Page 6 - Atlas_MultiTrip_Sspecimen
P. 6
SCHEDULE OF BENEFITS AND LIMITS
Plan Details $1,000,000
Overall Maximum Limit $1,000,000
$250 per covered trip
Maximum per Injury / Illness We will pay 100% of eligible expenses, after the deductible, to the
Deductibles overall maximum limit.
Coinsurance
Eligible expenses are subject to deductible, overall maximum limit,
and are per certificate period unless specifically indicated otherwise.
SPECIMENBENEFIT LIMIT
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit
Local Ambulance Up to the overall maximum limit
Emergency Room Co-payment Usual, reasonable and customary charges, when covered illness
or injury results in hospitalization as inpatient.
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.
Urgent Care Center Co-payment Claims incurred outside the U.S.
No co-payment
Claims incurred in U.S.
For each visit, you shall be responsible for a $15 co-payment.
– Co-payment is waived for members with a $0 deductible.
– not subject to deductible
Outpatient Physical Therapy & Claims incurred outside the U.S.
Chiropractic Care No co-payment
Up to $50 maximum per day. Must be ordered in advance by a
Emergency Dental (Acute Onset of Pain) physician.
Emergency Eye Exam for a Covered Up to $250 - not subject to deductible
Loss
Up to $150. $50 deductible per occurrence (plan deductible is
waived).
Acute Onset of Pre-existing Condition Up to the overall maximum limit
(excludes chronic and congenital $25,000 lifetime maximum for Emergency Medical Evacuation
conditions) (only available to members
under age 70) Up to $50,000 lifetime maximum, eligible medical expenses only.
Up to the overall maximum limit
Terrorism
All Other Eligible Medical Expenses Limit
Emergency Travel Benefits Up to $1,000,000 lifetime maximum, except as provided under
Acute Onset of Pre-existing Condition
Emergency Medical Evacuation - not subject to deductible or overall maximum limit
6 Atlas MultiTrip Description of Coverage | Tokio Marine HCC - MIS Group
Plan Details $1,000,000
Overall Maximum Limit $1,000,000
$250 per covered trip
Maximum per Injury / Illness We will pay 100% of eligible expenses, after the deductible, to the
Deductibles overall maximum limit.
Coinsurance
Eligible expenses are subject to deductible, overall maximum limit,
and are per certificate period unless specifically indicated otherwise.
SPECIMENBENEFIT LIMIT
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit
Local Ambulance Up to the overall maximum limit
Emergency Room Co-payment Usual, reasonable and customary charges, when covered illness
or injury results in hospitalization as inpatient.
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.
Urgent Care Center Co-payment Claims incurred outside the U.S.
No co-payment
Claims incurred in U.S.
For each visit, you shall be responsible for a $15 co-payment.
– Co-payment is waived for members with a $0 deductible.
– not subject to deductible
Outpatient Physical Therapy & Claims incurred outside the U.S.
Chiropractic Care No co-payment
Up to $50 maximum per day. Must be ordered in advance by a
Emergency Dental (Acute Onset of Pain) physician.
Emergency Eye Exam for a Covered Up to $250 - not subject to deductible
Loss
Up to $150. $50 deductible per occurrence (plan deductible is
waived).
Acute Onset of Pre-existing Condition Up to the overall maximum limit
(excludes chronic and congenital $25,000 lifetime maximum for Emergency Medical Evacuation
conditions) (only available to members
under age 70) Up to $50,000 lifetime maximum, eligible medical expenses only.
Up to the overall maximum limit
Terrorism
All Other Eligible Medical Expenses Limit
Emergency Travel Benefits Up to $1,000,000 lifetime maximum, except as provided under
Acute Onset of Pre-existing Condition
Emergency Medical Evacuation - not subject to deductible or overall maximum limit
6 Atlas MultiTrip Description of Coverage | Tokio Marine HCC - MIS Group
