INF Premier Plan: Medical Benefits.pdf

All non-US residents plan members ages 70 to 99 of the Policyholder who are traveling outside of their Home are eligible for coverage. Their Dependents (lawful spouse and unmarried children, subject to Dependent age limits in the state where the Policy is issued) are also covered if they are traveling with them and they have elected and paid for Dependent coverage.

The Premier Plan provides Medical Expense Benefits with a Total Maximum for all Accident or Sickness Expense Benefits of $100,000. The Maximum for Inpatient Room & Board Charges is up to $1,750 per day to a maximum of 30 days, with an additional $750 per day for ICU Room & Board Charges to a maximum of 8 days. Doctor Surgical Expenses are up to $5,000, Anesthetics are up to $1,250, and Assistant Surgeon Expenses are up to $1,250.

Maximum for Outpatient Surgical Room and Supply Expenses is up to $1,100, Doctor Surgical Expenses are up to $5,000, Anesthetics are up to $1,250, and Assistant Surgeon Expenses are up to $1,250. Doctor Non-Surgical Treatment/Examination Expenses are up to $100 per visit, subject to 1 visit per day, up to a maximum of 10 visits. X-rays, laboratory procedures are up to $650, CAT Scan, PET Scan or MRI are up to an additional $650, and Hospital Emergency Room is up to $500.

Prescription Drug Expenses are up to $150, Ambulance Expenses are up to $450, Rehabilitative braces or appliances are up to $1,100, Dental Treatment (Injury Only) is up to $500, and Physical and Occupational Therapy is up to $45 per visit, subject to 1 visit per day, up to a maximum of 12 visits. Private Duty Nurse is up to $500.

Pre-existing Conditions are covered with a Maximum Benefit of $15,000 or $25,000, subject to a $1,000 or $5,000 Deductible. Deductible options are $100, $250, $500, $1,000, $2,500, or $5,000. Co-insurance Rate is 100% of the Usual and Customary Charges. Urgent Care Visits are covered with a $25 copay.

Incurral Period is 90 days after the date of Covered Accident or Sickness, Maximum Benefit Period is the earlier of the date the Covered Person's Trip ends, or 364 days from the date of a Covered Accident or Sickness. Maximum Period of Coverage is 364 days. Accidental Death and Dismemberment Benefit is $25,000, Trip Interruption Benefit is $1,000, Emergency Medical Evacuation Benefit is up to $20,000, and Repatriation of Remains Benefit is up to $15,000.