Seguro Internacional | Full
International Evolution Premium 10000 - 20%
Deductible: 10.000 USD and Max. Coverage: 1.500.000 USD/Year
From
US$ 94 . 19
EICML/EVO/TOB/01/22Evolution Health Plan | Table of benefitsPage 1 of 9
Evolution Health Plan
This is the maximum amount of money we will pay to, or on behalf of, each insured person
in each period of insurance
1,000,000
Overall maximum limit
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
A. In-patient hospital stay, including
Full refund
Full refund
Full refund
Full refund
1 Hospital Benefits
Full refund
500,000
Full refund
Full refund
Full refund
Full refund
Full refund
750,000
Full refund
Full refund
Full refund
Full refund
Full refund
1,500,000
Full refund
Full refund
Full refund
Full refund
Full refund
2,000,000
Full refund
Full refund
Full refund
Full refund
Full refund
Hospital accommodation, nursing, theatre and ICU/HDU costs
Surgeons’, anaesthetists’ consultants and physicians’ fees
Physiotherapy
Internal prostheses, medical aids/devices where used as an integral part of a surgical procedure
Prescribed drugs and medicines
Full refundFull refund Full refund Full refund Full refundDiagnostic procedures including x-rays, pathology and MRI/CT/PET scans
B. Day-patient treatment when a period of recovery is required in a hospital bed Full refundFull refund Full refund Full refund Full refund
C. Parental hospital stay for one insured person to stay with an insured child (under age
19) who is an in-patient
Full refundFull refund Full refund Full refund Full refund
Pre-authorisation is required for benefits A, B, D, G, H and I
Table of Benefits
ALL BENEFITS ARE SUBJECT TO PROVIDER NETWORK OR PRE-AUTHORISATION IF
OUTSIDE OF NETWORK.
Evolution Health Plan
This is the maximum amount of money we will pay to, or on behalf of, each insured person
in each period of insurance
1,000,000
Overall maximum limit
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
A. In-patient hospital stay, including
Full refund
Full refund
Full refund
Full refund
1 Hospital Benefits
Full refund
500,000
Full refund
Full refund
Full refund
Full refund
Full refund
750,000
Full refund
Full refund
Full refund
Full refund
Full refund
1,500,000
Full refund
Full refund
Full refund
Full refund
Full refund
2,000,000
Full refund
Full refund
Full refund
Full refund
Full refund
Hospital accommodation, nursing, theatre and ICU/HDU costs
Surgeons’, anaesthetists’ consultants and physicians’ fees
Physiotherapy
Internal prostheses, medical aids/devices where used as an integral part of a surgical procedure
Prescribed drugs and medicines
Full refundFull refund Full refund Full refund Full refundDiagnostic procedures including x-rays, pathology and MRI/CT/PET scans
B. Day-patient treatment when a period of recovery is required in a hospital bed Full refundFull refund Full refund Full refund Full refund
C. Parental hospital stay for one insured person to stay with an insured child (under age
19) who is an in-patient
Full refundFull refund Full refund Full refund Full refund
Pre-authorisation is required for benefits A, B, D, G, H and I
Table of Benefits
ALL BENEFITS ARE SUBJECT TO PROVIDER NETWORK OR PRE-AUTHORISATION IF
OUTSIDE OF NETWORK.
EICML/EVO/TOB/01/22Evolution Health Plan | Table of benefitsPage 2 of 9
1 Hospital Benefits — continued
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
D. In-patient psychiatric treatment up to the number of nights shown in each period of
insurance
Full refund -
Maximum 15 nights
Not covered Full refund -
Maximum 15 nights
Full refund -
Maximum 30 nights
Full refund -
Maximum 30 nights
E. Accident and emergency room treatment which results in eligible in-patient, day-
patient treatment
Full refundFull refund Full refund Full refund Full refund
F. External prosthesis related to a surgical operation 2,5002,500 2,500 2,500 2,500
H. Kidney dialysis benefit when required temporarily for sudden kidney failure resulting from
a disease or injury which is covered by the plan. The maximum lifetime limit applies to this
benefit
Up to 20,000
lifetime limit
Not covered Up to 20,000
lifetime limit
Up to 20,000
lifetime limit
Up to 20,000
lifetime limit
I. Organ implantation benefit for kidney, liver, heart, lung, stem cell, bone marrow, and skin
grafts
200,000Not covered 100,000 250,000 300,000
G. Rehabilitation care received on an in-patient basis related to an accident/illness/injury that
occurred whilst insured on the plan
Full refund -
Maximum 13 weeks
Full refund -
Maximum 13 weeks
Full refund -
Maximum 13 weeks
Full refund -
Maximum 13 weeks
Full refund -
Maximum 13 weeks
Pre-authorisation is required for benefits A, B, D, G, H and I
J. Day-patient psychiatric cover up to four separate day admissions in each period of
insurance
Not covered Full refund
Limited to 4 separate day case
admissions per period of cover
Full refund
Limited to 4 separate day case
admissions per period of cover
Full refund
Limited to 4 separate day case
admissions per period of cover
Full refund
Limited to 4 separate day case
admissions per period of cover
K. Local ambulance services when required for transportation to hospital in the event of a
medical emergency
L. In-patient chronic conditions benefit diagnosed after the start date of the policy or
agreed to be covered in writing at application stage.
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
1 Hospital Benefits — continued
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
D. In-patient psychiatric treatment up to the number of nights shown in each period of
insurance
Full refund -
Maximum 15 nights
Not covered Full refund -
Maximum 15 nights
Full refund -
Maximum 30 nights
Full refund -
Maximum 30 nights
E. Accident and emergency room treatment which results in eligible in-patient, day-
patient treatment
Full refundFull refund Full refund Full refund Full refund
F. External prosthesis related to a surgical operation 2,5002,500 2,500 2,500 2,500
H. Kidney dialysis benefit when required temporarily for sudden kidney failure resulting from
a disease or injury which is covered by the plan. The maximum lifetime limit applies to this
benefit
Up to 20,000
lifetime limit
Not covered Up to 20,000
lifetime limit
Up to 20,000
lifetime limit
Up to 20,000
lifetime limit
I. Organ implantation benefit for kidney, liver, heart, lung, stem cell, bone marrow, and skin
grafts
200,000Not covered 100,000 250,000 300,000
G. Rehabilitation care received on an in-patient basis related to an accident/illness/injury that
occurred whilst insured on the plan
Full refund -
Maximum 13 weeks
Full refund -
Maximum 13 weeks
Full refund -
Maximum 13 weeks
Full refund -
Maximum 13 weeks
Full refund -
Maximum 13 weeks
Pre-authorisation is required for benefits A, B, D, G, H and I
J. Day-patient psychiatric cover up to four separate day admissions in each period of
insurance
Not covered Full refund
Limited to 4 separate day case
admissions per period of cover
Full refund
Limited to 4 separate day case
admissions per period of cover
Full refund
Limited to 4 separate day case
admissions per period of cover
Full refund
Limited to 4 separate day case
admissions per period of cover
K. Local ambulance services when required for transportation to hospital in the event of a
medical emergency
L. In-patient chronic conditions benefit diagnosed after the start date of the policy or
agreed to be covered in writing at application stage.
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
Full refund
EICML/EVO/TOB/01/22Evolution Health Plan | Table of benefitsPage 3 of 9
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
2 Cancer Care Benefit
A. Cancer treatment from the date an insured person is diagnosed as suffering from
cancer, all and any treatment will be assessed and paid for under this benefit
Full refundFull refund Full refund Full refund Full refund
Pre-authorisation is required
B. Out-patient services, including 1,000 for
treatment
received pre or
post op or within
6 weeks following
an eligible in-
patient stay
Full refundPhysician and consultants fees
Prescribed drugs, medication and dressings
E. MRI/CT/PET scans Full refundNot covered Full refund Full refund Full refund
F. Physiotherapy 1,000Not covered 500 1,500 2,000
C. Diagnostic tests, x-rays, pathology
D. Out-patient chronic conditions benefit diagnosed after the start date of the policy or
agreed to be covered in writing at application stage.
Not covered
Not covered
Combined limit
of 2,500
Combined limit
of 5,000
Combined limit
of 10,000
3 Out-Patient Benefits
A. Out-patient minor surgery where no period of recovery is required in a hospital bed Full refundFull refund Full refund Full refund Full refund
Benefit J is subject to a 12 month waiting period and pre-authorisation is required
Full refund
Combined limit
of 2,500
Combined limit
of 5,000
Combined limit
of 10,000
Full refund
Combined limit
of 2,500
Combined limit
of 5,000
Combined limit
of 10,000
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
2 Cancer Care Benefit
A. Cancer treatment from the date an insured person is diagnosed as suffering from
cancer, all and any treatment will be assessed and paid for under this benefit
Full refundFull refund Full refund Full refund Full refund
Pre-authorisation is required
B. Out-patient services, including 1,000 for
treatment
received pre or
post op or within
6 weeks following
an eligible in-
patient stay
Full refundPhysician and consultants fees
Prescribed drugs, medication and dressings
E. MRI/CT/PET scans Full refundNot covered Full refund Full refund Full refund
F. Physiotherapy 1,000Not covered 500 1,500 2,000
C. Diagnostic tests, x-rays, pathology
D. Out-patient chronic conditions benefit diagnosed after the start date of the policy or
agreed to be covered in writing at application stage.
Not covered
Not covered
Combined limit
of 2,500
Combined limit
of 5,000
Combined limit
of 10,000
3 Out-Patient Benefits
A. Out-patient minor surgery where no period of recovery is required in a hospital bed Full refundFull refund Full refund Full refund Full refund
Benefit J is subject to a 12 month waiting period and pre-authorisation is required
Full refund
Combined limit
of 2,500
Combined limit
of 5,000
Combined limit
of 10,000
Full refund
Combined limit
of 2,500
Combined limit
of 5,000
Combined limit
of 10,000
EICML/EVO/TOB/01/22Evolution Health Plan | Table of benefitsPage 4 of 9
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
4 Chronic Condition Benefits
A. Hospice care treatment for an insured person who is terminally ill and cared for in a
hospice
B. HIV and AIDS treatment where contracted as a result of a blood transfusion 2,500 each
insured period
Up to 37,500
lifetime limit
Not covered Not covered 5,000 each
insured period
Up to 37,500
lifetime limit
7,500 each
insured period
Up to 37,500
lifetime limit
Full refund -
Maximum 14 nights
Full refund -
Maximum 14 nights
Full refund -
Maximum 14 nights
Full refund -
Maximum 14 nights
Full refund -
Maximum 14 nights
Pre-authorisation is required. Benefit B is subject to a 2 year waiting period.
3 Out-Patient Benefits — continued Benefit J is subject to a 12 month waiting period and pre-authorisation is required
J. Out-patient psychiatric treatment, when referred by a physician Full refund -
Maximum 10 visits
Not covered Full refund -
Maximum 5 visits
Full refund -
Maximum 15 visits
Full refund -
Maximum 30 visits
K. Home nursing on the recommendation of a physician immediately following an in-
patient hospital stay
Full refund -
Maximum 12 weeks
Not covered Full refund -
Maximum 3 weeks
Full refund -
Maximum 26 weeks
Full refund -
Maximum 26 weeks
H. Complementary therapies, including chiropractic, homeopathy, osteopathy,
acupuncture, ayurvedic, herbal and Chinese medicines, with registered practitioners
and associated prescribed drugs and medicines
1,000Not covered 500 1,500 2,000
I. Hormone replacement therapy to relieve the symptoms of the menopause Not coveredNot covered Not covered 250 350
G. Medical aids and devices including the hire of mobility aids 1,000Not covered 500 1,500 2,000
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
4 Chronic Condition Benefits
A. Hospice care treatment for an insured person who is terminally ill and cared for in a
hospice
B. HIV and AIDS treatment where contracted as a result of a blood transfusion 2,500 each
insured period
Up to 37,500
lifetime limit
Not covered Not covered 5,000 each
insured period
Up to 37,500
lifetime limit
7,500 each
insured period
Up to 37,500
lifetime limit
Full refund -
Maximum 14 nights
Full refund -
Maximum 14 nights
Full refund -
Maximum 14 nights
Full refund -
Maximum 14 nights
Full refund -
Maximum 14 nights
Pre-authorisation is required. Benefit B is subject to a 2 year waiting period.
3 Out-Patient Benefits — continued Benefit J is subject to a 12 month waiting period and pre-authorisation is required
J. Out-patient psychiatric treatment, when referred by a physician Full refund -
Maximum 10 visits
Not covered Full refund -
Maximum 5 visits
Full refund -
Maximum 15 visits
Full refund -
Maximum 30 visits
K. Home nursing on the recommendation of a physician immediately following an in-
patient hospital stay
Full refund -
Maximum 12 weeks
Not covered Full refund -
Maximum 3 weeks
Full refund -
Maximum 26 weeks
Full refund -
Maximum 26 weeks
H. Complementary therapies, including chiropractic, homeopathy, osteopathy,
acupuncture, ayurvedic, herbal and Chinese medicines, with registered practitioners
and associated prescribed drugs and medicines
1,000Not covered 500 1,500 2,000
I. Hormone replacement therapy to relieve the symptoms of the menopause Not coveredNot covered Not covered 250 350
G. Medical aids and devices including the hire of mobility aids 1,000Not covered 500 1,500 2,000
EICML/EVO/TOB/01/22Evolution Health Plan | Table of benefitsPage 5 of 9
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
F. Laser eye benefit for surgery to correct vision Full refundNot covered Not covered Full refund Full refund
G. Hearing test benefit for one annual hearing test Not coveredNot covered Not covered Full refund Full refund
H. Hearing aid benefit for the cost of a hearing aid Not coveredNot covered Not covered 150 300
C. Child vaccinations for prevention of illness, up to the age of 10 75Not covered 50 100 150
D. Optical benefit for one annual eye test Not coveredNot covered Not covered Full refund Full refund
E. Vision benefit for the cost of spectacles/contact lenses Not coveredNot covered Not covered 100 300
5 Wellness Benefits
A. Wellness screening including cancer screening and routine health tests for early
diagnosis of medical conditions
20050 100 500 1,000
B. Travel vaccinations/preventative medications for overseas travel 75Not covered 50 100 150
All benefits under this item are subject to a 12 month waiting period
6 Dental Treatment Benefits
A. Emergency dental treatment - dental treatment required immediately following an
accident to repair sound natural teeth
Full refundFull refund Full refund Full refund Full refund
B. Non-emergency routine dental treatment including routine examinations, x-rays,
moulds, cleaning/polishing, fillings, extractions (except wisdom teeth)
750Not covered Not covered 1,000 1,500
A 10% co-insurance and a 6 month waiting period applies to benefits B, C, D and E of this item
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
F. Laser eye benefit for surgery to correct vision Full refundNot covered Not covered Full refund Full refund
G. Hearing test benefit for one annual hearing test Not coveredNot covered Not covered Full refund Full refund
H. Hearing aid benefit for the cost of a hearing aid Not coveredNot covered Not covered 150 300
C. Child vaccinations for prevention of illness, up to the age of 10 75Not covered 50 100 150
D. Optical benefit for one annual eye test Not coveredNot covered Not covered Full refund Full refund
E. Vision benefit for the cost of spectacles/contact lenses Not coveredNot covered Not covered 100 300
5 Wellness Benefits
A. Wellness screening including cancer screening and routine health tests for early
diagnosis of medical conditions
20050 100 500 1,000
B. Travel vaccinations/preventative medications for overseas travel 75Not covered 50 100 150
All benefits under this item are subject to a 12 month waiting period
6 Dental Treatment Benefits
A. Emergency dental treatment - dental treatment required immediately following an
accident to repair sound natural teeth
Full refundFull refund Full refund Full refund Full refund
B. Non-emergency routine dental treatment including routine examinations, x-rays,
moulds, cleaning/polishing, fillings, extractions (except wisdom teeth)
750Not covered Not covered 1,000 1,500
A 10% co-insurance and a 6 month waiting period applies to benefits B, C, D and E of this item
EICML/EVO/TOB/01/22Evolution Health Plan | Table of benefitsPage 6 of 9
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
6 Dental Treatment Benefits — continued A 10% co-insurance and a 6 month waiting period applies to benefits B, C, D and E of this item
E. Orthodontic treatment for insured children under age 19 Not coveredNot covered Not covered 500 1,000
C. Non-emergency major dental treatment including crowns, inlays, bridges, dentures,
root canal treatment and treatment of infections
750Not covered Not covered 1,000 1,500
D. Extraction of wisdom teeth as an in-patient, out-patient or day-patient Full refundNot covered Not covered Full refund Full refund
A. Complications of pregnancy and childbirth 10,000
B. Normal pregnancy and childbirth Not covered
7 Maternity Benefits
C. Paediatric benefit for the initial medical check-up of a newborn Not covered
Not covered
Not covered
Not covered
2,500
Not covered
Not covered
15,000
7,500
150
Full refund
10,000
300
D. Premature baby treatment received within the first two months following birth Not coveredNot covered Not covered Full refund Full refund
A 10 month waiting period applies and pre-authorisation is required
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
6 Dental Treatment Benefits — continued A 10% co-insurance and a 6 month waiting period applies to benefits B, C, D and E of this item
E. Orthodontic treatment for insured children under age 19 Not coveredNot covered Not covered 500 1,000
C. Non-emergency major dental treatment including crowns, inlays, bridges, dentures,
root canal treatment and treatment of infections
750Not covered Not covered 1,000 1,500
D. Extraction of wisdom teeth as an in-patient, out-patient or day-patient Full refundNot covered Not covered Full refund Full refund
A. Complications of pregnancy and childbirth 10,000
B. Normal pregnancy and childbirth Not covered
7 Maternity Benefits
C. Paediatric benefit for the initial medical check-up of a newborn Not covered
Not covered
Not covered
Not covered
2,500
Not covered
Not covered
15,000
7,500
150
Full refund
10,000
300
D. Premature baby treatment received within the first two months following birth Not coveredNot covered Not covered Full refund Full refund
A 10 month waiting period applies and pre-authorisation is required
EICML/EVO/TOB/01/22Evolution Health Plan | Table of benefitsPage 7 of 9
A. Congenital benefit for conditions not discovered at birth but which can subsequently
be corrected with surgery. A maximum lifetime limit applies to this benefit.
Not covered
8 Additional Benefits
Not covered Not covered Full refund -
Up to 20,000
lifetime limit
Full refund -
Up to 20,000
lifetime limit
A 12 month waiting period applies to Benefit A and C
B. Congenital/birth defects benefit for conditions diagnosed within one year of birth for
babies conceived by natural means. A maximum lifetime limit applies to this benefit.
Not coveredNot covered Not covered Full refund -
Up to 20,000
lifetime limit
Full refund -
Up to 20,000
lifetime limit
C. Infertility benefit investigations into the medical cause of infertility, where both
members are insured under this policy and when the couple’s treating physician
believes there are symptoms and/or evidence to suggest a medical cause.
Not coveredNot covered Not covered 2,000 3,000
9 Cash Benefits Benefit B is subject to a 10 month waiting period
A. Hospital cash benefit when in-patient treatment received is free of charge 50 per night -
Maximum 30 nights
100 per night -
Maximum 30 nights
200 per night -
Maximum 30 nights
200 per night -
Maximum 30 nights
100 per night -
Maximum 30 nights
B. Maternity cash benefit payable on the birth of a child when no claim has been made
under the maternity benefit
Not covered Not covered 250 500Not covered
C. Convalescence cash benefit payable for each complete week of confinement to home
(excluding first week) - benefit limited to 4 weeks in each period of insurance
Not covered Not covered Not covered 500Not covered
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite
A. Congenital benefit for conditions not discovered at birth but which can subsequently
be corrected with surgery. A maximum lifetime limit applies to this benefit.
Not covered
8 Additional Benefits
Not covered Not covered Full refund -
Up to 20,000
lifetime limit
Full refund -
Up to 20,000
lifetime limit
A 12 month waiting period applies to Benefit A and C
B. Congenital/birth defects benefit for conditions diagnosed within one year of birth for
babies conceived by natural means. A maximum lifetime limit applies to this benefit.
Not coveredNot covered Not covered Full refund -
Up to 20,000
lifetime limit
Full refund -
Up to 20,000
lifetime limit
C. Infertility benefit investigations into the medical cause of infertility, where both
members are insured under this policy and when the couple’s treating physician
believes there are symptoms and/or evidence to suggest a medical cause.
Not coveredNot covered Not covered 2,000 3,000
9 Cash Benefits Benefit B is subject to a 10 month waiting period
A. Hospital cash benefit when in-patient treatment received is free of charge 50 per night -
Maximum 30 nights
100 per night -
Maximum 30 nights
200 per night -
Maximum 30 nights
200 per night -
Maximum 30 nights
100 per night -
Maximum 30 nights
B. Maternity cash benefit payable on the birth of a child when no claim has been made
under the maternity benefit
Not covered Not covered 250 500Not covered
C. Convalescence cash benefit payable for each complete week of confinement to home
(excluding first week) - benefit limited to 4 weeks in each period of insurance
Not covered Not covered Not covered 500Not covered
£/$/€ £/$/€ £/$/€ £/$/€ £/$/€
Standard Standard Plus Comprehensive Premium Elite