| |
Plan A - US$25,000 maximum
benefit per life of plan |
Plan B - US$50,000 maximum
benefit per life of plan |
Plan C - US$100,000 maximum
benefit per life of plan |
| Inpatient Treatment |
| Hospital room & board |
Up to US US$825 per day, 30 day maximum per
period of coverage |
Up to US US$1,400 per day, 30 day maximum per period
of coverage |
Up to US US$1,950 per day, 30 day maximum per period
of coverage |
| Intensive Care |
Additional US$400 per day, 8 day maximum per
period of coverage |
Additional US$660 per day, 8 day maximum per period
of coverage |
Additional US$850 per day, 8 day maximum per period
of coverage |
| Surgical Treatment |
US$2,000 per surgical session |
US$3,300 per surgical session |
US$5,500 per surgical session |
| Consult physician |
US$350 per period of coverage |
US$450 per period of coverage |
US$500 per period of coverage |
| Pre-admission tests |
US$750 per period of coverage |
US$1,100 per period of coverage |
US$1,100 per period of coverage |
| Private duty nurse |
US$400 per period of coverage |
US$550 per period of coverage |
US$550 per period of coverage |
| Physician visits |
US$40 allowable charge per visit, 30 visits
per period of coverage |
US$55 allowable charge per visit, 30 visits per
period of coverage |
US$85 allowable charge per visit, 30 visits per
period of coverage |
| Outpatient Treatment |
| Surgical treatment |
US$2,000 per surgical session |
US$3,300 per surgical session |
US$5,500 per surgical session |
| Diagnostic x-ray & lab |
US$650 per period of coverage, (US$325 allowable
charge per procedure) |
US$800 per period of coverage, (US$400 allowable
charge per procedure) |
US$950 per period of coverage, (US$475 allowable
charge per procedure) |
| Hospital emergency room |
US$200 allowable charge per visit |
75% of URC to US$330 |
75% of URC to US$550 |
| Prescription drugs |
US$150 per period of coverage |
US$250 per period of coverage |
US$250 per period of coverage |
| Physician visits |
US$50 allowable charge per visit, 10 visits
per period of coverage |
US$55 allowable charge per visit, 10 visits per
period of coverage |
US$85 allowable charge per visit, 10 visits per
period of coverage |
| Miscellaneous Inpatient
& Outpatient Services |
| Anesthetist |
US$450 per surgical session |
25% of surgical benefit |
25% of surgical benefit |
| Assistant surgeon |
US$450 per surgical session |
25% of surgical benefit |
25% of surgical benefit |
| Other Coverages |
| Ambulance |
US$250 per period of coverage |
US$450 per period of coverage |
US$450 per period of coverage |
| Dental for accident to sound natural teeth |
US$350 per period of coverage |
US$550 per period of coverage |
US$550 per period of coverage |
| Physiotherapy |
US$25 per visit per day, 12 visits per period
of coverage |
US$40 per visit per day, 12 visits per period of
coverage |
US$40 per visit per day, 12 visits per period of
coverage |
Atlas
