Schedule of Benefits
IMPORTANT:Medical expenses incurred in the British Virgin Islands are not covered under this Plan. Such medical expenses should be submitted to the Virgin Islands National Health Insurance office for appropriate reimbursement.
IMPORTANT: This Schedule of Benefits should be read in conjunction with the Certificate of insurance and is subject to the definitions, terms, conditions, warranties, limitations, exclusions and to all other provisions of the Certificate of insurance. Covered Medical Expenses are based on the lesser of the Usual, Customary and Reasonable fees or the rates negotiated by Underwriters for the Medically Necessary treatment of an Illness or Injury covered under the Certificate.
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. This 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 Person and per Family Deductibles are applied to the Covered Medical Expenses before the Co-insurance factors. The resulting net amount (after applications of Deductibles and Co-insurance) is always subject to any stipulated maximum dollar limit payable by Underwriters for the applicable Covered Medical Expense. Any stipulated per Insured Person or per Family Out of Pocket Expenses Cap amount is always in addition to any stipulated per Insured Person or per Family Deductible amount.
IMPORTANT: Once the Underwriters limit has been exhausted in respect of a specific benefit then any further expenses relating to any treatment or condition falling under that benefit are no longer covered, irrespective of any Maximum Out of Pocket Expenses Cap.
IMPORTANT: All potential or actual claims that may result in a Covered Medical Expense under this Certificate, even if such Covered Medical Expense falls wholly or partly within the applicable Deductible, must be submitted to the Agent or Third Party Administrator in accordance with the “Submission of a Claim” condition within the Certificate. Failure to comply with this condition will lead to denial of the claim.
|
Non – Preferred Provider |
Preferred Provider USA & Worldwide |
Preferred Provider Puerto Rico |
|
| Lifetime Maximum |
$2,000,000 |
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| Annual Deductible Per Insured Person
|
$250 |
$250 |
$250 Waived |
| Family Annual DeductibleK (2 Family members to satisfy) |
$500 |
$500 |
$500 Waived |
| Dental Annual Deductible, if applicable
|
$50 |
$50 |
$50 |
| Dental Annual Deductible, if applicable (2 Family members to satisfy) |
$100 |
$100 |
$100 |
| Co-Insurance |
See Below |
See Below |
See Below |
| Maximum Out of Pocket Expenses Cap
per Insured Person per year for Covered Medical Expenses |
$10,000 |
$4,000 |
$2,500
|
| Maximum Out of Pocket Expenses Cap
per Family each year for Covered Medical Expenses |
$20,000 |
$8,000 |
$5,000
|
| Non Pre-certification penalty |
50% |
35% |
35% |
Covered Medical Expenses and Coinsurance Factors
|
Percentage of Covered Medical Expenses payable by Underwriters |
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|
Non-Preferred Provider |
Preferred Provider USA & Worldwide |
Preferred Provider Puerto Rico |
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| Hospital Treatment Benefit including:
Semi-private room – after 60 days of Confinement, the Rehabilitation Facility benefit applies Surgeon, Physician and anaesthesiologist’s fees, Assistant Surgeon’s fees (limited to 20% of Surgeon’s fees) Pre-certification Required |
75% |
80% |
90% |
||
| Rehabilitation Facility Benefit
Maximum of $400 per day Pre-certification Required |
75% |
80% |
90% |
||
|
Subject to a maximum amount of $12,000 per year |
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| Emergency Room Benefit including:
Non-emergency treatment in an emergency room |
75% |
80% |
90% |
||
| Diagnostic Testing Benefit
MRI, CT Scans, Endoscopy, Cardiovascular studies and other diagnostic procedures. |
75% |
80% |
90% |
||
| Pre-certification Required | |||||
| Prescription Drugs Benefit |
75% |
80% |
90% |
||
| Physician Visits Benefit |
75% |
80% |
90% |
||
| Second Surgical Opinion Benefit
Pre-certification Required |
75% |
80% |
90% |
||
| Annual Physical Exam Benefit, including Pap Smear, Mammogram, Immunisations, Vaccinations and other Routine Diagnostic Studies |
100% |
100% |
100% |
||
|
Subject to a maximum amount of $1,000 per year for each Insured Person |
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| Organ Transplant Benefit including pre and post-
operative treatments |
75% |
80% |
90% |
||
| Pre-certification Required |
Subject to a lifetime maximum amount of $250,000 |
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| Air Ambulance Benefit |
100% |
100% |
100% |
||
| Pre-certification Required |
Subject to a maximum amount of $30,000 per year for each Insured Person |
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| Air Travel Benefits
Limited to $300 per ticket. Treatment must be medically necessary. Maximum of 3 tickets per year Pre-certification Required |
100% |
100% |
100% |
||
| Ground Ambulance Benefit @ $300 per trip
Pre-certification Required |
100% |
100% |
100% |
||
|
Subject to a maximum amount of $600 per year for each Insured Person |
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|
|
Percentage of Covered Medical Expenses payable by Underwriters |
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|
Non-Preferred Provider
|
Preferred Provider USA & Worldwide |
Preferred Provider Puerto Rico |
|
| Birth Abnormalities, Congenital Conditions, Premature Birth, or Other Defects in Newborn ChildrenThe benefit only applies if the newborn is covered by the Maternity Benefit of this Certificate on the date the Certificate Holder acquires the newborn child. |
75% |
80% |
100% |
| Pre-certification Required |
Subject to a maximum amount for any newborn Insured Person of $50,000
|
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| AIDS, HIV and ARC Benefit |
75% |
80% |
90% |
| Pre-certification Required |
Subject to a maximum amount of $5,000 per year, lifetime maximum of $25,000 |
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| Radiotherapy Benefit |
75% |
80% |
90% |
| Pre-certification Required | |||
| Chemotherapy Benefit
Pre-certification Required |
75% |
80% |
90% |
| Mental and Nervous Disorders Benefit
Maximum $50 per visit per year |
75% |
80% |
90% |
| Physical Therapy Benefit – 25 one hour sessions per year – maximum of $50 per session
Pre-certification Required |
75% |
80% |
90% |
|
Subject to a maximum amount of $1,250 per year for each Insured Person |
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| Occupational Therapy Benefit – maximum of $50 per session
Pre-certification Required |
75% |
80% |
90% |
| Speech Therapy Benefit – maximum of $50 per session
Pre-certification Required |
75% |
80% |
90% |
| Extended Care Facility Benefit
Pre-certification Required |
75% |
80% |
90% |
|
Subject to a maximum of $10,000 per year for each Insured Person |
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| Home Health Care Benefit and Hospice Care Benefit
Pre-certification Required |
75% |
80% |
90% |
|
Subject to a maximum of $10,000 per year for each Insured Person |
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| Chiropractic Services Benefit – maximum 25 treatments per year, maximum $40 per treatment
Pre-certification Required |
75% |
80% |
90% |
|
Subject to a maximum amount of $1,000 per year for each Insured Person |
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| Private Duty Nursing Benefit –30 days per year |
75% |
80% |
90% |
| Pre-certification Required |
Subject to a maximum amount of $1,500 per year for each Insured Person |
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|
Percentage of Covered Medical Expenses payable by Underwriters |
|
| Dental Benefits:
Class 1 Diagnostic/Preventative (no Deductible) |
100% |
|
Orthodontic |
Subject to a maximum of $2,000 per year for each Insured Person 75% (deductible applies) Subject to a maximum of $2,000 per lifetime for each Insured Person |
| Vision Care Benefits: per Insured Person, per year
Eye examination – one |
80% |
|
Subject to a maximum of $600 per year for each Insured Person
|
Maternity Care Benefit:
The Underwriter will pay Covered Maternity Benefits for the pregnancy of the Certificate Holder or the Certificate Holder’s spouse up to a maximum of $7,500 per pregnancy for Medically Necessary treatment, care and services, including Physicians’ fees and Hospital fees relating to prenatal care, postnatal care, delivery, complications of pregnancy, and charges relating to Well Baby Care.
IMPORTANT: The pregnancy of any Insured Person other than the Certificate Holder or the Certificate Holder’s spouse is not covered under this Certificate.
IMPORTANT: There is a 12 month Waiting Period for Maternity Care benefits.
| Percentage of Covered Medical Expenses payable by Underwriters | ||||
| Maternity Care Benefit | Non-Preferred Provider | Preferred Provider – USA & Worldwide | Preferred Provider –Puerto Rico | |
| Physician and Hospital fees: Normal delivery Caesarean section Ectopic or other complications Medically Necessary abortionPre and post natal care office visits: Well Baby Care: Elective abortions are not covered Pre-certification Required |
90%
90% |
90%
90% |
90%
90% |
|
| Subject to a maximum of $7,500 per pregnancy | ||||