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PLAN BENEFITS - SELECT
Benefit
Certificate period maximum
Maximum benefit - per injury / illness
Deductible inside PPO network
Deductible all other locations
Emergency room copay
Student health center copay
Physician office copay
Urgent care copay
Inpatient/Outpatient Hospital copay
Co-insurance - In Network (inside USA)
Co-insurance - out of network (Inside USA)
Co-Insurance (Outside of USA)
AirDoctor virtual telemedecine
Hospital room & board
Local ambulance if hospitalized as inpatient
Intensive care unit
Outpatient treatment
Outpatient prescriptions
Mental health (outpatient) excludes student health center
Mental health (inpatient) excludes student health center
Emergency Dental Treatment
Dental treatment due to accident
Pre-existing Conditions
Acute onset of pre-existing conditions
Maternity (care for covered pregnancy)
Newborn care (routine nursery of newborn)
Therapeutic termination of pregnancy
Outpatient physiotherapy & chiropractic care
Sports cover
Intercollegiate, interscholastic, intramural & club sports
Leisure, recreational, entertainment of fitness
Terrorism (medical expenses only)
Emergency medical evacuation
Emergency reunion
Accidental death & dismemberment
Repatriation of remains
Personal liability
Vaccinations
Limit
$600,000
$300,000
$35 - per injury / illness
$70 - per injury / illness
$200 - for treatment received in the ER
$10 - per visit
$50 - per visit in network ($100 out of network)
$50 - per visit in network ($100 out of network)
$100 - per visit in network ($200 out of network)
80% coverage up to $5,000 - 100% thereafter
Usual, reasonable & customary (URC)
100% up to the maximum
Max 3 visits for polices over 180 days
Average semi-private room rate
$750 - not subject to co-insurance
Up to overall maximum
Up to overall maximum
50% of actual charge
Maximum of 30 visits - includes drug & alcohol abuse
Maximum of 30 days - includes drug & alcohol abuse
$100
$250 per tooth - $500 maximum
Excluded until 6 months continuous coverage
$25,000 lifetime maximum
$10,000 lifetime maximum
$750 - not subject to coinsurance
$500 - not subject to coinsurance
$50 per visit per day - excludes student health center
$5,000 per injury
Up to overall maximum
$50,000 lifetime maximum
$300,000 lifetime maximum
$5,000 - maximum 15 days
Death $25,000, Loss of 2 limbs $25,000, Loss of 1 limb - £12,500
$50,000 lifetime maximum
Not insured
Not insured
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