Global Medical Insurance Benefits & Exclusions

Benefit Description Subject to deductible and coinsurance unless otherwise noted	Silver	Gold	Platinum
Coverage Area	Two options: worldwide or worldwide excluding the U.S. and Canada	Two options: worldwide or worldwide excluding the U.S. and Canada	Two options: worldwide or worldwide excluding the U.S. and Canada
Policy Maximum	$5,000,000 lifetime per individual	$5,000,000 lifetime per individual	$8,000,000 lifetime per individual
Deductible	Ranges from $250 to $10,000 per period of coverage, 50% reduction within PPO	Ranges from $250 to $10,000 per period of coverage, 50% reduction within PPO, Carry forward deductible - last 30 days of certificate year	Ranges from $100 to $10,000 per period of coverage, 50% reduction within PPO, Carry forward deductible - last 30 days of certificate year
Family Deductible	3x the single	3x the single	2x the single
Coinsurance within the U.S. and Canada	80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage	80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage	90% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage
Coinsurance within the PPO network and outside the U.S. and Canada	100%	100%	100%
Hospitalization / Room & Board	$600 per day (maximum of 240 consecutive days per covered event)	Average semi-private room rate	Private room rate
Intensive Care Unit	$1,500 per day (maximum of 180 consecutive days per covered event)	Usual, Reasonable and Customary (URC)	Usual, Reasonable and Customary (URC)
Surgery	URC	URC	URC
Anesthetist's Charges Associated with Surgery	20% of surgery benefit	URC	URC
Transplants	$250,000 per transplant	$1,000,000 lifetime maximum	$2,000,000 lifetime maximum
Outpatient	Visits/Exams - 25 visits per insured person per period of coverage to the maximum limit as outlined: physician $70; specialist $70; psychiatrist $60; chiropractor $50; surgical intervention consultation $500; X-rays - $250 per exam maximum limit; Lab Tests - $300 per exam maximum limit	URC	URC
Rx Coverage	URC	URC	URC
Emergency Room Illness	URC - subject to an additional $250 deductible if not admitted	URC - subject to an additional $250 deductible if not admitted	URC - subject to an additional $250 deductible if not admitted
Emergency Room Accident	URC	URC	URC
Local Ambulance	$1,500 per covered event - not subject to deductible or coinsurance	URC	URC
Emergency Evacuation	$50,000 per period of coverage - not subject to deductible or coinsurance	Limited to policy maximum - not subject to deductible or coinsurance	Limited to policy maximum - not subject to deductible or coinsurance
Emergency Reunion	NA (Not Applicable)	$10,000 lifetime maximum	$10,000 lifetime maximum
Return of Mortal Remains	$25,000 lifetime maximum per insured - not subject to deductible or coinsurance	$25,000 lifetime maximum per insured -not subject to deductible or coinsurance	$50,000 lifetime maximum per insured -not subject to deductible or coinsurance
Maternity	Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section, $200 child wellness benefit for first 12 months - not subject to deductible or coinsurance. Available after 10 months of coverage benefits reduced by 50% for births that occur in11th or 12th month of continuous coverage	Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section, $200 child wellness benefit for first 12 months - not subject to deductible or coinsurance. Available after 10 months of coverage benefits reduced by 50% for births that occur in11th or 12th month of continuous coverage	Same As Any Illness (SAAI) $1,000 additional deductible, $50,000 lifetime maximum, $200 child wellness benefit for first 12 months. Available after 10 months of coverage
Supplemental Accident	NA	$300 per occurrence - not subject to deductible or coinsurance	$500 per occurrence - not subject to deductible or coinsurance
Mental/Nervous	Outpatient only - (see Outpatient) Available after 12 months of continuous coverage	$10,000 per period of coverage up to a $50,000 lifetime maximum. Available after 12 months of continuous coverage	SAAI $50,000 lifetime maximum. Available after 12 months of continuous coverage
Adult Wellness	NA	$250 per period of coverage - not subject to deductible or coinsurance Available for those 30 years of age and over after 12 months of continuous coverage	$500 per period of coverage - not subject to deductible or coinsurance Available for those 18 years of age and over after 12 months of continuous coverage
Child Wellness	Three visits per period of coverage -maximum $70 per visit. Available for children under 18 years of age after 12 months of continuous coverage	$200 maximum per period of coverage -not subject to deductible or coinsurance Available for children under 18 years of age after 12 months of continuous coverage	$400 maximum per period of coverage - not subject to deductible or coinsurance Available for children under 18 years of age after 12 months of continuous coverage
Other Services	Extended Care - limited to first 30 days of confinement Radiation Treatment - URC Home Nursing Care - limited 30 days per covered event Hospice Care - limited 30 days per covered event Prosthetic Devices - all URC	URC	URC
Physical Therapy	Maximum $40 per visit 30 visit maximum per period of coverage	Maximum $50 per visit	Maximum $50 per visit
High School Sports Injury	NA	NA	Up to $5,000 maximum
Recreational SCUBA	NA	URC	URC
Remote Transportation	NA	NA	Limited to $5,000 per certificate period up to a $20,000 lifetime maximum
Political Evacuation and Repatriation	NA	NA	Limited to $10,000 lifetime maximum
Complementary Medicine	NA	Acupuncture $150 Aroma Therapy $50 Herbal Therapy $50 Magnetic Therapy $75 Massage Therapy $150 Vitamin Therapy $100 Each per period of coverage	Acupuncture $150 Aroma Therapy $50 Herbal Therapy $50 Magnetic Therapy $75 Massage Therapy $150 Vitamin Therapy $100 Each per period of coverage
Non-emergency Dental	NA	NA	Calendar year maximum - $750 Individual deductible - $50 Schedule of benefits - Class I: 90% Class II: 70% Class III: 50% Ortho 0% (6 month waiting period)
Emergency Dental due to Accident	$1,000 per period of coverage	URC	URC
Emergency Dental due to Sudden Unexpected Pain	NA	$100 per period of coverage	See non-emergency dental benefits
Vision	NA	NA	Exams - up to $100 per 24 months Materials - up to $150 per 24 months
Global Concierge & Assistance Services	NA	NA	Included
Pre-existing Conditions	$5,000 per period of coverage up to a $50,000 lifetime maximum. Available after 24 months of continuous coverage	$5,000 per period of coverage up to a $50,000 lifetime maximum. Available after 24 months of continuous coverage	SAAI
NA (Not Applicable) / URC (Usual, Reasonable and Customary) / SAAI (Same As Any Illness)

After coverage has been in effect for 24 continuous months, the Silver and Gold plan options provide a US$50,000 lifetime benefit for eligible pre-existing conditions that existed at or prior to the effective date, subject to a maximum of US$5,000 per period of coverage. This benefit is payable whether or not you have received consultation or treatment for the condition(s) during the 24-month period. The Silver and Gold plan options do not rider or charge additional premium for pre-existing conditions. If you properly disclose a pre-existing condition at the time of application and are accepted into the plan, you will be covered for eligible medical expenses after 24 months of continuous coverage, subject to the foregoing limits and the other terms of the plan.*

The following illnesses which exist, manifest themselves or are treated or have treatment recommended prior to or during the first 180 days of coverage from the initial effective date are considered pre-existing conditions and are subject to the waiting period and other limitations of coverage described above: asthma, allergies, tonsillectomy, back conditions,
adenoidectomy, hemorrhoids or hemorrhoidectomy, disorders of the reproductive system, hysterectomy, hernia, gall stones or kidney stones, any condition of the breast, and any condition of the prostate.

On the Platinum plan option, conditions that are fully disclosed on the application and have not been excluded or restricted by a rider will be covered the same as any illness. Conditions, including any complications therefrom, that are not fully disclosed on the application will not be covered.

*This website contains only a consolidated and summary description of some of the current Global Medical Insurance benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate Wording for this insurance plan in the event this application and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request. .

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