SCHEDULE OF BENEFITS
Base Plan Benefits.
Hospital Plan Benefits.
Daily room and board……………........………. $ 150.
Period of confinement per disability…….60 days
Other hospital services per disability……. $1,500
Surgery Benefit
Disability Maximum………………..........……..$1,500
Anaesthesia Benefits…….25% of Surgery R&C.
Maternity
Normal delivery…………………………$2,000
Caesarean Section/
Extra Uterine Pregnancy………………$3,000
Miscarriage-Dilation & Curettage……$1000
Medical Benefits
Office Visit Maximum
Payable from first visit…………..…………$ 60
Hospital Visit Maximum………….………. $ 60
Home Visit Maximum……………………. $ 80
Disability Maximum……………………31 visits
Specialist Consultation (On referral)
Visit Maximum…80% to………………$ 80
Maximum…………….……………….5 visits
Diagnostic X-Ray And Laboratory Benefit
Disability Maximum 80% of Eligible Benefit
Prescribed Drugs
Disability Maximum…80% of Eligible Benefit
Deductible per Disability………………$ 10
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Preventative Care Benefits
Annual Medical Examination
for members only…….……………...$200
Annual Pap Smear
For Females…………………………..$65
Annual Mammogram
for females over age 35………………$150
Annual Test for Prostate Cancer
For Males……………………………..$75
Annual Glaucoma Test
for Members Only…………………...$50
Vaccinations
Children up to 2 years………………..$200
Supplementary Major Medical Benefits
Maximum Benefit (under 65)……$150,000
Maximum Benefit (over 65)……..$ 75,000
Benefit Period (under 65)…3 years
Deductible per calendar Year ……. $ 200
Co-insurance Factor
-On First $50,000…………….80%
-Thereafter…………………...100%
Carry Over Provision………..Last 3 Months
of Calendar Year
Hospital Room And Board
Application Overseas……………$ 2,000
Application Locally……………...$ 200
Psychiatric Benefit
Maximum per Treatment………..$ 60
Maximum $1200 per Calendar Year
Co-insurance Factor…………………80%
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Physiotherapy Benefit
Maximum per Treatment…………..…$ 60
Maximum of $1,200 Per Calendar Year
Coinsurance Factor…………………….80%
Airfare Benefit
Maximum per Calendar Year $ 3,000
Number of Trips per Calendar Yr…………2
Co-insurance factor…………………….80%
Air Ambulance Benefits
Maximum per Treatment………USD$15,000
Number of Trips per Calendar Year………1
Co-insurance Factor……………………80%
Dental Benefit
Maximum Benefit per Calendar Yr..$1 ,000
Deductible per Calendar Year……..$ 25
Preventative…………………………..100%
Basic Restorative………………………80%
Major Restorative……………………...60%
Waiting Period……………………6 months
Orthodontia
Maximum Lifetime Benefits……..$ 2, 000
Maximum Benefit per Calendar Yr $1, 000
Deductible per Calendar Year………….50
Co-insurance………………………….80%
Waiting Period…………………12 months
Vision Benefit
Max. Benefits per Calendar Yr…… $ 500
Deductible per Calendar Yr………..$ 75
Co-insurance…………………………80%
Waiting Period………………….6 months
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