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Global Medical Insurance - Bronze - International Health Insurance

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Paper Application

Please use this high level information as a guide only and do not make any decisions solely based on this comparison. If you have any concerns, doubts or questions, please refer to the individual policy details for complete information as it is not possible to accurately represent all the details in concise information such as follows. Please call us for further details. If there is any discrepancy between this comparison and the actual policy details, the policy details will override.

All the amounts are in U.S. dollars.

General

GMI Bronze - Area 2
Fixed Coverage
Worldwide, Excluding the United States, Canada, China, Hong Kong, Japan, Macau, Singapore and Taiwan
$1,000,000 Lifetime
Outside U.S.: 50% of deductible waived up to $2,500. After deductible, plan pays 100% to policy maximum.

Medical - Outpatient

$500 maximum Pre-inpatient or post-inpatient treatment
$500 maximum Pre-inpatient or post-inpatient treatment
$500 maximum Pre-inpatient or post-inpatient treatment
-
-
To policy maximum
$600, maximum of 90 days per covered event. Orphan Drugs or Biologic Drugs do not apply to the maximum limit per event.
X-ray $250 per exam; Lab services $300 per test
To policy maximum
To policy maximum
20% of primary surgeon's eligible fee.

Medical - Inpatient

Average semi-private room rate, to policy maximum.
To policy maximum
To policy maximum
To policy maximum
20% of primary surgeon's eligible fee.
To policy maximum

Medical - Other Treatment And Services

-
To policy maximum
$600, maximum of 90 days per covered event.
-
$1,500 per covered event Illness must result in hospital admission.
-
Inpatient: To policy maximum Outpatient: $40 per visit, maximum of 10 visits within 90 days per covered event. Must be ordered in advance by physician.
None
Yes
-
-
100% if requested, reduced to 50% if not obtained when required.
Transplants, Interfacility Ambulance Transfer, Medical Evacuation, Orphan Drugs or Biologic Drugs - no coverage if not pre-certified; otherwise covered at 100%; All other - 50%
180 days
$250,000 lifetime
$600 per covered event Prior to inpatient treatment.
-
To policy maximum
$150 per day, maximum of 30 days.
-
Included

Maternity Coverage

-
-
-

Dental

Optional
$1,000

Wellness

-
-

Travel

$10,000, maximum of 15 days; $25 per day meal maximum.
$50,000
$25,000
$5,000

Life

Included in Optional Term Life Insurance
-
Optional

Alternative Medicine

-
-
-
-
-
-

Other

Private Hospital: $400 per night, maximum of $4,000 Public Hospital: $500 per night, maximum of $5,000
-

Plan Features

Before effective date, full refund. After effective date, short rate refund.
$0
$0
Health Travel Preventative Coverage: $250 for vaccinations and preventative prescription drugs administered by a Physician 30 days prior to initial effective date and before departure.
$250 Up to 74
$500 Up to 74
$1,000 Up to 74
$2,500 Up to 74
$5,000 Up to 74
$10,000 Up to 74
International Medical Group (IMG)
SiriusPoint Specialty Insurance Corporation

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  • URC - Usual, Reasonable and Customary Charges.
  • For medical benefits, to policy maximum, refer to the Usual, Reasonable and Customary Charges. Deductible and coinsurance apply, unless otherwise noted.
  • Whenever there is a difference in benefits levels within PPO network and outside PPO network, the benefits shown above are applicable when availing treatment within PPO network.
  • Coverages shown are per person unless noted otherwise.
  • The dash (-) in the fields above means Not Applicable (N/A).
DISCLAIMER: This is a high level description of the insurance plan meant to provide a quick overview. It may not describe all possible scenarios or coverages in all different cases. Please refer to the brochure and the certificate wording for complete details. Even though we have tried our best to accurately describe the plan, if there is any discrepancy between this description and the certificate wording, the certificate wording will prevail.

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