|Hospitalization/room and board||In U.S. –100% of average semi-private room rate.
Outside of U.S. - 100% of private room rate (not to exceed 150% of semi-private room rate).
|Assistant Surgeon||20% of surgery benefit|
Office visits and Diagnostic/X-Ray
|Chemotherapy or Radiation Therapy||Usual, reasonable and customary charges|
|Transplants||$1,000,000 lifetime maximum|
|Emergency room illness (Additional $250 deductible if not admitted as an in patient)||100%|
|Emergency room accident||100%|
|Local ambulance due to injury or illness resulting in hospitalization||100%|
|Mental/Nervous||$10,000 maximum per period of coverage with a $50,000 lifetime maximum - Available after 12 months of continuous coverage.|
|Emergency evacuation||Up to maximum limit.
Not subject to deductible or coinsurance.
|Emergency reunion||$10,000 lifetime maximum|
|Return of mortal remains||$25,000 lifetime maximum - not subject to deductible or coinsurance.|
|Child Wellness (Through age 18)||$200 maximum per period of coverage - not subject to deductible or coinsurance.
Available after 12 months of continuous coverage.
|Adult Wellness (Through age 19 or older)||$250 per period of coverage - not subject to deductible or coinsurance. Available after 12 months of continuous coverage.|
|Physical therapy||Maximum $50 per visit|
|Complementary Medicine||Acupuncture $150; Aroma Therapy $50; Herbal Therapy $50; Magnetic Therapy $75; Massage Therapy $150; Vitamin Therapy $100;
Each per period of coverage not subject to deductible or coinsurance
|Emergency dental due to accident||100%|
|Emergency dental due to sudden unexpected pain||$100 per period of coverage|
|Hospital indemnity (Outside the U.S. only)||Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage.
|Pre-Existing Conditions Limitation||$50,000 lifetime maximum; $5,000 per period of coverage after 24 months|