| The OverseasCare™ Visitors Insurance™ Plan Schedule of Benefits |
| BENEFITS |
BASIC COVERAGE
(Age 5 years to 79) |
PREMIER COVERAGE
(Age 5 years to 79) |
COVERAGE OPTION
for AGE 80+ |
Sudden onset of a Pre-ex Look Back - up to age 69
($25,000 Maximum Limit for Medical Evacuations) |
$50,000 Maximum Limit |
$75,000 Maximum Limit |
No Coverage. |
| Pre-existing Condition/Pre-existing Look Back |
No Coverage/3 years |
No Coverage/2 years |
No Coverage/Permanent |
| INPATIENT Treatment |
$60,000 Maximum per Injury/Illness |
$110,000 Maximum per injury/illness |
$55,000 Maximum per injury/illness |
| Hospital Room & Board including Laboratory Tests, X-rays,
Prescription Medical and other miscellaneous: |
Up to $1,500 per day, 30 day Maximum |
Up to $2,000 per day, 30 day Maximum |
Up to $1,000 per day, 30 day Maximum |
| Hospital Intensive Care Unit |
Up to $2,000 per day, 7 day Maximum
(including Hospital Room & Board) |
Up to $2,500 per day, 7 day Maximum
(including Hospital Room & Board) |
Up to $2,000 per day, 7 day Maximum
(including Hospital Room & Board |
| Surgical Treatment |
Up to $3,500 |
Up to $6,000 |
Up to $2,000 |
| Anesthesia |
Up to $1,000 |
Up to $1,500 |
Up to $400 |
| Assistant Surgeon |
Up to $1,000 |
Up to $1,500 |
Up to $650 |
| Physician's Non-Surgical Visits |
Up to $60 per unit, 1 visit per day, 10 day Maximum |
Up to $80 per unit, 1 visit per day, 10 day Maximum |
Up to $50 per unit, 1 visit per day, 10 day Maximum |
| Consultant Physician, when requested by attending Physician |
Up to $450 |
Up to $500 |
Up to $350 |
| Pre-Admission Tests within 7 days before Hospital admission |
Up to $1000 |
Up to $1250 |
Up to $750 |
| OUTPATIENT TREATMENT |
| Surgical Treatment |
Up to $3500 |
Up to $6000 |
Up to $2000 |
| Outpatient Surgical Facility |
Up to $500 |
Up to $1500 |
Up to $400 |
| Anesthesia |
Up to $1000 |
Up to $1500 |
Up to $400 |
| Assistant Surgeon |
Up to $1000 |
Up to $1000 |
Up to $650 |
| PPhysician's Non-Surgical/Urgent Care Visits |
Up to $60 per unit, 1 visit per day, 10 day Maximum |
Up to $40 per unit, 1 visit per day, 10 day Maximum |
Up to $50 per unit, 1 visit per day, 8 day Maximum |
| Diagnostic X-ray & Lab Services |
Up to $800 |
Up to $1,000 |
Up to $300 |
| Scan, PAT, CAT & MRI |
Up to $500 |
Up to $500 |
Up to $250 |
| Hospital Emergency Room |
Up to $300 Maximum (Additional $100 Deductible) |
Up to $400 Maximum (Additional $75 Deductible) |
Up to $300 Maximum (Additional $100 Deductible) |
| Prescription Drugs |
Up to $250 |
Up to $500 |
Up to $100 |
| Day Surgery - related to a scheduled outpatient surgery at a
Hospital or licensed outpatient surgery center; including the
cost of operating room, anesthesia, drugs and medications and
medical supplies. |
Up to $1,000 |
Up to $1,200 |
Up to $750 |
| OTHER TREATMENT & SERVICES |
| Ambulance Services |
Up to $500 |
Up to $550 |
Up to $250 |
| Dental Treatment (injury ONLY ), Injury to Sound, Natural Teeth |
Up to $500 |
Up to $550 |
Up to $250 |
| Ambulance Services |
Up to $500 (if admitted for overnight stay) |
Up to $750 (if admitted for overnight stay) |
Up to $400 (if admitted for overnight stay) |
| Emergency Evacuation |
Up to $5,000 |
Up to $7,500 |
Up to $5,000 |
| Physiotherapy |
Up to $25 per unit, per day, 10 visits Maximum |
Up to $50 per unit, per day, 10 visits Maximum |
Up to $25 per unit, per day, 10 visits Maximum |
| AD&D Principal Sum |
Up to $25,000 Common Carrier |
Up to $25,000 Common Carrier |
Up to $25,000 Common Carrier |
| TRAVEL RELATED COVERAGE |
| Loss of Passport |
Up to $100 |
Up to $150 |
Up to $100 |
| Lost Checked Luggage - Commercial Carrier |
Up to $100 (secondary coverage ONLY) |
Up to $100 (secondary coverage ONLY) |
Up to $100 (secondary coverage ONLY) |
| Mental & Nervous Disorder/Substance Abuse |
No Coverage |
No Coverage |
No Coverage |
| Skin Disease |
No Coverage |
No Coverage |
No Coverage |
| Coverage - International Travel (excluding Participating
Member's Home Country |
Yes |
Yes |
No Coverage |
| Coverage - Mexico and Canada (starting port must be based in US) |
Yes |
Yes |
No Coverage |