| Gold Plan Coverage |
Participant
|
| Coverage A - |
|
Medical Expenses Lifetime Maximum Benefits |
$ 1,000,000 |
Medical Expenses Policy Year Maximum Benefits |
$ 250,000 |
| Medical Expenses per Injury or
Sickness Maximum Benefits |
$ 250,000 |
| Basic Medical Expenses Benefit
per Injury or Sickness |
Up to $5,000 Maximum;
100% of Reasonable Expenses after Deductible |
| Supplemental Major Medical Expense
Benefit (SMM) per Injury or Sickness After Basic Medical Expense
Benefit Maximum has Been Paid: |
80% of reasonable
expenses paid up to an additional
$ 245,000 maximum |
Pregnancy Coverage
|
The insurer will pay
the actual expenses incurred as a result of pregnancy, childbirth, miscarriage, or any complications resulting
from any of these, except to the extent shown in the Schedule of Benefits. Conception must have occurred while Covered Person
was insured under the Policy. |
Deductible
(Deductible is reduced to $50 if treatments received at Recognized
Student Health Center or if initial treatment is received at Recognized
Student Health Center) |
$100 per Injury
or Sickness |
| Benefit Period |
After the Covered
Person’s effective date, until coverage terminates under the policy,
whichever is less |
Coverage B -
Accidental, Death and Dismemberment |
Maximum Benefit Principal
Sum up to $10,000 |
Coverage C -
Repatriation of Remains |
Maximum Benefit up
to $25,000 |
Coverage D –
Medical Evacuation |
Maximum Lifetime
Benefit for all Evacuations up to $100,000 |
Coverage E –
Bedside Visit |
Up to a maximum benefit
of $1,500 for the cost of one economy round trip airfare ticket to, and the hotel accomodations in, the place of the Hospital Confinement for one (1) person. |
|
|
|
