Page 3 - AtlasGroup_Brochure
P. 3
PLAN DETAILS
Deductibles $0, $100, $250, $500, $1,000, $2,500 or $5,000 per certificate period.
Overall Maximum Limit 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.
Coinsurance We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.
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.
Local Ambulance Usual, reasonable and customary charges when covered illness or injury results in hospitalization as inpatient.
Intensive Care Unit Up to the overall maximum limit.
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 you are admitted to
the hospital.
There will be no copayment for emergency room treatment of an injury.
Claims incurred outside the U.S.
No co-payment
Urgent Care Center 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
Claims incurred outside the U.S.
No co-payment
Outpatient Physical Therapy and Chiropractic Care Up to $50 maximum per day. Must be ordered in advance by a physician.
All Other Eligible Medical Expenses Up to the overall maximum limit.
Acute Onset of Pre-existing Condition (excludes chronic and congen- Age 70 to 79: Up to the overall maximum limit or $100,000, whichever is lower
ital conditions) (only available to members under age 80) Under age 70: Up to the overall maximum limit.
Up to $25,000 lifetime maximum for Emergency Medical Evacuation.
Terrorism Up to $50,000 lifetime maximum. Eligible medical expenses only.
Emergency Dental (Acute Onset of Pain) Up to $250 – not subject to deductible
Emergency Eye Exam for a Covered Loss Up to $150. $50 deductible per occurrence (plan deductible is waived).
EMERGENCY TRAVEL BENEFITS LIMIT
Emergency Medical Evacuation Up to $1,000,000 lifetime maximum, except as provided under Acute Onset of Pre-existing Condition.
– not subject to deductible or overall maximum limit
Return of Minor Children Up to $50,000 – not subject to deductible
Pet Return Up to $1,000 – not subject to deductible
Repatriation of Remains Up to the overall maximum limit – not subject to deductible
Emergency Reunion Up to $100,000, subject to a maximum of 15 days – not subject to deductible
Natural Disaster – Replacement Accommodations Up to $250 a day for 5 days – not subject to deductible
Trip Interruption Up to $10,000 – not subject to deductible
Travel Delay Up to $100 a day after a 12-hour delay period requiring an unplanned overnight stay. Subject to a maximum of 2
days.– not subject to deductible
Lost Checked Luggage Up to $500 – not subject to deductible
Political Evacuation Up to $100,000 lifetime maximum – not subject to deductible
Accidental Death & Dismemberment (excludes loss due to common carrier accident)
$250,000 maximum benefit any one family or group. Ages 18 through 69 Ages 70 through 74
– not subject to deductible or overall maximum limit Lifetime Maximum - $50,000 Lifetime Maximum - $12,500
Death - $50,000 Death - $12,500
Loss of 2 Limbs - $50,000 Loss of 2 Limbs - $12,500
Loss of 1 Limb - $25,000 Loss of 1 Limb - $6,250
Under age 18 Ages 75 and older
Lifetime Maximum - $5,000 Lifetime Maximum - $6,250
Death - $5,000 Death - $6,250
Loss of 2 Limbs - $5,000 Loss of 2 Limbs - $6,250
Loss of 1 Limb - $2,500 Loss of 1 Limb - $3,125
Common Carrier Accidental Death $50,000
Ages 18 through 69 $25,000
Under age 18 $12,500
Ages 70 through 74 $6,250
Ages 75 and older Subject to a maximum of $250,000 any one family or group.
- not subject to deductible or overall maximum limit
Crisis Response - Ransom, Personal Belongings, and Crisis Up to $10,000 – not subject to deductible or overall maximum limit
Response Fees and Expenses
Hospital Indemnity $100 per day of inpatient hospitalization – not subject to deductible
Personal Liability Up to:
$10,000 lifetime maximum
$10,000 third person injury
$10,000 third person property
$2,500 related third person property
– not subject to deductible or overall maximum limit
Bedside Visit Up to $1,500 – not subject to deductible
Border Entry Protection Up to $500 if traveling on a valid B-2 visa and denied entrance at the U.S. border
– not subject to deductible
Deductibles $0, $100, $250, $500, $1,000, $2,500 or $5,000 per certificate period.
Overall Maximum Limit 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.
Coinsurance We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.
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.
Local Ambulance Usual, reasonable and customary charges when covered illness or injury results in hospitalization as inpatient.
Intensive Care Unit Up to the overall maximum limit.
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 you are admitted to
the hospital.
There will be no copayment for emergency room treatment of an injury.
Claims incurred outside the U.S.
No co-payment
Urgent Care Center 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
Claims incurred outside the U.S.
No co-payment
Outpatient Physical Therapy and Chiropractic Care Up to $50 maximum per day. Must be ordered in advance by a physician.
All Other Eligible Medical Expenses Up to the overall maximum limit.
Acute Onset of Pre-existing Condition (excludes chronic and congen- Age 70 to 79: Up to the overall maximum limit or $100,000, whichever is lower
ital conditions) (only available to members under age 80) Under age 70: Up to the overall maximum limit.
Up to $25,000 lifetime maximum for Emergency Medical Evacuation.
Terrorism Up to $50,000 lifetime maximum. Eligible medical expenses only.
Emergency Dental (Acute Onset of Pain) Up to $250 – not subject to deductible
Emergency Eye Exam for a Covered Loss Up to $150. $50 deductible per occurrence (plan deductible is waived).
EMERGENCY TRAVEL BENEFITS LIMIT
Emergency Medical Evacuation Up to $1,000,000 lifetime maximum, except as provided under Acute Onset of Pre-existing Condition.
– not subject to deductible or overall maximum limit
Return of Minor Children Up to $50,000 – not subject to deductible
Pet Return Up to $1,000 – not subject to deductible
Repatriation of Remains Up to the overall maximum limit – not subject to deductible
Emergency Reunion Up to $100,000, subject to a maximum of 15 days – not subject to deductible
Natural Disaster – Replacement Accommodations Up to $250 a day for 5 days – not subject to deductible
Trip Interruption Up to $10,000 – not subject to deductible
Travel Delay Up to $100 a day after a 12-hour delay period requiring an unplanned overnight stay. Subject to a maximum of 2
days.– not subject to deductible
Lost Checked Luggage Up to $500 – not subject to deductible
Political Evacuation Up to $100,000 lifetime maximum – not subject to deductible
Accidental Death & Dismemberment (excludes loss due to common carrier accident)
$250,000 maximum benefit any one family or group. Ages 18 through 69 Ages 70 through 74
– not subject to deductible or overall maximum limit Lifetime Maximum - $50,000 Lifetime Maximum - $12,500
Death - $50,000 Death - $12,500
Loss of 2 Limbs - $50,000 Loss of 2 Limbs - $12,500
Loss of 1 Limb - $25,000 Loss of 1 Limb - $6,250
Under age 18 Ages 75 and older
Lifetime Maximum - $5,000 Lifetime Maximum - $6,250
Death - $5,000 Death - $6,250
Loss of 2 Limbs - $5,000 Loss of 2 Limbs - $6,250
Loss of 1 Limb - $2,500 Loss of 1 Limb - $3,125
Common Carrier Accidental Death $50,000
Ages 18 through 69 $25,000
Under age 18 $12,500
Ages 70 through 74 $6,250
Ages 75 and older Subject to a maximum of $250,000 any one family or group.
- not subject to deductible or overall maximum limit
Crisis Response - Ransom, Personal Belongings, and Crisis Up to $10,000 – not subject to deductible or overall maximum limit
Response Fees and Expenses
Hospital Indemnity $100 per day of inpatient hospitalization – not subject to deductible
Personal Liability Up to:
$10,000 lifetime maximum
$10,000 third person injury
$10,000 third person property
$2,500 related third person property
– not subject to deductible or overall maximum limit
Bedside Visit Up to $1,500 – not subject to deductible
Border Entry Protection Up to $500 if traveling on a valid B-2 visa and denied entrance at the U.S. border
– not subject to deductible
