Benefit

Platinum

Coverage Area

Worldwide

Overall Policy Maximum

$5,000,000 Lifetime

Deductibles Available

$250, $500, $1,000 or $2,500 per Certificate Period.

Coinsurance -- Claims incurred in US or Canada

80% of the next $5,000 of Eligible Medical Expenses after the Deductible, then 100% to the Overall Policy Maximum.

Coinsurance -- claims incurred outside US or Canada

100% of Eligible Medical Expenses after the Deductible to the Overall Policy Maximum.

Hospital Room and Board -- In US or Canada

Average Semi-private room rate.

Hospital Room and Board -- Outside US or Canada

Average Private room rate.

Intensive Care Unit -- In US or Canada

3 times the Average Semi-private room rate.

Intensive Care Unit -- Outside US or Canada

3 times the Average Private room rate.

Mental or Nervous Disorders

$10,000 per Certificate Period (after 12 months of continuous coverage); $25,000 Lifetime Maximum.

Maternity -- Normal Delivery

Same as any other Illness (after 12 months of continuous coverage) including pre-natal, Delivery and post-natal care.

Maternity -- Complicated Delivery

Same as any other Illness (after 12 months of continuous coverage).

Maximum for Maternity

$50,000 Lifetime

Newborn Care

$25,000 Maximum Limit for maximum of 31 days.

Pre-existing Conditions

Same as any other Injury or Illness if disclosed on Application and not excluded or limited by Rider.

Local Ambulance

$2,500 Lifetime Maximum.

Physical Therapy

$50 Maximum per visit.

Wellness

$150 per Certificate Period (after 24 months of continuous coverage) for Members age 35 or older. Not subject to Deductible.

Human Organ/Tissue Transplants

Same as any other Illness for Covered Transplants.

All Other Eligible Expenses

Usual, Reasonable and Customary.

Emergency Medical Evacuation

$25,000 Lifetime Maximum.

Pre-certification Penalty

50%

Benefit

Premier

Coverage Area

Worldwide, except US and Canada

Overall Policy Maximum

$1,000,000 Lifetime

Deductibles Available

$250, $500, $1,000 or $2,500 per Certificate Period.

Coinsurance–Claims incurred in US or Canada

No coverage in US or Canada.

Coinsurance–claims incurred outside US or Canada

100% of Eligible Medical Expenses after the Deductible to the Overall Policy Maximum.

Hospital Room and Board–In US or Canada

No coverage in US or Canada.

Hospital Room and Board–Outside US or Canada

Average Private room rate.

Intensive Care Unit–In US or Canada

No coverage in US or Canada.

Intensive Care Unit–Outside US or Canada

3 times the Average Private room rate.

Mental or Nervous Disorders

$5,000 per Certificate Period (after 24 months of continuous coverage); $10,000 Lifetime Maximum.

Maternity–Normal Delivery

$3,500 per Pregnancy (after 24 months of continuous coverage) including pre-natal, Delivery and post-natal care.

Maternity–Complicated Delivery

$6,000 per Pregnancy (after 24 months of continuous coverage) including pre-natal, Delivery and post-natal care.

Maximum for Maternity

$10,000 Lifetime

Newborn Care

$5,000 Maximum Limit for maximum of 31 days.

Pre-existing Conditions

$25,000 Lifetime Maximum (after 24 months of continuous coverage).

Local Ambulance

$1,000 Lifetime Maximum.

Physical Therapy

No coverage.

Wellness

No coverage.

Human Organ/Tissue Transplants

Same as any other Illness for Covered Transplants.

All Other Eligible Expenses

Usual, Reasonable and Customary.

Emergency Medical Evacuation

No coverage.

Pre-certification Penalty

50%

Age

Basic Life Principal Sum

Supplemental Life Principal Sum

19 to 59

$50,000

$50,000

60 to 64

$25,000

$25,000

65 to 69

$10,000

Not Available

Dependent Child

$5,000

Not Available