The Gold Plan
All rates and benefits are in U.S. Dollars ($US)
|Lifetime Benefit||$5,000,000 per person.|
|Deductible||$250 to $25,000|
|Deductible Carry Forward2||Included|
|Treatment3 : Standard Room||Semi-Private|
|Intensive Care Unit||Subject to deductible and coinsurance|
|Inpatient and Outpatient Surgery||Up to maximum limit (Assistant Surgeon: 20% of surgery benefit)|
|Emergency Room||Subject to deductible and coinsurance (Additional $250 deductible if not admitted as an inpatient)|
|Hospital Indemnity||Outside the US:
|Diagnostic Services: CAT Scans, MRI, Echocardiography, Endoscopy, Gastroscopy, Cystoscopy||Subject to deductible and coinsurance|
|Cancer Treatment||Subject to deductible and coinsurance|
|Transplants||$1,000,000 lifetime maximum|
|Prescription Drugs||For all covered conditions, outpatient and Inpatient prescription drugs : 90-day supply per prescription|
|Pre-existing Conditions||$50,000 lifetime maximum; $5,000 per period of coverage for unknown conditions. Available after 24 months of continuous coverage.|
|Physical Therapy & Rehab||$50 per visit per person, following a covered illness.|
|Durable Medical Equipment||Medically Necessary rental of Durable Medical Equipment, up to the purchase price paid by the Insured Person.|
|Emergency Evacuation||Up to maximum limit; Not subject to deductible or coinsurance.|
|Local Ambulance due to Injury or Illness resulting in Hospitalization||Subject to deductible and coinsurance|
|Interfacility Ambulance Transfer||Not subject to deductible or coinsurance. US only.|
|Political Evacuation and Repatriation||NA|
|Return of Mortal Remains||$25,000 lifetime maximum
- not subject to deductible or coinsurance. -
|Mental / Nervous||$10,000 maximum per period of coverage with a $50,000 lifetime maximum
Available after 12 months of continuous coverage:
|Adult Wellness||Not subject to deductible or coinsurance.
$250 per period of coverage.
Available after 12 months of continuous coverage
|Child Wellness||$200 maximum per period of coverage. Available after 12 months of continuous coverage.
Not subject to deductible or coinsurance.
|Dental||Traumatic Dental injury: 100%
Treatment Due to Unexpected Pain to Sound, Natural Teeth: 100%
Non-Emergency Treatment at a Dental Provider due to an Accident: $500 per period of coverage
Non-Emergency Dental : Optional Rider
Covered medical expenses are required to be usual, reasonable and customary. Unless otherwise indicated, covered medical expenses are subject to deductible and coinsurance.
Coinsurance: International – 100%; U.S. in-network – 100%; U.S. out-of-network – 80%
Notes re the GMI Plans: (Of the four GMI plans, Gold is the premium quality plan of choice for most of CAPCO's clients.)
- Senior Plan: gives lifetime coverage; it is available if one of the GMI Plans is taken out before age 65 and maintained to age 75
- Deductible Carry Forward: If the Deductible has not been met during the Period of Coverage, then Expenses incurred during the last 30 days of the Period of Coverage will be applied toward satisfaction of the Deductible for the next Period of Coverage.
- Treatment :
- Treatment Outside the US: 50% of deductible waived, up to a maximum of $2,500. No coinsurance
- Treatment Inside the US using Medical Coincierge: 50% of deductible waived, up to a maximum of $2,500. No coinsurance
- Treatment Inside the US, PPO Network: Subject to deductible. No coinsurance.
- Treatment Inside the US, Non-PPO Network: Subject to deductible & coinsurance: Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage.