All amounts shown are in U.S. dollars.
| SUMMARY OF BENEFITS | |
| Maximum Limits | Individual: $50,000, $100,000, $500,000, $1,000,000, $2,000,000 Group: $100,000, $250,000, $1,000,000 |
| Individual Deductible | Individual: $0, $100, $250, $500, $1,000 or $2,500 On the Application Form, you will be asked to circle your choice of a deductible. Your premium rate is dependent on the deductible you choose. Please see the Application Form for more information. |
| Coinsurance | For treatment received outside the U.S. & Canada: No coinsurance For treatment received within the U.S. & Canada: In the PPO Network: The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Maximum Limit Outside the PPO Network: The plan pays 80% of eligible expenses up to $5,000, then 100% up to the Maximum Limit |
| Benefit Period | Three months If a covered injury or illness requires continuing treatment after the Period of Coverage expires, the three-month Benefit Period may offer continued coverage for that injury or illness. When the Certificate expires, the Company will review the date of initial treatment for the covered injury or illness. If treatment began less than three months before the Period of Coverage expired, benefits for the covered injury or illness continues. This is subject to the Maximum Limits and the other terms of the plan until there have been three months of continuous coverage for the covered injury or illness. |
| INPATIENT OR OUTPATIENT SERVICES | |
| Eligible Medical Expenses | Up to the maximum limit |
| COVID-19 / SARS-CoV-2 Coverage | COVID-19/SARS-CoV-2 shall be considered by the Company the same as any other Illness or Injury, subject to all other Terms and conditions of this insurance |
| Physician Visits / Services | Up to the maximum limit |
| Hospital Emergency Room: Inside the U.S. |
Up to the maximum limit Injury: not subject to additional deductible Illness: additional $250 deductible if not admitted |
| Hospital Emergency Room: Outside the U.S. | Up to the Maximum Limit |
| Hospitalization / Room & Board | Average semi-private room rate up to the maximum limit. Includes nursing service |
| Intensive Care | Up to the maximum limit |
| Outpatient Surgical / Hospital Facility | UUp to the maximum limit |
| Laboratory Up | Up to the maximum limit |
| Radiology / X-ray | Up to the maximum limit |
| Chemotherapy / Radiation Therapy | Up to the maximum limit |
| Pre-Admission Testing | Up to the maximum limit |
| Surgery | Up to the maximum limit |
|
Reconstructive Surgery Surgery is incidental to and follows surgery that was covered under the plan | Up to the maximum limit |
| Assistant Surgeon | 20% of the primary surgeons eligible fee |
| Anesthesia | Up to the maximum limit |
| Durable Medical Equipment | Up to the maximum limit |
|
Chiropractic Care Medical order or treatment plan required | Up to the maximum limit |
|
Physical Therapy Treatment Medical order or treatment plan required | Up to the maximum limit |
|
Extended Care Facility Upon direct transfer from an acute facility | Up to the maximum limit |
|
Home Nursing Care Upon direct transfer from an acute facility Provided by a home health care agency | Up to the maximum limit |
| PRESCRIPTION DRUGS and MEDICATIONS | |
|
Prescription Drugs and Medications Obtained through Retail Pharmacy, Inpatient and Outpatient Surgery, Emergency Room and Outpatient Office Visits Dispensing maximum for Retail Pharmacy: 90 days per prescription Dispensing limit per perscription: 90 days |
| EMERGENCY SERVICES | Not subject to deductible and coinsurance unless otherwise noted. |
|
Emergency Medical Evacuation Must be approved in advance and coordinated by the company | $500,000 maximum limit |
|
Emergency Reunion Must be approved in advance by the company | Up to $50,000 lifetime maximum |
|
Political Evacuation & Repatriation Must be approved in advance by the company | Up to $10,000 |
|
Return of Minor Children Must be approved in advance by the company | Up to $50,000 |
|
Return of Mortal Remains or Cremation/Burial
Must be approved in advance by the company | Up to $50,000 for return of mortal remains or $5,000 for cremation/burial |
| OTHER SERVICES | |
|
Accidental Death & Dismemberment (AD&D) Death must occur within 90 days of the accident | $25,000 principal sum. Not subject to deductible. |
| Common Carrier Accidental Death | $50,000 per insured adult and $250,000 maximum limit per family. Not subject to deductible. |
| Dental Treatment - Accident |
$100 Limit Treatment due to an Accidental Injury and obtained at a Dental Provider’s office |
|
Traumatic Dental Injury Treatment at a hospital due to an accident | Up to the maximum limit. Additional treatment for the same injury rendered by a dental provider will be paid at 100%. |
| Hospital Indemnity | $100 per overnight inpatient hospitaization, maximum limit of 10 overnights. Not subject to deductible. |
| Identity Theft Assistance | Up to $500. Not subject to deductible |
| Lost Luggage | Limit $250, $50 maximum per item |
| Natural Disaster | $100 per day and maximum limit of 5 days for accommodations. Not subject to deductible. |
| Terrorism $ | $50,000 maximum limit. Not subject to deductible. |
| Trip Interruption | Up to $5,000. Not subject to deductible |
* 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.