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Lifetime Maximum Benefit
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$5,000,000 per Insured Person.
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Deductible
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$100, $250, $500 Maximum of 3 deductible payments for families enrolling on one application.
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Coinsurance Outside of the United States
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After the Deductible, the Policy pays 100% of eligible expenses to the Policy Maximum.
Hospital Admissions must be Pre-Notified using SRI's Pre-Notification Program. Expenses described above which are not Pre-Notified to SRI may be subject to a 25% reduction of eligible expenses.
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Coinsurance Inside of the United States
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After the Deductible, the Policy pays 80% of the next $5,000 of eligible expenses, then 100% up to the Policy Maximum.
Expenses incurred inside the United States must be Pre-Notified using SRI's Pre-Notification Program. Expenses described above which are not Pre-Notified to SRI may be subject to a 25% reduction of eligible expenses.
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Hospital Expenses
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Policy maximum limit for average semi-private room and board, URC physician charges, prescription medications, durable medical equipment, nursing services, and x-rays.
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Intensive Care
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Policy maximum limit for intensive care room and board, URCphysician charges, prescription medications, durable medical equipment, nursing services and x-rays.
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Surgery
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Policy maximum limit for URC Charges for surgery, physician and anesthetics.
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Outpatient Treatment
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Policy maximum limit for URC Charges for emergency treatment, surgery, andprescription medication.
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Physiotherapy, Chiropractic
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$75 limit per visit (limit of 12 visits per policy year) & $10,000 lifetime maximum, when referred in advance by a physician. Benefit begins after 12 month waiting period.
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Ambulance
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Policy maximumlimit for URC charges.
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Well Child Care
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$200 limit per policy period for checkups/routine visits age 18 and younger(limit of 3 visits per year). Benefit begins after 12 month waiting period.
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Preventive Benefits
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$175 limit per policy period for checkups/routine visitsage 19 and older. Deductible and coinsurance do not apply. Benefit begins after 12 month waiting period.
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Maternity
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No coverage
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Newborn Benefit
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No coverage
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Mental & Nervous
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$10,000 limit per policy period & $30,000 lifetime maximum. URC charges are covered after a 12 month waiting period.
Inpatient limit of 45 days per policy period. Outpatient limit of 40 visits (separate coinsurance of 70% applies) per policy period.
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Emergency Dental
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$500 limit per policy period, $50 per occurrence deductible. This benefit covers URC Charges for repair and replacement of sound, natural teeth damaged as a result of an accident.
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Emergency Medical Evacuation
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$50,000 limit per policy period. This benefit applies when adequate medical facilities and/or treatment are not available in yourarea and a medically necessary evacuation is ordered by your physician.
Requires pre-approval.
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Return of Remains
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$25,000 limit. This benefit pays to return your remains to your country of residence.
Requires pre-approval.
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Emergency Medical Reunion
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$10,000 limit per occurrence. When an emergency medical evacuation occurs, and the physician recommends a family memberaccompany you, we will arrange roundtrip economy air fare for an individual of your choice to travel to your side and also pay accommodation expenses at $250 or less per day for up to 10 days (including travel). Requires pre-approval.
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Accidental Death & Dismemberment (AD&D)*
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Principal Sum: $10,000 Insured and Spouse, $2,000 Dependent Children.
Common Carrier: Principal Sum: $40,000 Insured and Spouse, $8,000 Dependent Children.
*The total paid for all insured person(s) for any one covered accident shall not exceed $200,000
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Lifetime Transplant Benefit
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Up to $1,000,000 per Insured Person.
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Hospital Daily Indemnity
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For every medically necessary night you are an inpatient in a hospital outside of the U.S. and Canada, we will pay you $50 (maximum of $1,000 per policy period). This is in addition to coverage for hospital expenses.
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