Under the IG Personal Health Plan you have four deductible options of $200, $500, $1,000 and $5,000. You will need to pay your deductible once per year, and then the insurance will cover you as per the benefits below.
The maximum individual out of pocket expenses you will incur under this plan is $1,000, and for a family is $3,000
|
North America |
Rest of the World |
|
Plan 1
PPO |
Members
Non PPO* |
Plan 1 & 2 |
| Hospital Inpatient & Surgery
Room and Board: Hospital's average semi private charge per day of confinement |
90% |
70% |
100% |
| Intensive Care Unit |
90% |
70% |
100% |
| Inpatient ancillary services * |
90% |
70% |
100% |
| Physician Office Visits & Specialist Fees |
90% |
70% |
90% |
| Outpatient Surgery |
90% |
70% |
100% |
| Emergency Room |
90% |
70% |
100% |
| Diagnostic and Therapeutic Services (Outpatient) ** |
90% |
70% |
90% |
| Other Medical expenses |
90% |
70% |
90% |
| Maternity Expense:
(12 month waiting period)
Normal delivery limited to $10,000 per pregnancy. Treated the same as any other condition for Insured and eligible dependents.
This benefit does not extend to dependent children. Caesarean Section and Complications of Pregnancy limited to $12,000 per pregnancy.
Routine Nursery: As any other treatment including room and board, physician charges and circumcision for males prior to discharge. |
90% |
70% |
90% |
| New-Born Cover
New-Born includes:
Premature Births, Congenital Conditions and Birth Anomalies.
Life Time Maximum: US $25,000 |
90% |
70% |
100% |
| Prescription Program
In PPO no deductible applies brand name drugs at 80% and generic drugs at 90%. Out of network (in USA only) deductible applies and no out-of-pocket lime applies. Overseas deductible applies. |
80% / 90% |
70% |
90% |
Mental Health Benefits
(Inpatient & Outpatient)
Lifetime Maximum - US $25,000
Lifetime Mental Illness, Maximum Per Insured (In-Hospital)*** 60 days
Lifetime Mental Illness, Maximum Per Insured (Out-of-Hospital)*** 80 visits
Calendar Year Mental Illness, Maximum (Out-of-Hospital)*** 15 visits - US$2,500 per year |
90% |
70% |
90% |
Notes:
* Blood transfusions, plasma - $5,000 per person per calendar year
** Physical Therapy: per visit limit US$ 75, calendar year max 30 visits; Occupational
therapy: per visit limit US$ 75, calendar year max 30 visits
*** No OOP max. applies
Transplant Procedures: Lifetime maximum of US $250,000
Only available through the Managed Transplant Program.
Transplant must be pre-certified and approved by Colonial Medical. Failure to comply
will result in treatment not being covered by your individual or group health insurance international policy.
Dental Care:
Limited to accidental injury of sound, natural teeth sustained while covered under
the plan. You also have the option to add further dental coverage:
Optional Dental
This is a brief summary of the coverage available. Some restrictions
may apply. Please speak to your Integra Global representative if you
have any questions. The Dental Option can only be purchased in conjunction
with medical coverage.
| Plan Features |
Dental Plan Option |
| Individual Deductible |
$50 |
| Family Deductible |
$150 |
Class I Expenses:
Diagnostic - General; Preventive.
Deductibles do not apply to Class I Services |
100% |
Class II Expenses:
Restorative (Basic); Endodontics; Periodontics; Prosthodontics - Removable
(Maintenance); Prosthodontics - Fixed Bridge (Maintenance); Oral Surgery |
80% |
Class III Expenses:
Restorative (Major); Prosthodontics - Removable (Installation);
Prosthodontics - Fixed Bridge (Installation) |
50% |
| Calendar Year Maximum |
$1,500 |
| Orthodontic Lifetime Maximum |
$1,500 |
Orthodontic and Class III services are available after 6 months of continuous enrollment
in the Dental Plan.
Orthodontic services are only available for children under 18 years of age.
Preventive Care / Wellness Benefits
(Subject to Calendar Year Maximums (CYM) with no deductible)
6 Month Waiting Period for both Adults and Children
Child Immunizations & Routine Medical Exams: 100% coinsurance not subject to deductible
for children from birth to age 18 for immunization against diphtheria, hepatitis B, measles,
mumps, pertussis, polio, rubella, tetanus, varicella, haemophilias, influenza B, and
hepatitis A, up to the dollar limits indicated.
Child Preventive Care Services: 100% coinsurance not subject to deductible. Services
include: health history, physical examinations, development assessments, anticipatory guidance,
appropriate immunizations and laboratory tests.
Child Preventive Care is subject to the following limitations:
|
Calendar Year Maximum |
| Child - Birth to age 12 months |
US $350 |
| Child -13 months through age 17 |
US $100 |
| Child - Age 18 to 23 (only if full time student) |
US $200 |
Adult Routine Physical Exams: 90% coinsurance not subject to the deductible for
charges made for or in connection with the overall health and well being for Insureds
and Spouses or Domestic Partners age 18 years and over. Calendar Year Maximum US$ 500.
Papanicolaou Screening Test: Treated like any other illness but not subject to
deductible. Up to one test per calendar year for all eligible females.
Prostate Cancer Screening: Treated like any other illness but not subject deductible.
One test per calendar year for males age 50 or over.
Mammograms: Treated like any other illness not subject to deductible per the following schedule:
- Ages 35-39: one baseline exam.
- Ages 40-49: one exam every one or two years for asymptomatic women, but no
sooner than two years after a woman's baseline.
- Age 50 & over: one exam annually.
- Any Age: Whenever prescribed by a physician.
Vision Care Cover
(6 Month Waiting Period applies) Percentage of Reasonable and Customary Cost: 100%
During a 24-Month period Maximum Benefit Per Insured: US $300
Medical Evacuation and Assistance
Insured and Insured Dependents:
Lifetime Maximum Benefit Per Insured: US $150,000
Other Medical Benefits
HIV/Aids Treatment
Lifetime Maximum: US $25,000
Private Duty Nursing: Lifetime maximum US $7,500. Per Calendar year 240 hours
Benefit payable at 90%
Skilled Nursing Facility: As any other treatment up a US $7,500 Lifetime Maximum
Home Health Care: As any other treatment up to a US $7,500 Lifetime Maximum.
Chiropractic Services: As any other treatment up to a US$ 750 Calendar Year Maximum.
Referral letter required from medical physician.
Durable Medical Equipment: As any other treatment up to a US $15,000 lifetime maximum.
Hospice Care Services: As any other treatment up to a US $10,000 Lifetime Maximum.
TMJ Treatment: As any other treatment US $1,000 Lifetime Maximum.
Policy Limitations & Exclusions
Pre-Existing Condition Limitation (Applies to Medical coverage Only)
Pre-Existing conditions are covered after a 12 month waiting period. Thereafter,
at US $5,000 annual maximum and US $50,000 maximum lifetime unless otherwise stated.
New-Born Cover, Premature Births Congenital conditions and birth anomalies:
Life Time Maximum $25,000
Infertility: Procedures directly related to diagnosis are covered. Treatment, prescription
drugs, and or other methods to bypass (i.e. In-vitro) are not covered.
Expenses for oral contraceptives and contraceptive devices are excluded. Expenses for
prenatal vitamins, and smoking cessation products are excluded. Over the counter medications
are excluded.
Plan 2 does not include any cover for North America (USA and Canada)
Overall Lifetime Maximum Per Insured:
US $2,000,000
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