amount of $50,000 per policy year | |||
| Radiotherapy | 50% | 80% | 80% |
| Pre-certification Required | Subject to a maximum amount of $50,000 per policy year | ||
| Chronic Conditions | 50% | 80% | 80% |
| Physical Therapy – up to 20 one hour sessions per annual insurance period – maximum $30 per session | 50% | 80% | 80% |
| Psychiatric Care, including prescription drugs – Limited to 20 treatments per annum with a maximum of $20 per office visit | 50% | 50% | 50% |
| Subject to a maximum amount of $10,000 per policy year and lifetime maximum of $25,000 | |||
| Durable Medical Equipment By prescription only |
50% | 80% | 80% |
| Alcoholism and Substance Abuse | 50% | 80% | 80% |
| Subject to a maximum of $2,500 per policy year and lifetime maximum of $15,000 | |||
| Percentage of Covered Expenses payable by Underwriters | |
| Dental Care Benefits:
Diagnostic/preventative Basic restorative Major Replacement |
80% (deductible waived)
80% (deductible waived) 80% (deductible applies) Subject to a maximum of $1,000 per policy year per insured person |
| Orthodontia | 80% (deductible applies)
Subject to a lifetime maximum benefit payable per member of $1,000.00 |
| Vision Care Benefits: per person, per year $400
Eye Examination – one per year Lenses (All types) – one pair per year Frames – one pair per year Contact Lenses |
80% 80% 80% 80% |
| Subject to a maximum of $400 per policy year per insured person |
Maternity Benefits
The Underwriter will pay covered Maternity Benefits for a Covered Insured or Spouse up to a maximum of $6,000 per pregnancy, for services, including doctors fees, Hospital fees and hospitalisation relating to prenatal care, postnatal care, delivery, complication of pregnancy, and charges relating to well baby nursery care.
| Percentage of Covered Expenses payable by Underwriters | |
| Pre and Post Natal Care Office visits
Doctors Fees: Caesarean Section Ectopic or other complications |
80%
80% 80% 80% 80% |
| Hospital Fees: Maternity Pre-certification Required |
|
| Subject to a maximum of $4,000 per pregnancy |