Page 6 - AtlasGroup_Specimen
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Except for a benefit period, coverage provided under this Master Policy is for a maximum duration of
364 days.
Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole
option, elect to cancel all members of the same sex, age, class or geographic location, provided we
give no less than 30 days advance written notice by mail to your last known address.
SCHEDULE OF BENEFITS AND LIMITS
Plan Details Age 80 or older $10,000.
Overall Maximum Limit Age 70 to 79: $50,000, $100,000, or $250,000.
Maximum per Injury / Illness All others: $50,000, $100,000, $250,000, $500,000, $1,000,000, or
$2,000,000.
Deductibles
Coinsurance Age 80 or older $10,000.
Age 70 to 79: $50,000, $100,000, or $250,000.
All others: $50,000, $100,000, $250,000, $500,000, $1,000,000, or
$2,000,000.
$0, $100, $250, $500, $1,000, $2,500, or $5,000 per certificate
period
We will pay 100% of eligible expenses after the deductible up to the
overall maximum limit.
SPECIMEN
Eligible expenses are subject to deductible, overall maximum limit,
and are per certificate period unless specifically indicated otherwise.
Benefit Limit
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit Up to the overall maximum limit
Local Ambulance Usual, reasonable and customary charges, when covered illness
or injury results in hospitalization as inpatient.
Emergency Room Co-payment Claims incurred in U.S.
You shall be responsible for a $200 co-payment for each use of
emergency room for an illness unless you are admitted to the
hospital. There will be no co-payment for emergency room
treatment of an injury.
Claims incurred outside the U.S.
No co-payment
Urgent Care Center Co-payment Claims incurred in U.S.
For each visit, you shall be responsible for a $15 co-payment
Outpatient Physical Therapy and – Co-payment is waived for members with a $0 deductible.
Chiropractic Care – not subject to deductible
Claims incurred outside the U.S.
No co-payment
Up to $50 maximum per day. Must be ordered in advance by a
physician.
Emergency Dental (Acute Onset of Pain) Up to $250 - not subject to deductible
6 Atlas Group Description of Coverage | Tokio Marine HCC - MIS Group
364 days.
Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole
option, elect to cancel all members of the same sex, age, class or geographic location, provided we
give no less than 30 days advance written notice by mail to your last known address.
SCHEDULE OF BENEFITS AND LIMITS
Plan Details Age 80 or older $10,000.
Overall Maximum Limit Age 70 to 79: $50,000, $100,000, or $250,000.
Maximum per Injury / Illness All others: $50,000, $100,000, $250,000, $500,000, $1,000,000, or
$2,000,000.
Deductibles
Coinsurance Age 80 or older $10,000.
Age 70 to 79: $50,000, $100,000, or $250,000.
All others: $50,000, $100,000, $250,000, $500,000, $1,000,000, or
$2,000,000.
$0, $100, $250, $500, $1,000, $2,500, or $5,000 per certificate
period
We will pay 100% of eligible expenses after the deductible up to the
overall maximum limit.
SPECIMEN
Eligible expenses are subject to deductible, overall maximum limit,
and are per certificate period unless specifically indicated otherwise.
Benefit Limit
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit Up to the overall maximum limit
Local Ambulance Usual, reasonable and customary charges, when covered illness
or injury results in hospitalization as inpatient.
Emergency Room Co-payment Claims incurred in U.S.
You shall be responsible for a $200 co-payment for each use of
emergency room for an illness unless you are admitted to the
hospital. There will be no co-payment for emergency room
treatment of an injury.
Claims incurred outside the U.S.
No co-payment
Urgent Care Center Co-payment Claims incurred in U.S.
For each visit, you shall be responsible for a $15 co-payment
Outpatient Physical Therapy and – Co-payment is waived for members with a $0 deductible.
Chiropractic Care – not subject to deductible
Claims incurred outside the U.S.
No co-payment
Up to $50 maximum per day. Must be ordered in advance by a
physician.
Emergency Dental (Acute Onset of Pain) Up to $250 - not subject to deductible
6 Atlas Group Description of Coverage | Tokio Marine HCC - MIS Group
