CitizenSecureSM Economy Benefits and Limits
| Benefits | Limits |
| Coverage Area | Worldwide |
| Overall Maximum Limit | $5,000,000 Lifetime |
| Deductibles Available | $250, $500, $1,000, $2,500 or $5,000 per person per Certificate Period |
| Coinsurance -- Claims Incurred in US or Canada | After the Deductible, Underwriters will pay 80% of the next $5,000 of Eligible Medical 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 Medical Expenses per Member per Certificate Period to the Overall Maximum Limit |
| Acute Onset of Pre-existing Condition | $1,000 during the first Certificate Period and $2,500 during the second Certificate Period |
| Pre-existing Conditions | $5,000 per Certificate Period subject to a Lifetime Maximum of $50,000 (including Acute Onset claims) after 24 months of continuous coverage under the plan |
| Maternity | $5,000 per Pregnancy after 12 months of continuous coverage under the plan, including Inpatient, Outpatient and other benefits provided under the plan. Not subject to Coinsurance |
| Newborn care | $15,000 per covered Pregnancy, including Inpatient, Outpatient and other benefits as provided under the plan, during the first 60 days of life |
| Organ Transplants | $250,000 Lifetime maximum for Covered Transplants* |
| INPATIENT BENEFITS (All Subject to Deductible and Coinsurance) | |
| Hospital Room and Board | $600 per day, maximum of 240 days per Hospitalization (including ICU days) |
| Intensive Care Unit (ICU) | $1,500 per day, maximum of 240 days per Hospitalization (including non ICU days) |
| Lab, x-rays and other covered Inpatient services & supplies | Usual, Reasonable and Customary Charges (except as limited under the plan) |
| OUTPATIENT BENEFITS (All Subject to Deductible and Coinsurance) | |
| Office Visits (Including Physician, Specialist Physical, Psychiatrist, Chiropractor, Surgical Consultant, Physical or Occupational Therapist) | 25 visits per Certificate Period per person as provided under the plan |
| Physician | $70 per visit |
| Specialist Physician | $70 per visit |
| Psychiatrist | $60 per visit, after 12 months of continuous coverage under the plan |
| Chiropractors | $50 per visit (must be prescribed by another non-Chiropractor Physician) |
| Surgical Consultant | $500 per consultation prior to Surgery |
| Physical or Occupational Therapy | $50 per visit (must be prescribed by a Physician who is not affiliated with the Physical Therapy practice) |
| X-rays | $250 per exam (includes Sonograms, Ultrasounds and diagnostic Mammograms) |
| Laboratory | $300 per exam (includes all procedures carried out on one specimen) |
| Emergency Room | Usual, Reasonable and Customary for covered Illnesses if hospitalized as Inpatient and for covered Injuries |
| Local Ambulance | $1,500 per Certificate Period per person |
| INPATIENT or OUTPATIENT BENEFITS (All Subject to Deductible and Coinsurance) | |
| Prescription Medications | Usual, Reasonable and Customary |
| Surgery | Usual, Reasonable and Customary |
| Assistant Surgeon | 20% of Surgeon benefit |
| Anesthesiologist | 20% of Surgeon benefit |
| Midwife Services | $500 per covered Pregnancy |
| MRI, CAT Scan, Echocardiography, Endoscopy, Gastroscopy, Colonoscopy and Cystoscopy | $600 per exam |
| Chemotherapy and Radiation Therapy | Usual, Reasonable and Customary |
| WELLNESS BENEFITS (Not Subject to Deductible) | |
| Well Child (under age 19) | $50 per visit for a maximum of 3 visits per Certificate Period (included in Office Visit limit), after 12 months of continuous coverage under the plan |
| Wellness (Adult 19+) | $250 per Certificate Period, after 24 months of continuous coverage under the plan, including Office Visit for $70 and X-Ray and Lab for $180 |
| OTHER BENEFITS (All Subject to Deductible and Coinsurance) | |
| Durable Medical Equipment | Usual, Reasonable and Customary charges for Wheelchair, Hospital Bed, and/or Toilet |
| Emergency Medical Evacuation | $50,000 Per Certificate Period |
| Repatriation of Remains | $25,000 Lifetime Maximum |
| Emergency Reunion | $5,000 Lifetime Maximum |
| 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(ren) | $5,000 | Not Available |
| 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 |
| Certificate Period 1 |
Certificate Period 2 |
Certificate Period 3 and after |
|
| 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 | $100 per Certificate Period | $100 per Certificate Period |
| Maximum Dental Benefits | $500 per Certificate Period | $750 per Certificate Period | $1,000 per Certificate Period |
| Sports Category | Lifetime Maximum |
| Extreme Sports | $25,000 |
| Contact Sports | $5,000 |
Copyright © 2009 HCC Medical Insurance Services. All rights reserved.