Seguro Internacional | Full
Silver 10000- Worldwide
Deductible: 10.000 USD and Max. Coverage: 5.000.000 USD/Lifetime
Bronze
Silver
Gold
Platinum
Plan Options:
G L O B A L M E D I C A L I N S U R A N C E ®A WORLDWIDE MEDICAL INSURANCE
PROGRAM FOR INDIVIDUALS AND FAMILIES.W W W . I M G L O B A L . C O M
Silver
Gold
Platinum
Plan Options:
G L O B A L M E D I C A L I N S U R A N C E ®A WORLDWIDE MEDICAL INSURANCE
PROGRAM FOR INDIVIDUALS AND FAMILIES.W W W . I M G L O B A L . C O M
Being a global citizen can be an exciting experience, but it also
comes with potential complications. Your health care while
traveling should not be one of those concerns. With Global
Medical Insurance, a revolutionary program from International
Medical Group® (IMG®), you will receive the worldwide medical
coverage you need, backed by the world-class services you
expect.
Global Medical Insurance allows you to choose from several plan
options, areas of coverage, multiple deductibles, and modes
of payment. With your medical history in mind, the program
provides different underwriting methods to extend medical
coverage to you that may be declined by other companies.
With IMG, you will rest assured knowing that we have a
dedicated department working to keep your insurance as
affordable as possible. The costs of health care are rising, but
we are committed to controlling those costs. As part of that
commitment, IMG offers a Medical Concierge program, an
unparalleled service that saves you on out-of-pocket medical
expenses. We also offer a cash incentive, waiving 50% of your
deductible for choosing to receive treatment from some of the
best medical facilities outside the United States.
You need the proper worldwide coverage, provided by a
company that’s there for you when you need us most. When
you select Global Medical Insurance, you receive IMG’s promise
to deliver exceptional medical benefits, medical assistance, and
service—all designed to give you Global Peace of Mind®.
Global Medical Insurance®
Worldwide Coverage. World-Class Services.
comes with potential complications. Your health care while
traveling should not be one of those concerns. With Global
Medical Insurance, a revolutionary program from International
Medical Group® (IMG®), you will receive the worldwide medical
coverage you need, backed by the world-class services you
expect.
Global Medical Insurance allows you to choose from several plan
options, areas of coverage, multiple deductibles, and modes
of payment. With your medical history in mind, the program
provides different underwriting methods to extend medical
coverage to you that may be declined by other companies.
With IMG, you will rest assured knowing that we have a
dedicated department working to keep your insurance as
affordable as possible. The costs of health care are rising, but
we are committed to controlling those costs. As part of that
commitment, IMG offers a Medical Concierge program, an
unparalleled service that saves you on out-of-pocket medical
expenses. We also offer a cash incentive, waiving 50% of your
deductible for choosing to receive treatment from some of the
best medical facilities outside the United States.
You need the proper worldwide coverage, provided by a
company that’s there for you when you need us most. When
you select Global Medical Insurance, you receive IMG’s promise
to deliver exceptional medical benefits, medical assistance, and
service—all designed to give you Global Peace of Mind®.
Global Medical Insurance®
Worldwide Coverage. World-Class Services.
Why IMG?
Since 1990, IMG has provided global benefits and assistance services to millions of members in nearly every country. We’re committed
to being there with our members wherever they may be in the world, delivering Coverage Without Boundaries®. With 24/7 medical
management services, multilingual claims administrators, and highly trained customer service professionals, IMG is confident in its
ability to provide the products international members need, backed by the services they want.
Why Global Medical Insurance?
A Company and a Program
Designed to Meet Your Needs
FINANCIAL STABILITY.
Owned by SiriusPoint*, an ‘A-’ rated, multibillion-
dollar global enterprise, IMG offers the financial
security and reputation demanded by international
consumers.
ACCESSIBLE TECHNOLOGY.
Full access to MyIMGSM member portal allows
you to submit and view your claims, manage
your account, search for providers, live chat with
representatives, and more.
INTERNATIONAL EMERGENCY CARE.
When you’re away from home and a medical
emergency occurs, you may not be able to wait for
regular business hours. With our on-site medical
staff, you have 24-hour access to highly qualified
coordinators of emergency medical services and
international treatment.
GLOBAL SUPPORT.
With offices and partners around the globe, IMG
provides the support you need, when you need it.
In fact, it is our corporate mission to be there to
protect and enhance your health and well-being.
SERVICE WITHOUT OBSTACLES.
With a team of international, multilingual
specialists, we are accustomed to working in
multiple time zones, languages, and currencies.
Our global reach means we can work without
barriers.
INTERNATIONAL PROVIDER ACCESS SM (IPA).
In addition to the expansive UnitedHealthcare PPO
network available for treatment received within
the U.S., our proprietary IPA network of more than
18,550 accomplished physicians and facilities
allows you to access quality care worldwide. Our
direct billing arrangements can also ease the time
and upfront expense at select providers.
Plan Flexibility - Multiple plan options and payment
modes to fit your budget
Choice of Coverage Area - Worldwide or Worldwide
Excluding the U.S., Canada, China, Hong Kong, Japan,
Macau, Singapore, and Taiwan
Freedom to Choose - Select your own health care
provider, no matter where you are in the world
Travel Intelligence - Receive location-specific alerts on
health, transportation, security, and weather
Assistance Services - Available on all plans
Preventative Care - No waiting period on wellness
benefits
Healthy Travel Preventative Coverage - Receive
vaccinations and preventative prescriptions prior to
departure
Pre-Existing Condition Waiver - For individuals with
proof of comprehensive health insurance and no
significant break in coverage (63 days)
Benefits are subject to exclusions and limitations. This is only a summary and does not
supersede in any way the Certificate of Insurance and governing policy documents
(together the “Insurance Contract”). The Insurance Contract is the only source of the
actual benefits provided.
*SiriusPoint is the DBA of SiriusPoint Ltd.
3
Since 1990, IMG has provided global benefits and assistance services to millions of members in nearly every country. We’re committed
to being there with our members wherever they may be in the world, delivering Coverage Without Boundaries®. With 24/7 medical
management services, multilingual claims administrators, and highly trained customer service professionals, IMG is confident in its
ability to provide the products international members need, backed by the services they want.
Why Global Medical Insurance?
A Company and a Program
Designed to Meet Your Needs
FINANCIAL STABILITY.
Owned by SiriusPoint*, an ‘A-’ rated, multibillion-
dollar global enterprise, IMG offers the financial
security and reputation demanded by international
consumers.
ACCESSIBLE TECHNOLOGY.
Full access to MyIMGSM member portal allows
you to submit and view your claims, manage
your account, search for providers, live chat with
representatives, and more.
INTERNATIONAL EMERGENCY CARE.
When you’re away from home and a medical
emergency occurs, you may not be able to wait for
regular business hours. With our on-site medical
staff, you have 24-hour access to highly qualified
coordinators of emergency medical services and
international treatment.
GLOBAL SUPPORT.
With offices and partners around the globe, IMG
provides the support you need, when you need it.
In fact, it is our corporate mission to be there to
protect and enhance your health and well-being.
SERVICE WITHOUT OBSTACLES.
With a team of international, multilingual
specialists, we are accustomed to working in
multiple time zones, languages, and currencies.
Our global reach means we can work without
barriers.
INTERNATIONAL PROVIDER ACCESS SM (IPA).
In addition to the expansive UnitedHealthcare PPO
network available for treatment received within
the U.S., our proprietary IPA network of more than
18,550 accomplished physicians and facilities
allows you to access quality care worldwide. Our
direct billing arrangements can also ease the time
and upfront expense at select providers.
Plan Flexibility - Multiple plan options and payment
modes to fit your budget
Choice of Coverage Area - Worldwide or Worldwide
Excluding the U.S., Canada, China, Hong Kong, Japan,
Macau, Singapore, and Taiwan
Freedom to Choose - Select your own health care
provider, no matter where you are in the world
Travel Intelligence - Receive location-specific alerts on
health, transportation, security, and weather
Assistance Services - Available on all plans
Preventative Care - No waiting period on wellness
benefits
Healthy Travel Preventative Coverage - Receive
vaccinations and preventative prescriptions prior to
departure
Pre-Existing Condition Waiver - For individuals with
proof of comprehensive health insurance and no
significant break in coverage (63 days)
Benefits are subject to exclusions and limitations. This is only a summary and does not
supersede in any way the Certificate of Insurance and governing policy documents
(together the “Insurance Contract”). The Insurance Contract is the only source of the
actual benefits provided.
*SiriusPoint is the DBA of SiriusPoint Ltd.
3
The following is a summary schedule of benefits for eligible medical expenses.
Charges and expenses incurred by the Insured Person during the Period of Coverage
with respect to an Illness or Injury suffered or sustained by the Insured Person
during the Period of Coverage and while this Certificate is in effect, so long as the
Charges are Usual, Reasonable and Customary and are incurred for Treatment or
supplies that are Medically Necessary (“Eligible Medical Expenses”).
Summary Schedule of Benefits
BENEFIT BRONZE SILVER GOLD PLATINUM
Lifetime Maximum Limit $1,000,000 per individual $5,000,000 per individual $5,000,000 per individual $8,000,000 per individual
Deductible (Per period of coverage) $250 to $10,000 $250 to $10,000 $250 to $25,000 $100 to $25,000
Treatment outside the U.S.
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
Treatment inside the U.S.
using Medical Concierge
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
Treatment inside the U.S. -
PPO Network
Subject to deductible.
No coinsurance
Subject to deductible.
No coinsurance
Subject to deductible.
No coinsurance
Subject to deductible.
No coinsurance
Treatment inside the U.S. -
Non-PPO Network
Subject to deductible.
Plan pays 80% of the next $5,000
of eligible expenses, then 100% to
the overall maximum per period of
coverage
Subject to deductible.
Plan pays 80% of the next $5,000
of eligible expenses, then 100% to
the overall maximum per period of
coverage
Subject to deductible.
Plan pays 80% of the next $5,000
of eligible expenses, then 100% to
the overall maximum per period
of coverage
Subject to deductible.
Plan pays 80% of the next $5,000
of eligible expenses, then 100% to
the overall maximum per period
of coverage
Coinsurance
International - 100%
U.S. in-network – 100%
U.S. out-of-network - 80%
International - 100%
U.S. in-network – 100%
U.S. out-of-network - 80%
International - 100%
U.S. in-network – 100%
U.S. out-of-network - 80%
International - 100%
U.S. in-network – 100%
U.S. out-of-network - 80%
Outpatient
$300 maximum per visit - lab
tests; $250 maximum per visit -
diagnostic X-rays
$500 maximum limit - specialists/
physician charges (pre-inpatient/
post-inpatient)
Subject to deductible and
coinsurance
$300 maximum per visit - lab
tests; $250 maximum per visit -
diagnostic X-rays
25 combined maximum visits
$70 per visit/examination -
specialists/physician charges
$50 per visit/examination -
chiropractor charges (medical
order or treatment plan required)
$500 per consultation -
surgery intervention consultation
charges
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Mental/Nervous N/A
Subject to deductible and
coinsurance.
Outpatient after 12 months of
continuous coverage
Subject to deductible and
coinsurance.
$10,000 maximum.
Available after 12 months of
continuous coverage
Subject to deductible and
coinsurance.
$50,000 lifetime maximum.
Available after 12 months of
continuous coverage
Hospital Emergency Room
Injury
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Hospital Emergency Room
Illness
Subject to deductible and
coinsurance. Covered only if
admitted as inpatient
Subject to deductible and
coinsurance.
Additional $250 deductible
if not admitted as an inpatient
Subject to deductible and
coinsurance.
Additional $250 deductible
if not admitted as an inpatient
Subject to deductible and
coinsurance.
Additional $250 deductible
if not admitted as an inpatient
Hospitalization/
Room & Board
Subject to deductible and
coinsurance for average semi-
private room rate
Subject to deductible and
coinsurance for average semi-
private room rate.
All subject to $600 per day; 240 day
maximum
Subject to deductible and
coinsurance for average semi-
private room rate
Subject to deductible and
coinsurance for average private
room rate
Intensive Care Unit Subject to deductible and
coinsurance
Subject to deductible and
coinsurance.
$1,500 limit per day - 180 days of
coverage per event
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents
(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
4
Charges and expenses incurred by the Insured Person during the Period of Coverage
with respect to an Illness or Injury suffered or sustained by the Insured Person
during the Period of Coverage and while this Certificate is in effect, so long as the
Charges are Usual, Reasonable and Customary and are incurred for Treatment or
supplies that are Medically Necessary (“Eligible Medical Expenses”).
Summary Schedule of Benefits
BENEFIT BRONZE SILVER GOLD PLATINUM
Lifetime Maximum Limit $1,000,000 per individual $5,000,000 per individual $5,000,000 per individual $8,000,000 per individual
Deductible (Per period of coverage) $250 to $10,000 $250 to $10,000 $250 to $25,000 $100 to $25,000
Treatment outside the U.S.
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
Treatment inside the U.S.
using Medical Concierge
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
50% of deductible waived,
up to a maximum of $2,500.
No coinsurance
Treatment inside the U.S. -
PPO Network
Subject to deductible.
No coinsurance
Subject to deductible.
No coinsurance
Subject to deductible.
No coinsurance
Subject to deductible.
No coinsurance
Treatment inside the U.S. -
Non-PPO Network
Subject to deductible.
Plan pays 80% of the next $5,000
of eligible expenses, then 100% to
the overall maximum per period of
coverage
Subject to deductible.
Plan pays 80% of the next $5,000
of eligible expenses, then 100% to
the overall maximum per period of
coverage
Subject to deductible.
Plan pays 80% of the next $5,000
of eligible expenses, then 100% to
the overall maximum per period
of coverage
Subject to deductible.
Plan pays 80% of the next $5,000
of eligible expenses, then 100% to
the overall maximum per period
of coverage
Coinsurance
International - 100%
U.S. in-network – 100%
U.S. out-of-network - 80%
International - 100%
U.S. in-network – 100%
U.S. out-of-network - 80%
International - 100%
U.S. in-network – 100%
U.S. out-of-network - 80%
International - 100%
U.S. in-network – 100%
U.S. out-of-network - 80%
Outpatient
$300 maximum per visit - lab
tests; $250 maximum per visit -
diagnostic X-rays
$500 maximum limit - specialists/
physician charges (pre-inpatient/
post-inpatient)
Subject to deductible and
coinsurance
$300 maximum per visit - lab
tests; $250 maximum per visit -
diagnostic X-rays
25 combined maximum visits
$70 per visit/examination -
specialists/physician charges
$50 per visit/examination -
chiropractor charges (medical
order or treatment plan required)
$500 per consultation -
surgery intervention consultation
charges
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Mental/Nervous N/A
Subject to deductible and
coinsurance.
Outpatient after 12 months of
continuous coverage
Subject to deductible and
coinsurance.
$10,000 maximum.
Available after 12 months of
continuous coverage
Subject to deductible and
coinsurance.
$50,000 lifetime maximum.
Available after 12 months of
continuous coverage
Hospital Emergency Room
Injury
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Hospital Emergency Room
Illness
Subject to deductible and
coinsurance. Covered only if
admitted as inpatient
Subject to deductible and
coinsurance.
Additional $250 deductible
if not admitted as an inpatient
Subject to deductible and
coinsurance.
Additional $250 deductible
if not admitted as an inpatient
Subject to deductible and
coinsurance.
Additional $250 deductible
if not admitted as an inpatient
Hospitalization/
Room & Board
Subject to deductible and
coinsurance for average semi-
private room rate
Subject to deductible and
coinsurance for average semi-
private room rate.
All subject to $600 per day; 240 day
maximum
Subject to deductible and
coinsurance for average semi-
private room rate
Subject to deductible and
coinsurance for average private
room rate
Intensive Care Unit Subject to deductible and
coinsurance
Subject to deductible and
coinsurance.
$1,500 limit per day - 180 days of
coverage per event
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents
(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
4
(CONTINUED)
Summary Schedule of Benefits
BENEFIT BRONZE SILVER GOLD PLATINUM
CAT Scans, MRI,
Echocardiography,
Endoscopy,
Gastroscopy, Cystoscopy
Subject to deductible and
coinsurance.
$600 maximum limit per
examination
Subject to deductible and
coinsurance.
$600 maximum limit per
examination
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Surgery Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Assistant Surgeon 20% of primary surgeon’s charge 20% of primary surgeon’s charge 20% of primary surgeon’s charge 20% of primary surgeon’s charge
Chemotherapy or
Radiation Therapy
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Maternity
Delivery, preventative care, newborn care
& congenital disorders, Family Matters
Maternity Program (available after 10
months of coverage)
N/A N/A N/A
$2,500 additional deductible per
pregnancy.
$50,000 lifetime maximum.
$200 newborn preventative care
benefit for the first 31 days -12
months after birth.
$250,000 maximum for newborn
care & congenital disorders for
the first 31 days after birth
Podiatry Care N/A N/A $750 maximum limit $750 maximum limit
Physical Therapy
Subject to deductible and
coinsurance.
$40 maximum per visit - 10
visit limit per event. Available
for 90 days following inpatient
treatment or outpatient surgery
Subject to deductible and
coinsurance.
$40 maximum per visit -
30 visit limit
Subject to deductible and
coinsurance.
$50 maximum per visit
Subject to deductible and
coinsurance.
$50 maximum per visit
Transplants $250,000 lifetime maximum $250,000 lifetime maximum $1,000,000 lifetime maximum $2,000,000 lifetime maximum
Prescription Drugs,
Dressings, and Durable
Medical Equipment
Subject to deductible and
coinsurance.
Available for 90 days following
related inpatient treatment or
outpatient surgery.
$600 maximum limit per event
(includes dressings and durable
medical equipment)
Subject to deductible and
coinsurance.
90-day supply per prescription
following related covered event.
U.S. Retail Pharmacy
out-of-network: 80%
International Retail Phamacy:
100%
Subject to deductible and
coinsurance.
90-day supply per prescription.
U.S. Retail Pharmacy
out-of-network: 80%
International Retail Phamacy:
100%
U.S. Retail Pharmacy:
prescription drug card required.
Copay per 30-day supply: $20 for
generic/$40 for brand name where
generic is not available.
International Retail Pharmacy
(subject to deductible): 100%
Expatriate Prescription
Services Program N/A N/A N/A
Copay per 30-day supply:
$20 for generic/$40 for
non-preferred brand name.
Must enroll via provider website:
www.expatps.com
Dispensing maximum: 180 days
Orphan or Biologic Drugs
(Available when all conditions are met)
» Approved in writing by
company
» Medically necessary
» Not experimental or
investigational
Applies to period of coverage max.
Max limit applies towards lifetime max.
Inpatient Treatment
maximum limit: $250,000.
Outpatient Surgery:
up to the maximum limit.
Subject to deductible and
coinsurance.
Does not apply to maximum
limit per event
Outpatient and Emergency
Department Treatment
maximum limit: $250,000.
Subject to deductible and
coinsurance
Inpatient & Outpatient Treatment
maximum limit: $250,000.
Subject to deductible and
coinsurance
Maximum limit $250,000.
U.S. Retail Pharmacy & expatriate
prescription services program:
Subject to copayments.
International retail pharmacy:
Subject to deductible and
coinsurance.
Inpatient/outpatient medical
treatment: Subject to deductible
and coinsurance
Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents
(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
5
Summary Schedule of Benefits
BENEFIT BRONZE SILVER GOLD PLATINUM
CAT Scans, MRI,
Echocardiography,
Endoscopy,
Gastroscopy, Cystoscopy
Subject to deductible and
coinsurance.
$600 maximum limit per
examination
Subject to deductible and
coinsurance.
$600 maximum limit per
examination
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Surgery Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Assistant Surgeon 20% of primary surgeon’s charge 20% of primary surgeon’s charge 20% of primary surgeon’s charge 20% of primary surgeon’s charge
Chemotherapy or
Radiation Therapy
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Subject to deductible and
coinsurance
Maternity
Delivery, preventative care, newborn care
& congenital disorders, Family Matters
Maternity Program (available after 10
months of coverage)
N/A N/A N/A
$2,500 additional deductible per
pregnancy.
$50,000 lifetime maximum.
$200 newborn preventative care
benefit for the first 31 days -12
months after birth.
$250,000 maximum for newborn
care & congenital disorders for
the first 31 days after birth
Podiatry Care N/A N/A $750 maximum limit $750 maximum limit
Physical Therapy
Subject to deductible and
coinsurance.
$40 maximum per visit - 10
visit limit per event. Available
for 90 days following inpatient
treatment or outpatient surgery
Subject to deductible and
coinsurance.
$40 maximum per visit -
30 visit limit
Subject to deductible and
coinsurance.
$50 maximum per visit
Subject to deductible and
coinsurance.
$50 maximum per visit
Transplants $250,000 lifetime maximum $250,000 lifetime maximum $1,000,000 lifetime maximum $2,000,000 lifetime maximum
Prescription Drugs,
Dressings, and Durable
Medical Equipment
Subject to deductible and
coinsurance.
Available for 90 days following
related inpatient treatment or
outpatient surgery.
$600 maximum limit per event
(includes dressings and durable
medical equipment)
Subject to deductible and
coinsurance.
90-day supply per prescription
following related covered event.
U.S. Retail Pharmacy
out-of-network: 80%
International Retail Phamacy:
100%
Subject to deductible and
coinsurance.
90-day supply per prescription.
U.S. Retail Pharmacy
out-of-network: 80%
International Retail Phamacy:
100%
U.S. Retail Pharmacy:
prescription drug card required.
Copay per 30-day supply: $20 for
generic/$40 for brand name where
generic is not available.
International Retail Pharmacy
(subject to deductible): 100%
Expatriate Prescription
Services Program N/A N/A N/A
Copay per 30-day supply:
$20 for generic/$40 for
non-preferred brand name.
Must enroll via provider website:
www.expatps.com
Dispensing maximum: 180 days
Orphan or Biologic Drugs
(Available when all conditions are met)
» Approved in writing by
company
» Medically necessary
» Not experimental or
investigational
Applies to period of coverage max.
Max limit applies towards lifetime max.
Inpatient Treatment
maximum limit: $250,000.
Outpatient Surgery:
up to the maximum limit.
Subject to deductible and
coinsurance.
Does not apply to maximum
limit per event
Outpatient and Emergency
Department Treatment
maximum limit: $250,000.
Subject to deductible and
coinsurance
Inpatient & Outpatient Treatment
maximum limit: $250,000.
Subject to deductible and
coinsurance
Maximum limit $250,000.
U.S. Retail Pharmacy & expatriate
prescription services program:
Subject to copayments.
International retail pharmacy:
Subject to deductible and
coinsurance.
Inpatient/outpatient medical
treatment: Subject to deductible
and coinsurance
Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents
(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
5
BENEFIT BRONZE SILVER GOLD PLATINUM
Healthy Travel
Preventative Coverage
$250 lifetime maximum.
Not subject to deductible
or coinsurance. Applies to
vaccinations and preventative
prescription drugs administered
by a physician within 30 days
prior to the insured person’s
initial effective date and before
departing to any destination
$250 lifetime maximum.
Not subject to deductible
or coinsurance. Applies to
vaccinations and preventative
prescription drugs administered
by a physician within 30 days
prior to the insured person’s
initial effective date and before
departing to any destination
$250 lifetime maximum.
Not subject to deductible
or coinsurance. Applies to
vaccinations and preventative
prescription drugs administered
by a physician within 30 days
prior to the insured person’s
initial effective date and before
departing to any destination
$250 lifetime maximum.
Not subject to deductible
or coinsurance. Applies to
vaccinations and preventative
prescription drugs administered
by a physician within 30 days
prior to the insured person’s
initial effective date and before
departing to any destination
Vision Optional Rider Optional Rider Optional Rider
$100 maximum per 24 months for
exams. $150 per 24 months for
materials
Emergency Local
Ambulance
(Injury or illness resulting in an inpatient
hospital admission)
$1,500 maximum limit per event.
Not subject to deductible or
coinsurance
$1,500 maximum limit per event.
Not subject to deductible or
coinsurance
Subject to deductible and
coinsurance
Not subject to deductible or
coinsurance
Emergency Evacuation
$50,000 maximum per period
of coverage. Not subject to
deductible or coinsurance
$50,000 maximum per period
of coverage. Not subject to
deductible or coinsurance
Up to lifetime maximum limit.
Not subject to deductible or
coinsurance
Up to lifetime maximum limit.
Not subject to deductible or
coinsurance
Emergency Reunion
$10,000 lifetime maximum.
Not subject to deductible or
coinsurance
N/A
$10,000 lifetime maximum.
Not subject to deductible or
coinsurance
$10,000 lifetime maximum.
Not subject to deductible or
coinsurance
Interfacility Ambulance
Transfer (Transfer from one licensed
health care facility to another licensed
health care facility)
$1,500 maximum limit per event.
Not subject to deductible or
coinsurance. U.S. only
$1,500 maximum limit per event.
Not subject to deductible or
coinsurance. U.S. only
Subject to deductible and
coinsurance.
U.S. only
Not subject to
deductible or coinsurance.
U.S. only
Political Evacuation
and Repatriation N/A N/A N/A $10,000 lifetime maximum
Remote Transportation N/A N/A N/A
$5,000 per period of coverage
up to $20,000 lifetime maximum.
Not subject to deductible or
coinsurance
Return of Mortal Remains
$10,000 lifetime maximum.
Not subject to deductible or
coinsurance
$25,000 lifetime maximum.
Not subject to deductible or
coinsurance
$25,000 lifetime maximum.
Not subject to deductible or
coinsurance
$50,000 lifetime maximum.
Not subject to deductible or
coinsurance
Complementary Medicine N/A N/A $500 maximum limit per period of
coverage
$500 maximum limit per period of
coverage
Traumatic Dental Injury
Treatment at a hospital facility $1,000 per period of coverage $1,000 per period of coverage Up to the lifetime maximum limit Up to the lifetime maximum limit
Treatment Due to
Unexpected Pain to Sound,
Natural Teeth
N/A N/A $100 per period of coverage 100%
Non-Emergency Treatment
at a Dental Provider due to
an Accident
N/A N/A $500 per period of coverage See Non-Emergency Dental
benefit
Non-Emergency Dental Optional Rider Optional Rider Optional Rider
$750 maximum per period of cov-
erage; $50 individual deductible,
applies to minor restorative and
major restorative services
Hospital Indemnity
(Inpatient hospitalization outside the
U.S. only)
Private Hospitals: $400 maximum
limit per overnight and $4,000
maximum limit per period of
coverage
Public Hospitals: $500 maximum
limit per overnight and $5,000
maximum limit per period of
coverage. Not subject to
deductible or coinsurance
Private Hospitals: $400 maximum
limit per overnight and $4,000
maximum limit per period of
coverage
Public Hospitals: $500 maximum
limit per overnight and $5,000
maximum limit per period of
coverage. Not subject to
deductible or coinsurance
Private Hospitals: $400 maximum
limit per overnight and $4,000
maximum limit per period of
coverage
Public Hospitals: $500 maximum
limit per overnight and $5,000
maximum limit per period of
coverage. Not subject to
deductible or coinsurance
Private Hospitals: $400 maximum
limit per overnight and $4,000
maximum limit per period of
coverage
Public Hospitals: $500 maximum
limit per overnight and $5,000
maximum limit per period of
coverage. Not subject to
deductible or coinsurance
(CONTINUED)
Summary Schedule of Benefits
Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents
(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
6
Healthy Travel
Preventative Coverage
$250 lifetime maximum.
Not subject to deductible
or coinsurance. Applies to
vaccinations and preventative
prescription drugs administered
by a physician within 30 days
prior to the insured person’s
initial effective date and before
departing to any destination
$250 lifetime maximum.
Not subject to deductible
or coinsurance. Applies to
vaccinations and preventative
prescription drugs administered
by a physician within 30 days
prior to the insured person’s
initial effective date and before
departing to any destination
$250 lifetime maximum.
Not subject to deductible
or coinsurance. Applies to
vaccinations and preventative
prescription drugs administered
by a physician within 30 days
prior to the insured person’s
initial effective date and before
departing to any destination
$250 lifetime maximum.
Not subject to deductible
or coinsurance. Applies to
vaccinations and preventative
prescription drugs administered
by a physician within 30 days
prior to the insured person’s
initial effective date and before
departing to any destination
Vision Optional Rider Optional Rider Optional Rider
$100 maximum per 24 months for
exams. $150 per 24 months for
materials
Emergency Local
Ambulance
(Injury or illness resulting in an inpatient
hospital admission)
$1,500 maximum limit per event.
Not subject to deductible or
coinsurance
$1,500 maximum limit per event.
Not subject to deductible or
coinsurance
Subject to deductible and
coinsurance
Not subject to deductible or
coinsurance
Emergency Evacuation
$50,000 maximum per period
of coverage. Not subject to
deductible or coinsurance
$50,000 maximum per period
of coverage. Not subject to
deductible or coinsurance
Up to lifetime maximum limit.
Not subject to deductible or
coinsurance
Up to lifetime maximum limit.
Not subject to deductible or
coinsurance
Emergency Reunion
$10,000 lifetime maximum.
Not subject to deductible or
coinsurance
N/A
$10,000 lifetime maximum.
Not subject to deductible or
coinsurance
$10,000 lifetime maximum.
Not subject to deductible or
coinsurance
Interfacility Ambulance
Transfer (Transfer from one licensed
health care facility to another licensed
health care facility)
$1,500 maximum limit per event.
Not subject to deductible or
coinsurance. U.S. only
$1,500 maximum limit per event.
Not subject to deductible or
coinsurance. U.S. only
Subject to deductible and
coinsurance.
U.S. only
Not subject to
deductible or coinsurance.
U.S. only
Political Evacuation
and Repatriation N/A N/A N/A $10,000 lifetime maximum
Remote Transportation N/A N/A N/A
$5,000 per period of coverage
up to $20,000 lifetime maximum.
Not subject to deductible or
coinsurance
Return of Mortal Remains
$10,000 lifetime maximum.
Not subject to deductible or
coinsurance
$25,000 lifetime maximum.
Not subject to deductible or
coinsurance
$25,000 lifetime maximum.
Not subject to deductible or
coinsurance
$50,000 lifetime maximum.
Not subject to deductible or
coinsurance
Complementary Medicine N/A N/A $500 maximum limit per period of
coverage
$500 maximum limit per period of
coverage
Traumatic Dental Injury
Treatment at a hospital facility $1,000 per period of coverage $1,000 per period of coverage Up to the lifetime maximum limit Up to the lifetime maximum limit
Treatment Due to
Unexpected Pain to Sound,
Natural Teeth
N/A N/A $100 per period of coverage 100%
Non-Emergency Treatment
at a Dental Provider due to
an Accident
N/A N/A $500 per period of coverage See Non-Emergency Dental
benefit
Non-Emergency Dental Optional Rider Optional Rider Optional Rider
$750 maximum per period of cov-
erage; $50 individual deductible,
applies to minor restorative and
major restorative services
Hospital Indemnity
(Inpatient hospitalization outside the
U.S. only)
Private Hospitals: $400 maximum
limit per overnight and $4,000
maximum limit per period of
coverage
Public Hospitals: $500 maximum
limit per overnight and $5,000
maximum limit per period of
coverage. Not subject to
deductible or coinsurance
Private Hospitals: $400 maximum
limit per overnight and $4,000
maximum limit per period of
coverage
Public Hospitals: $500 maximum
limit per overnight and $5,000
maximum limit per period of
coverage. Not subject to
deductible or coinsurance
Private Hospitals: $400 maximum
limit per overnight and $4,000
maximum limit per period of
coverage
Public Hospitals: $500 maximum
limit per overnight and $5,000
maximum limit per period of
coverage. Not subject to
deductible or coinsurance
Private Hospitals: $400 maximum
limit per overnight and $4,000
maximum limit per period of
coverage
Public Hospitals: $500 maximum
limit per overnight and $5,000
maximum limit per period of
coverage. Not subject to
deductible or coinsurance
(CONTINUED)
Summary Schedule of Benefits
Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents
(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
6