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MEDICAL EXPENSE BENEFITS UP TO $50,000 MAXIMUM BENEFIT PAID AS
SPECIFIED BELOW (FOR EACH INJURY OR SICKNESS) |
|
COVERED SERVICES |
BENEFIT PAYABLE |
|
Room and Board |
80%
of the semi-private or intensive care unit rate |
|
Hospital Miscellaneous Expenses |
80% of the expenses incurred during a hospital
confinement or as an outpatient for day surgery.
Benefit includes anesthesia, operating room, laboratory
test, x-rays, oxygen tent, drugs, medicines, dressings,
and other necessary non-room and board hospital expenses |
|
Surgical Expense (Inpatient or Outpatient) |
80%
up to a maximum per operation of $5,000 |
|
Anesthetist |
30%
of the amount payable for the operation |
|
Assistant Surgeon |
30%
of the amount payable for the operation |
|
Inpatient Physician’s Fees Expense |
80% |
|
Ambulance Expense |
$500 maximum benefit |
|
Outpatient Expenses |
80%
up too the a maximum benefit of 2,500 for services provided in a
doctor’s office, hospital or outpatient department or emergency room,
clinical lab, radiological facility or other similar licensed facility
|
|
Physiotherapy |
Included in Outpatient Expenses provided that it is prescribed by a
licensed physician and the prescription is for a stated number of
treatments. |
|
Outpatient Expense Co-pays |
- Hospital emergency room
visit that does not result in admission - $100
- Hospital emergency room
visit that does not result in admission when doctor ordered - $50
- Hospital outpatient
department visit - $50
- Doctor visit - $25
Deductible and Coinsurance
will also be waived for emergency medical services for an Injury or
Sickness, which, if not treated at once, would place your life in
danger.
|
|
High Cost Procedure Expense |
In
addition to the coverage above, for specific outpatient services costing
over $200 (C.A.T. scan, MRI, Laser Treatment) we will pay 80% up to a
maximum benefit of $2,000. |
|
Consultant or Specialist Expense |
$300 maximum benefit |
|
Prescribed Medicine Expense |
80%
up to a maximum benefit of $50 per injury or sickness, after a $5 co-pay
|
|
Maternity Expense |
Same as any other Sickness. Voluntary abortion is payable at 100% up to
$400 |
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Outpatient Contraceptive Services |
Covered as any other Outpatient Expense |
|
Repatriation Expense Benefit |
$7,500 |
|
Medical Evacuation Benefit |
$10,000 |
|
Pre-Existing Conditions Limitations |
No
coverage unless no medical advice or treatment given for that condition
within 6 months prior to the effective date of coverage |
|
Mandated Benefits |
Policy will pay according to Massachusetts Insurance Laws |
This summary is intended to give a brief overview of coverage. The
benefits and limits described above are subject to policy conditions and
exclusions, which will be detailed when brochure is completed.
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