Secutive | Compass Insurance Booking: GACC

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Travel Medical Insurance

Medical Maximum Benefit: USD 100.000

24INT07870 | 5129

2.80 USD per day

Details

Schedule of Benefits

ACCIDENT & SICKNESS MEDICAL EXPENSE BENEFITS

Benefits will be provided only for the coverages listed below and will be paid only up to the amounts shown. Benefits are not provided for coverages marked “NIL”.

Per Injury or Sickness Maximum:	$100,000
Deductible (Outpatient Services Only) Per Injury or Sickness:	$0
Coinsurance:	100% of Usual, Reasonable & Customary (URC) Charges or Preferred Allowance, if a contracted Provider is used
Pre-Existing Conditions: (subject to 36-month look back period, see definition)	12 month waiting period, then limited to $5,000 thereafter
Home Country Coverage	NIL
BENEFIT COVERAGE		COVERED BENEFIT
Hospital Room & Board Benefit: Subject to Semi-private room rate		100% URC
Intensive Care/Cardiac Care Unit Benefit		100% URC
Hospital Miscellaneous Expense Benefit		100% URC
Surgeon (In or Outpatient) Benefits		100% URC
Assistant Surgeon Benefit		100% URC
Pre-Admission Testing Benefit		100% URC
Anesthesia Benefit		100% URC
Day Surgery Miscellaneous Benefit		100% URC
Diagnostic X-Ray and Lab Benefit		100% URC
Ambulance Benefit		100% URC, up to $5,000 maximum
Physician Visit Benefit (Inpatient)		100% URC
Physician Visit Benefit (Outpatient)		100% URC
Consultant Physician Benefit		100% URC
Radiation/Chemotherapy Benefit		100% URC
Emergency Room Benefit Triage is mandatory Co-Payment only applies to services rendered in the USA		100% URC, subject to a $350 Co-Payment, waived if admitted, or in an accident

Emergency Dental Expense Benefit Limited to accidental Injury of sound natural teeth sustained while covered	100% URC
Palliative Dental • Sudden onset of pain • Maximum Benefit per Period of Insurance: $200 per tooth	100% URC
Physiotherapy Expense Benefit - Inpatient	100% URC
Physiotherapy Expense Benefit - Outpatient	100% URC, up to $2,500 maximum
Durable Medical Equipment Expense Benefit	100% URC
Emergency Medical Evacuation Expense Benefit	100% of actual expense, up to $250,000 maximum benefit
Emergency Medical Repatriation Expense Benefit	100% of actual expense, up to $50,000
Emergency Reunion	100% of actual expense, up to $5,000
Prescription Drug Benefit	100% URC
Return Ticket Benefit	100% up to $1,500 per Period of Insurance
Emergency Treatment of a Pre-Existing Condition Physician and clinic visits	100% URC, up to a maximum of $500 per Period of Insurance

BENEFIT COVERAGE	COVERED BENEFIT
Personal Accident	Up to $15,000
Trip Interruption Benefit	Up to $1,500

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First Name
Last Name
Date of Birth	/ /
Gender
Start Date
End Date
Home Country
Travel Destination

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Selected insurance coverage	Rate per person / travel day: 2.80 USD
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