ChoiceAmerica™
All amounts shown are in U.S. dollars.
All amounts shown are in U.S. dollars.
| PLAN INFORMATION | |||
| Benefits | Plan A | Plan B | Plan C |
|---|---|---|---|
| Maximum | $50,000 per certificate period | $100,000 per certificate period | $150,000 per certificate period |
|
Deductible ($0 deductible not available for ages 70-79) | $0, $50, or $100 per certificate period | $0, $50, or $100 per certificate period | $0, $50, or $100 per certificate period |
| Inpatient Treatment | |||
| Inpatient Physician Visits |
Up to $75 per visit, 30 visits per certificate period |
Up to $90 per visit, 30 visits per certificate period |
Up to $120 per visit, 30 visits per certificate period |
| Specialist Consultation | Up to $450 per consultation | Up to $500 per consultation | Up to $650 per consultation |
| Hospital Room & Board |
Up to $1,400 per day, 30-day maximum certificate period |
Up to $2,000 per day, 30-day maximum per certificate period |
Up to $3,000 per day, 25-day maximum per certificate period |
| Intensive Care |
Up to an additional $700 per day, 8-day maximum per certificate period |
Up to an additional $1,000 per day, 8-day maximum per certificate period |
Up to an additional $1,500 per day, 8-day maximum per certificate period |
| Private Duty Nurse | Up to $550 per certificate period | Up to $550 per certificate period | Up to $700 per certificate period |
| Surgeon | Up to $4,000 per surgical session | Up to $6,000 per surgical session | Up to $7,500 per surgical session |
| Outpatient Treatment | |||
|
Outpatient Physician Visits (Includes Urgent Care Clinics and Walk-in Clinics) | Up to $65 per visit, 10 visits per certificate period | Up to $90 per visit, 10 visits per certificate period | Up to $130 per visit, 10 visits per certificate period |
| Pre-Admission Testing | Up to $1,100 per certificate period | Up to $1,100 per certificate period | Up to $1,500 per certificate period |
| Diagnostic Laboratory & Radiology | Up to $1,000 per certificate period | Up to $1,250 per certificate period | Up to $1,500 per certificate period |
| Hospital Emergency Room | Up to $400 per visit | Up to $600 per visit | Up to $800 per visit |
| Surgical Facility | Up to $900 per surgical session | Up to $1,000 per surgical session | Up to $1,500 per surgical session |
| Surgeon | Up to $4,000 per surgical session | Up to $4,500 per surgical session | Up to $8,000 per surgical session |
| Physical Therapy |
Up to $60 per visit per day, 15 visits per certificate period |
Up to $60 per visit per day, 15 visits per certificate period |
Up to $60 per visit per day, 15 visits per certificate period |
| Extended Care Facility | Up to $200 per day, 15 day maximum per certificate period | Up to $250 per day, 15 day maximum per certificate period | Up to $250 per day, 15 day maximum per certificate period |
| Prescriptions | Up to $350 per certificate period | Up to $350 per certificate period | Up to $350 per certificate period |
| Miscellaneous Inpatient & Outpatient Treatment | |||
| Assistant Surgeon | Up to $825 per surgical session | Up to $1,375 per surgical session | Up to $1,800 per surgical session |
| Anesthesia | Up to $825 per surgical session | Up to $1,375 per surgical session | Up to $1,800 per surgical session |
| Emergency Services | |||
| Common Carrier Accidental Death |
Up to $5,000 per insured or $25,000 maximum per family per certificate period |
Up to $5,000 per insured or $25,000 maximum per family per certificate period |
Up to $5,000 per insured or $25,000 maximum per family per certificate period |
| Emergency Local Ambulance | Up to $650 per certificate period | Up to $650 per certificate period | Up to $650 per certificate period |
| Emergency Medical Evacuation | Up to $50,000 per evacuation | Up to $50,000 per evacuation | Up to $100,000 per evacuation |
| Return of Mortal Remains to Home Country | Up to $7,500 maximum or $5,000 for local burial or cremation | Up to $7,500 maximum or $5,000 for local burial or cremation | Up to $7,500 maximum or $5,000 for local burial or cremation |
| Other Services | |||
|
COVID-19/SARS-CoV-2 Treatment | Up to the period of coverage maximum limit | Up to the period of coverage maximum limit | Up to the period of coverage maximum limit |
| Dental Accident | Up to $700 per certificate period | Up to $700 per certificate period | Up to $700 per certificate period |
| Influenza (flu) Vaccination |
Up to $50 per certificate period Deductible: $25 (plan deductible waived) Available only in the United States |
Up to $50 per certificate period Deductible: $25 (plan deductible waived) Available only in the United States |
Up to $50 per certificate period Deductible: $25 (plan deductible waived) Available only in the United States |
| Lost or Stolen Passport | Up to $100 per certificate period | Up to $100 per certificate period | Up to $100 per certificate period |
| Terrorism | Up to $50,000 per certificate period | Up to $50,000 per certificate period | Up to $50,000 per certificate period |
| Optional Coverages | |||
| Dental & Vision Rider |
Acute only: Dental - 1 exam up to $100. Tooth removal: $200 per certificate period Vision - 1 exam up to $150 per certificate period |
Acute only: Dental - 1 exam up to $100. Tooth removal: $200 per certificate period Vision - 1 exam up to $150 per certificate period |
Acute only: Dental - 1 exam up to $100. Tooth removal: $200 per certificate period Vision - 1 exam up to $150 per certificate period |
| Adventure Sports Rider |
Up to $50,000 per certificate period (Maximum limit varies by age) |
Up to $50,000 per certificate period (Maximum limit varies by age) |
Up to $50,000 per certificate period (Maximum limit varies by age) |
| Pre-Ex Rider |
Additional $50 deductible per
incident Physician visit: $150 per visit, 3 visits maximum Lab & X-ray: $1,000 Emergency room & hospitalization: $1,500 Prescription: $100 |
Additional $50 deductible per
incident Physician visit: $150 per visit, 3 visits maximum Lab & X-ray: $1,000 Emergency room & hospitalization: $1,500 Prescription: $100 |
Additional $50 deductible per
incident Physician visit: $150 per visit, 3 visits maximum Lab & X-ray: $1,000 Emergency room & hospitalization: $1,500 Prescription: $100 |
* This Web page contains only a consolidated and summary description of all current benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate Wording for this insurance plan in the event this Web page, application, and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.