DEDUCTIBLE OPTIONS
|
I |
II |
III |
IV |
| Outside USA |
US$2,000 |
US$5,000 |
US$10,000 |
US$20,000 |
| Inside USA |
PLAN INFORMATION
| BENEFIT |
COVERAGE |
| Maximum coverage per insured, per policy year |
US$1.000.000 |
| Age limit for applying |
Up to 79 years old |
| Waiting period |
30 days |
| Coverage outside the United States |
100%* with free choice of doctors and hospitals |
| Coverage within the United States |
• 100%* at LEVERAGE® US Network Providers
• Outside the LEVERAGE® US Network, coverage will be 60%, with a maximum daily rate of up to US$700 for a standard room and up to US$1,400 per day for intensive care
• Emergency medical treatment will be covered at 100%* up to the policy limits |
COVERED CONDITIONS
| BENEFIT |
COVERAGE |
| Neurological diseases (including strokes) |
US$200,000 |
| Cardiac revascularization surgery and angioplasty |
US$200,000 |
| Cancer (exams, medications, chemotherapy, radiation therapy, tumor surgery, and reconstructive surgery) |
US$250.000 |
| Multiple trauma (including rehabilitation) |
US$250,000 |
| Chronic kidney failure (dialysis or hemodialysis) |
US$200,000 |
| Severe burns (including reconstructive surgery) |
US$350,000 |
| Infectious diseases requiring hospitalization |
US$200,000 |
| Organ and tissue transplant |
US$550,000 lifetime Includes US$100,000 benefit for living donor expenses |
HOSPITAL BENEFITS
| BENEFIT |
COVERAGE |
| Standard hospital room |
100%* |
| Use of intensive care unit |
100%* |
| Bed expenses for an adult accompanying a hospitalized insured person |
For an Insured under 18 years of age |
US$150 per night, max. 30 nights |
| From an Insured over the age of 18 |
100%, max. 21 nights |
| Medications prescribed during hospitalization |
100%* |
| Physical and rehabilitation therapy |
100% UCR in covered conditions |
OUTPATIENT BENEFITS
| BENEFIT |
COVERAGE |
| Emergency room and urgent care services |
100% in covered conditions |
| Visits to physicians and specialists |
100% in covered conditions |
| Visits from doctors and specialists at home (where available) |
100% in covered conditions |
| Outpatient prescription medications |
US$5,000 |
| Home nursing or therapist care |
US$7,000 |
| Physical and rehabilitation therapy |
US$7,000 |
GENERAL BENEFITS
| BENEFIT |
COVERAGE |
| Surgeon and anesthesiologist Fees |
100% in covered conditions |
| Laboratory tests and diagnostic services (laboratory tests, pathology, X-rays, MRI/CT/PET scans) |
100% in Covered Conditions |
| Durable medical equipment |
US$7,000 in Covered Conditions |
| Congenital and/or Hereditary Conditions |
Diagnosed before age of 18 |
10% of the benefit in Covered Conditions, Lifetime |
| Diagnosed after age 18 |
50% of the benefit in Covered Conditions, Lifetime |
| Reconstructive surgery after an accident or illness |
Up to the maximum benefit |
| Emergency Transportation |
Ground Ambulance |
100%* for Covered Conditions, no deductible applies |
| Air Ambulance |
US$30,000 in Covered Conditions, no deductible applies |
| Repatriation or cremation of mortal remains |
US$10,000 |
OTHER BENEFITS
| BENEFIT |
COVERAGE |
| Treatment for injuries during training or practice of high-risk activities and/or non-professional sports |
US$100,000 lifetime benefit for multiple trauma or severe burns |
| Palliative care |
100%* of covered conditions |
| EVER® Expert Medical Review |
Access to a second medical opinion from renowned experts around the world, no deductible applies |
OPTIONAL ADDITIONAL BENEFITS (ANNEXES)
| BENEFIT |
COVERAGE |
| Emergency coverage when traveling abroad |
Up to US$5,000 for emergency medical treatment abroad |
