Description of Benefits
All coverage, benefits and premiums are in U.S. Dollar amounts. If an Injury or Illness occurs during the Period of Coverage and the Insured Person requires medical or surgical treatment, this plan will pay the following Covered Expenses, up to the selected policy maximum. (Subject to the selected deductible and applicable co-insurance, and exclusions)
Covered Expenses – Expenses that are incurred for medical care and supplies which are: (a) necessary and customary; (b) prescribed by a Physician for the therapeutic treatment of a disablement; (c) are not excluded under the policy; (d) are not more than the Reasonable and Customary charges (as determined by the Company); and (e) are incurred within 180 days from the date of the Disablement will be considered.
- Expenses made by a Hospital for room and board, floor nursing and other services, including Expenses for professional services, except personal services of a non-medical nature, provided, however, that Expenses do not exceed the Hospital’s average charge for semi-private room and board accommodation.
- Charges made for Intensive Care or Coronary Care charges and nursing services;
- Expenses made for diagnosis, Treatment and surgery by a Physician.
- Charges made for an operating room.
- Charges made for Outpatient Treatment, same as any other Treatment covered on an Inpatient basis. This includes ambulatory Surgical centers, Physician’s Outpatient visits/examinations, clinic care, and Surgical opinion consultations.
- Expenses made for administration of anesthetics.
- Expenses for medication, x-ray services, laboratory tests and services, the use of radium and radio-active isotopes, oxygen, blood transfusions, iron lungs, and medical Treatment.
- Expenses for physiotherapy, if recommended by a Physician, for the Treatment of a specific Disablement and administered by a licensed physiotherapist; With regards to chiropractic care, eligible charges up to $50.00 per visit, with a maximum of 10 visits.
- Dressings, drugs, and medicines that are prescribed by a Physician.
- Hotel room charge, when the insured, otherwise necessarily confined in a Hospital, shall be under the care of a duly qualified Physician in a hotel room owing to the unavailability of a Hospital room.
Policy Medical Maximum Choices
Plan A – $50,000
Plan B – $100,000
Plan C – $250,000
Plan D – $500,000
Plan E – $1,000,000
Persons up to age 69 are eligible for all plans;
Persons age 70-79 are eligible for plans A and B;
Persons age 80+ are limited to $20,000.
$0, $50, $100, $250, $500, $1,000, $2,500, $5000 per person per policy period.
Emergency Medical Evacuation – Benefits are paid for Covered Expense incurred up to $500,000 for any covered Injury or Illness that requires immediate transportation from the place where You are located (due to inadequate medical facilities).
Repatriation – If it is determined by the Assistance Company and your Physician that it is Medically Necessary for You to return to Your primary place of residence because of an unforeseen Sickness or Injury which is acute or life-threatening, the Transportation Expense incurred within 90 days from the date of the Covered Loss will be paid for Your return to Your Home Country or to a medical facility closest to Your primary place of residence.
Return of Mortal Remains – If death occurs, Benefits will be paid for Reasonable and Customary Covered Expenses to return Your remains to Your Home Country.
Emergency Medical Reunion – If it is determined by the Assistance Company and your Physician that it is necessary for You to have an Emergency Medical Evacuation, this Plan will arrange to bring an individual of Your choice, from Your current Home Country, to be at Your side while You are hospitalized and then accompany You during Your return home.
Return of Minor Child(ren) – Should the Insured Person be traveling alone with a Minor Child(ren) and be hospitalized because of a covered Illness or Injury and Your Minor Child(ren) is left unattended, the Assistance Company will arrange for a one way economy fare(s) to Your current Home Country.
Interruption of Trip – If Your trip is interrupted due to the Death of an Immediate Family Member or serious damage to your residence, benefits will be paid up to $5,000 for the Expense of economy travel less the value of applied credit from an unused return travel ticket to return You home to Your area of principal residence.
Loss of Baggage – This plan will reimburse You for loss, theft, or damage to Your baggage or personal effects checked with a Common Carrier, after coverage provided by a Common Carrier.
Political and Natural Disaster Evacuation – Coverage is provided up to $50,000 if the Insured requires emergency evacuation due to situations which place him/her in Imminent Bodily Harm or due to a Natural Disaster.
Emergency Dental Treatment (Accident) – Benefits are paid for Reasonable and Customary Expense for emergency Dental Treatment to natural teeth.
Emergency Dental Treatment (Palliative) – Benefits are paid up to $100 for emergency Treatment for the relief of pain to natural teeth.
*Some Exclusions Apply*
See the full Diplomat America Description of Coverage