Page 3 - AtlasMultiTrip_Brochure
P. 3
Plan Details $250 per covered trip
Deductible $1,000,000
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Coinsurance

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 the 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 the 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.

Acute Onset of Pre-existing Condition (excludes chronic Up to the overall maximum limit
and congenital conditions) (only available to members $25,000 lifetime maximum for Emergency Medical Evacuation
under age70)

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).

All Other Eligible Medical Expenses Up to the overall maximum limit

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

Hospital Indemnity $100 per day of inpatient hospitalization- not subject to deductible

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 per 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 Ages70 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
Lifetime Maximum- $6,250
Under age 18
Lifetime Maximum- $5,000 Ages 75 and older
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

Bedside Visit Subject to a maximum of $250,000 any one family or group.
Crisis Response- Ransom, Personal Belongings, and - not subject to deductible, or overall maximum limit
Crisis Response Fees and Expenses
Up to $1,500- not subject to deductible
Personal Liability
Up to $10,000- not subject to deductible, or overall maximum limit
Border Entry Protection
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,000
Up to $500 if traveling on a valid B-2 visa and denied entrance at the U.S. border
– not subject to deductible
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