Global Medical Insurance Schedule of Benefits

Global Medical Insurance^sm (GMI) covers the Usual, Reasonable and Customary (URC) charges for eligible expenses in the area where you receive treatment. Each person will only need to satisfy their deductible once per policy period (12 months) with a maximum of three deductibles per family per calendar year. For eligible expenses incurred in the U.S. and Canada: once the deductible is met, GMI pays 80% of the first US$5000 in eligible expenses and than 100% of eligible expenses up to the policy maximum. For eligible expenses incurred outside the U.S. and Canada: once the deductible is met, GMI will pay 100% up to the policy maximum.

MEDICAL INSURANCE	BENEFIT Subject to deductible and coinsurance
Coverage Area Policy Maximum Per Individual Hospitalization Policy Maximum Per Individual Hospitalization Semi-private room and board, nursing services, Prescription medication, physician charges, Diagnostic and laboratory testing, X-rays, Chemotherapy and radiation, Durable medical equipment, Treatment, services and supplies routinely provided	Worldwide US$5,000,000 lifetime
Intensive Care Unit	URC
Surgery Surgical care, Second surgical opinion, Anesthetics, Physician charges for surgery, Treatment, services and supplies routinely provided	URC
Transplants Covered only within IMG's PPO Transplant Facilities	US$1,000,000 lifetime
Outpatient Emergency treatment of illness or injury, Surgery, Rehabilitative treatment, Treatment, services or supplies routinely provided, Prescription medication	URC
Emergency Surgery or dental treatment following an accident, Emergency room following an accident	URC
Emergency Transportation by Ground Ambulance	URC
Emergency Medical Evacuation Included with Emergency Medical Evacuation is an Emergency Reunion benefit of US$10,000 lifetime	Up to Policy Maximum
Repatriation	US$25,000
Supplemental Accident The first $300 will be covered for each accidental injury	US$300 per occurrence (not subject to the deductible or coinsurance)
Maternity After 12 months of continuous coverage Pre and Post–natal care, Normal delivery or C–section, Well baby care and treatment of newborn coverage) for first 31 days	US$50,000 lifetime maximum of US$5,000 for normal delivery for each pregnancy, maximum of US$7,500 for C–Section delivery for each pregnancy
Newborns Eligible newborn children may be added without evidence of insurability. An application must be submitted within 31 days of child's birth	URC
Child Wellness Available for eligible children from 14 days to 18 years of age after 12 months of continuous coverage	US$50 maximum per visit; US$150 per policy period (not subject to deductible or coinsurance)
Pre–existing Conditions After 24 months of continuous coverage	US$50,000 lifetime (maximum US$5000 Per Policy Period)
Mental/Nervous Care After 12 months of continuous coverage, Inpatient and outpatient care by a licensed psychiatrist	US$10,000 per period, US$25,000 lifetime
Wellness Females and Males age 35 and over after 24 months on the plan. Routine physicals, Mammogram, ob/gyn visit, etc. (exams must be separated by 12 months)	US$250 per period (not subject to deductible or coinsurance)
Complimentary Medicine
Acupuncture	US$150
Aroma Therapy	US$50
Herbal Therapy	US$50
Magnetic Therapy	US$75
Massage Therapy	US$150
Vitamin therapy	US$100
Other Chiropractor when referred by a physician, Radiation treatment, Home nursing care, Hospice care, Physical therapy (maximum US$50 per visit), Prosthetic devices	URC

This is a summary of benefits. Please refer to the policy wording for a complete description.

You may seek treatment under Global Medical Insurance^sm worldwide, including the United States, at the hospital or doctor of your choice. When seeking treatment in the U.S, you may use IMG's^sm PPO, a network of over 325,000 physicians and 3,500 hospitals. The IMG^sm network reaches across the country and includes some of the most recognized university medical centers and transplant facilities in the United States.

Using the provider network will significantly reduce your out–of–pocket expenses. Your deductible will be reduced by 50% and any coinsurance applicable to that charge is waived when eligible treatment is received by a network provider. When a U.S. hospital outside the network is used, a co–payment of US$250 is required in addition to the regular deductible and coinsurance. This co–payment is waived if there is not a network provider within 50 miles from the location of treatment.

Schedule of benefits