International health & travel medical insurance

Benefit Description	Silver	Gold (1^st 36 months of continuous coverage)	Gold (Beginning the 1^st day of the 37^th month)	Gold Plus	Platinum
Lifetime Maximum Limit	$5,000,000 lifetime per individual	$5,000,000 lifetime per individual	$5,000,000 lifetime per individual	$5,000,000 lifetime per individual	$8,000,000 lifetime per individual
Deductible (Per Period of Coverage)	$250 to $10,000 50% waived within PPO network	$250 to $10,000 50% waived within PPO network	$250 to $10,000 50% waived within PPO network	$250 to $10,000 50% waived within PPO network	$100 to $10,000 50% waived within PPO network
Family Deductible	Three times the individual deductible	Three times the individual deductible	Three times the individual deductible	Three times the individual deductible	Two times the individual deductible
Coinsurance within the PPO network	No coinsurance	No coinsurance	No coinsurance	No coinsurance	No coinsurance
Coinsurance outside the U.S. and Canada	No coinsurance	No coinsurance	No coinsurance	No coinsurance	No coinsurance
Coinsurance inside the U.S. and Canada	80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage	80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage	80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage	80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage	90% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage
Hospitalization / Room & Board	$600 per day - 240 day maximum	Average semi-private room rate	Up to a limit of $2,250 per day	Average semi-private room rate	Private room rate
Intensive Care Unit	$1,500 per day - 180 day per event	URC	Up to a limit of $4,500 per day	URC	URC
Surgery	URC	URC	URC	URC	URC
Anesthetist's Charges Associated with Surgery	20% of surgery benefit	URC	20% of surgery benefit	URC	URC
Transplants	$250,000 per transplant	$1,000,000 lifetime maximum	$500,000 lifetime maximum	$1,000,000 lifetime maximum	$2,000,000 lifetime maximum
Out-patient	25 visits: $70 doctor/specialist; $60 psychiatrist; $50 chiropractor; $250 X-ray per exam maximum limit; $500 surgery intervention consultation; $300 lab tests per exam maximum limit	URC	Physician Charges - limit of $150 per visit; Hospital Charge - $100 co-pay unless admitted; Urgent Care Facility - $25 copay; Diagnostic Lab and X-Rays limited to $5,000 per certificate period; Physiotherapy - up to $75 per visit, $1,000 max per certificate period $10,000 lifetime maximum	URC	URC
Emergency Room Illness (Additional $250 deductible if not admitted)	URC	URC	URC	URC	URC
Emergency Room Accident	URC	URC	URC	URC	URC
Supplemental Accident	NA	$300 per occurrence	$300 per occurrence	$300 per occurrence	$500 per occurrence
Local Ambulance	$1,500 per covered event - not subject to deductible or coinsurance	URC	$100 per event - not subject to deductible or coinsurance	URC	URC
Mental/Nervous	Outpatient only after 12 months	$10,000 per period - $50,000 maximum - Available after 12 months of continuous coverage	$2,500 maximum per certificate period; In-patient limited to 25 days per certificate period; Out-patient limited to max of 20 visits per certificate period at 70% eligible expenses, up to $75 maximum per visit; Lifetime maximum of $30,000	$10,000 per period - $50,000 maximum - Available after 12 months of continuous coverage	SAAI - $50,000 lifetime maximum - Available after 12 months of continuous coverage
Child Wellness	3 visits per period of coverage - $70 maximum per period - Available after 12 months of continuous coverage	$200 maximum per period of coverage - Available after 12 months of continuous coverage	$200 maximum per period of coverage - Available after 12 months of continuous coverage	$200 maximum per period of coverage - Available after 12 months of continuous coverage	$400 maximum per period of coverage - Available after 6 months of continuous coverage
Adult Wellness	NA	$250 per period of coverage - not subject to deductible or coinsurance - Available for those 30 years of age and over after 12 months of continuous coverage	$250 per period of coverage - not subject to deductible or coinsurance - Available for those 30 years of age and over after 12 months of continuous coverage	$250 per period of coverage - not subject to deductible or coinsurance - Available for those 30 years of age and over after 12 months of continuous coverage	$500 per period of coverage - not subject to deductible or coinsurance - Available for those 18 years of age and over after 6 months of continuous coverage
Emergency Evacuation	$50,000 per period of coverage - not subject to deductible or coinsurance	Up to maximum limit - not subject to deductible or coinsurance	$250,000 limit per person per certificate period	Up to maximum limit - not subject to deductible or coinsurance	Up to maximum limit - not subject to deductible or coinsurance
Emergency Reunion	NA	$10,000 lifetime maximum	$10,000 lifetime maximum	$10,000 lifetime maximum	$10,000 lifetime maximum
Return of Mortal Remains	$25,000 lifetime maximum per insured - not subject to deductible or coinsurance	$25,000 lifetime maximum per insured - not subject to deductible or coinsurance	$15,000 lifetime maximum per insured - not subject to deductible or coinsurance	$25,000 lifetime maximum per insured - not subject to deductible or coinsurance	$50,000 lifetime maximum per insured -not subject to deductible or coinsurance
Remote Transportation	NA	NA	NA	NA	Limited to $5,000 per certificate period up to a $20,000 lifetime maximum
Political Evacuation and Repatriation	NA	NA	NA	NA	Limited to $10,000 lifetime maximum
Rx Coverage	URC	URC	$5,000 per certificate period for each insured person, out-patient only	URC	Outside U.S. - URC Inside U.S. - Rx drug card co-pay: $20 for generic / $40 for brand name where generic is not available
Other Services	Extended care: first 30 days; Radiation: URC; Home nursing: 30 days per covered event; Hospice: 30 days; Prosthetic Devices: all URC	URC	URC - Radiation & Chemotherapy treatments (in and out-patient) limited to $10,000 per year; $50,000 lifetime maximum	URC	URC
Physical Therapy	Maximum $40 per visit - 30 visit maximum	Maximum $50 per visit	Maximum $50 per visit	Maximum $50 per visit	Maximum $50 per visit
Complementary Medicine	NA	Acupuncture $150 Aroma Therapy $50 Herbal Therapy $50 Magnetic Therapy $75 Massage Therapy $150 Vitamin Therapy $100 Each per period of coverage	Acupuncture $150 Aroma Therapy $50 Herbal Therapy $50 Magnetic Therapy $75 Massage Therapy $150 Vitamin Therapy $100 Each per period of coverage	Acupuncture $150 Aroma Therapy $50 Herbal Therapy $50 Magnetic Therapy $75 Massage Therapy $150 Vitamin Therapy $100 Each per period of coverage	Acupuncture $150 Aroma Therapy $50 Herbal Therapy $50 Magnetic Therapy $75 Massage Therapy $150 Vitamin Therapy $100 Each per period of coverage
Recreational SCUBA	NA	URC	URC	URC	URC
Non-emergency Dental	NA	NA	NA	NA	Calendar year maximum - $750 Individual deductible - $50 Schedule of benefits - Class I: 90% Class II: 70% Class III: 50% Ortho 0% (6 month waiting period)
Emergency Dental due to Accident	$1,000 per period of coverage	URC	$500 per period	URC	URC
Emergency Dental due to Sudden Unexpected Pain	NA	$100 per period of coverage	$100 per period of coverage	$100 per period of coverage	See non-emergency dental benefits
High School Sports Injury	NA	NA	NA	NA	Up to $20,000 per certificate period
Vision	NA	NA	NA	NA	Exams - up to $100 Materials - up to $150 per 24 months
Global Concierge & Assistance Services	NA	NA	NA	NA	Included
Pre-existing Conditions	$5,000 per period of coverage up to a $50,000 lifetime maximum. Available after 24 months of continuous coverage	$5,000 per period of coverage up to a $50,000 lifetime maximum. Available after 24 months of continuous coverage	$5,000 per period of coverage up to a $50,000 lifetime maximum. Available after 24 months of continuous coverage	$5,000 per period of coverage up to a $50,000 lifetime maximum. Available after 24 months of continuous coverage	SAAI
Maternity Delivery, wellness, new born care & congenital disorders (not subject to deductible or coinsurance - available after 10 months of coverage	Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section, $200 child wellness benefit for the first 12 months, new born care & congenital disorders maximum of $250,000 for the first 31 days (Benefits reduced by 50% for births in that occur in the 11th or 12th month of continuous coverage)	Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section, $200 child wellness benefit for the first 12 months, new born care & congenital disorders maximum of $250,000 for the first 31 days (Benefits reduced by 50% for births in that occur in the 11th or 12th month of continuous coverage)	Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section, $200 child wellness benefit for the first 12 months, new born care & congenital disorders maximum of $250,000 for the first 31 days (Benefits reduced by 50% for births in that occur in the 11th or 12th month of continuous coverage)	Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section, $200 child wellness benefit for the first 12 months, new born care & congenital disorders maximum of $250,000 for the first 31 days (Benefits reduced by 50% for births in that occur in the 11th or 12th month of continuous coverage)	SAAI - $1,000 additional deductible, $50,000 lifetime maximum, $200 child wellness benefit for the first 12 months, new born care & congenital illness maximum of $250,000 for the first 31 days
NA (Not Applicable) / URC (Usual, Reasonable and Customary) / SAAI (Same As Any Illness)

This Web page contains only a consolidated and summary description of all current benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate Wording for this insurance plan in the event this Web page, application, and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.

Global Mission Medical InsuranceSM

Global Mission Medical Insurance^SM