|
|
||
CitizenSecureSM Benefits and Policy Limits
Medical Coverage
| BENEFIT | Limit - all limits are per Certificate Period except as specifically indicated otherwise |
| Overall Maximum Limit | $5,000,000 Lifetime |
| Coverage Area |
Option 1 - Including the US and Canada Option 2 - Excluding the US and Canada |
| Deductibles Available | $250, $500, $1,000, $2,500 or $5,000 per Member per Certificate Period |
| Family Deductible | Maximum of 3 Deductibles per Family per Certificate Period |
| Coinsurance -- Claims Incurred in US or Canada* | After the Deductible, Underwriters will pay 80% of the next $5,000 of Eligible Expenses per Member per Certificate Period, then 100% to the Overall Maximum Limit. The Coinsurance will be waived if expenses are incurred within the PPO and expenses are submitted to Underwriters for review and payment directly to the provider |
| Coinsurance -- Claims Incurred outside US or Canada | After the Deductible, Underwriters will pay 100% of Eligible Expenses per Member per Certificate Period to the Overall Maximum Limit |
| Family Coinsurance | After $3,000 of Coinsurance has been paid per Family per Certificate Period, Underwriters will pay 100% of Eligible Expenses to the Overall Maximum Limit |
| Hospital Room and Board -- In US or Canada* | Average Semi-private room rate |
| Hospital Room and Board -- Outside US or Canada | Average Private room rate |
| Intensive Care Unit | Usual, Reasonable and Customary |
| Prescription Drugs | Usual, Reasonable and Customary Subject to Deductible and Coinsurance |
| Mental Health Disorders | $10,000 per Certificate Period, $25,000 Lifetime Maximum, $50 Maximum per visit per day for outpatient care (after 12 months of continuous coverage) |
| Maternity -- Normal or Complicated Delivery | After the Deductible, Underwriters will pay 50% of the next $100,000 of Eligible Medical Expenses, then 100% to a Lifetime Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery, and post-natal care (after 12 months of continuous coverage) |
| Maternity -- Complicated Delivery | After the Deductible, Underwriters will pay 50% of the next $100,000 of Eligible Medical Expenses, then 100% to a Lifetime Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery, and post-natal care (after 12 months of continuous coverage) |
| Maximum for Maternity | $250,000 Lifetime |
| Newborn Care | Included as part of Maternity benefits for a maximum of 60 days |
| Pre-existing Conditions | Same as any other Injury or Illness if disclosed on Application and not excluded or limited by Rider |
| Local Ambulance | Usual, Reasonable and Customary |
| Physical Therapy | $50 Maximum per visit per day |
| Wellness | All Wellness benefits are available after 12 months of continuous coverage and are not subject to Deductible. Members under age 19: $50 per visit (including immunizations), maximum of three visits per Certificate Period. Members age 30 and over: $250 per Member per Certificate Period. Female Members age 40 and over (or qualifying Woman at Risk): $100 per Member per Certificate Period for a screening mammogram |
| Human Organ/Tissue Transplants | Same as any other Illness for Covered Transplants** |
| All Other Eligible Expenses | Usual, Reasonable and Customary |
| Emergency Medical Evacuation | $50,000 Lifetime Maximum |
| Repatriation of Remains | $25,000 Limit |
| Emergency Reunion | $10,000 Lifetime Maximum |
| Pre-certification Penalty | 50% |
|
* Benefits within the US and Canada are not available to applicants electing Option 2 as their Coverage Area. **Covered Transplants include Heart/Lung, Lung, Kidney/Pancreas, Liver and Allogenic and Autologous Bone Marrow. |
|
Back to the Index
Optional Term Life Insurance and Accidental Death and Dismemberment
(Not available to residents of the US, regardless of citizenship)
| Age | Option 1 Principal Sum |
Option 2 Principal Sum |
| 19 to 59 | $50,000 | $100,000 |
| 60 to 64 | $25,000 | $ 50,000 |
| 65 to 69 | $10,000 | Not Available |
| Dependent Child | $5,000 | Not Available |
| You may choose a different option for each family member taking Term Life coverage. | ||
| Accidental Death | Principal Sum to Beneficiary |
| Accidental Loss of Two Limbs | Principal Sum to Member |
| Accidental Loss of One Limb | 50% of Principal Sum to Member |
|
"Limb" means hand, foot or eye. The Benefit is based on age at time of death or dismemberment |
|
Back to the Index
Optional Dental Rider
| Certificate Period 1 |
Certificate Period 2 |
Certificate Period 3 |
|
| Preventative Dental Benefits Children age 9 through 16 (after 3 months of continuous coverage) |
100% | 100% | 100% |
| Basic Dental Benefits (after 6 months of continuous coverage) |
50% | 65% | 80% |
| Major Dental Benefits (after 6 months of continuous coverage) |
30% | 40% | 50% |
| Dental Deductible | $100 per Certificate Period per person | $100 per Certificate Period per person | $100 per Certificate Period per person |
| Maximum Dental Benefits | $500 per Certificate Period per person | $750 per Certificate Period per person | $1,000 per Certificate Period per person |
Back to the Index
Optional Sports Rider
| Sports Category | Lifetime Maximum |
| Extreme Sports | $25,000 |
| Contact Sports | $5,000 |
Back to the Index
Return to Coverage
Copyright © 2009 HCC Medical Insurance Services. All rights reserved.