Understanding Your Market. Exceeding Your Expectations.
It is rare to find an insurance provider that offers flexible, specialized products and associated services for the marine industry. Even rarer still to find a company with the dedication, resources and ability to professionally administer health care benefits and deliver claims cost containment on a global basis. However, we understand the unique needs of marine crew professionals. In fact, the administrator has an entire marine division dedicated to it.
Our team has provided specialized insurance programs for captains, officers and crew members. One such program is the International Marine Medical InsuranceSM (IMMI) plan. This customizable plan offers medical coverage to groups of two or more marine crew professionals who live and work aboard ocean-going vessels.
The IMMI program, coupled with our expertise in marine claims, medical management and international assistance services, will help you and your crew members properly prepare for injury or illness that occur while on assignment. We provide more than just insurance; we provide the Global Peace of Mind® marine crew professionals deserve, backed by a team of professionals committed to being there when you need us.
Medical Benefits Summary
| Maximum Limit | $5,000,000 per period of coverage | ||
|---|---|---|---|
| Benefit Levels | United States In-Network | United States Out-of-Network | International International |
| Deductible Options | $0 | $100 - $10,000 | $100 - $10,000 |
| Deductible per Family Maximum three deductibles per family | $0 | 3 deductibles | 3 deductibles |
| Deductible Carry Forward | Expenses incurred during the last three months of a calendar year will be applied toward satisfaction of the deductible for the next calendar year, but only if the deductible was not met during the prior calendar year. | ||
| Coinsurance In addition to deductible | Plan pays 100%, Member pays 0% | Plan pays 80%, Member pays 20% | Plan pays 100%, Member pays 0% |
| Out-of-pocket maximum | $0 | $1,000 | $0 |
| Medical Concierge | The Medical Concierge Service (MCS) is a proprietary service that helps our members navigate the U.S. healthcare system to identify the highest quality, most cost-effective providers for scheduled inpatient and certain outpatient treatments. | ||
| Pre-certification | |||
| |||
| Pre-existing Conditions Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Benefit | In-Network | Out-of-Network | International |
| Sudden and Unexpected Reoccurrence of Pre-existing Conditions Up to the calendar year maximum limit | 100% | 80% | 100% |
| Inpatient or Outpatient Services Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Benefit | In-Network | Out-of-Network | International |
| Eligible Medical Expenses | 100% | 80% | 100% |
| Physician Visits / Services | 100% | 80% | 100% |
| Hospital Emergency Room: United States Injury: Not subject to Emergency Room Deductible Illness: Subject to $250 deductible for each emergency room visit for treatment that does not result in a direct hospital admission Hospital Emergency Room: International | 100% | 80% | 100% |
| Hospitalization/Room & Board Average semi-private room rate. Includes nursing, miscellaneous, and ancillary services | 100% | 80% | 100% |
| Intensive Care | 100% | 80% | 100% |
| Outpatient Surgical/Hospital Facility | 100% | 80% | 100% |
| Laboratory | 100% | 80% | 100% |
| Radiology/X-rays | 100% | 80% | 100% |
| Chemotherapy/Radiation Therapy | 100% | 80% | 100% |
| Pre-admission Testing | 100% | 80% | 100% |
| Surgery | 100% | 80% | 100% |
| Reconstructive Surgery Surgery is incidental to and follows surgery that was covered under the plan | 100% | 80% | 100% |
| Assistant Surgeon 20% of the primary surgeon’s eligible fee | 100% | 80% | 100% |
| Second Surgical Opinion Payable at 100% if requested by the company. 50% reduction of eligible medical expenses for failure to obtain a second surgical opinion when requested by the company | 100% | 80% | 100% |
| Anesthetists | 100% | 80% | 100% |
| Pregnancy & Newborn Care After 10 months of continuous coverage. Result of natural insemination. Newborn routine care, diagnostic tests, and routine immunizations for the first 31 days of life | 100% | 80% | 100% |
| Pregnancy Complications After 10 months of continuous coverage | 100% | 80% | 100% |
| Durable Medical Equipment | 100% | 80% | 100% |
| Podiatry Care Maximum limit: $750 | 100% | 80% | 100% |
| Chiropractic Care Not subject to deductible. Maximum limit per visit: $75. Maximum visits: 20. Physician order not required | 50% | 50% | 50% |
| Chiropractic Care Must be part of a recovery treatment plan for a covered illness or injury. Medical order or treatment plan required | 50% | 50% | 50% |
| Physical Therapy Maximum limit per visit: $75. Medical order or treatment plan required | 100% | 80% | 100% |
| Extended Care Facility Upon direct transfer from acute care facility | 100% | 80% | 100% |
| Home Nursing Care Provided by a home healthcare agency. Upon direct transfer from an acute care facility | 100% | 80% | 100% |
| Transplant Lifetime maximum: $1,000,000. Per period of coverage transplant maximum limit: 1. Organ procurement and harvesting costs lifetime maximum: $10,000. Travel and lodging lifetime maximum expenses: $5,000. Covered transplants: cornea, heart, heart/lung, lung, kidney, kidney/ pancreas, liver, allogeneic or autologous bone marrow. Subject to Transplant Pre-certification provision and only when treatment is provided within the company's approved independent managed transplant system network | 100% | 80% | 100% |
|
Preventative Care NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Adult Preventative Care Ages 19 and over. Maximum limit: $250. Refer to the Preventative Care provision for further details and requirements | 100% | 100% | 100% |
| Child Preventative Care Ages 18 and younger. Maximum limit: $250. Refer to the Preventative Care provision for further details and requirements | 100% | 100% | 100% |
| Prescriptions Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Prescriptions Dispensing maximum: 90 days per prescription | 80% | 80% | 100% |
| Mental or Nervous, Substance Abuse, and Counseling Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Lifetime Maximum | $20,000 | ||
| Inpatient Mental or Nervous /Substance Abuse Maximum limit: $10,000 | 100% | 80% | 100% |
| Outpatient Mental or Nervous/Substance Abuse Maximum limit per visit: $100. Maximum visits per calendar year: 52 | 50% | 50% | 50% |
| Emergency Services NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Emergency Local Ambulance Subject to deductible and coinsurance. Injury/illness resulting in an inpatient hospital admission | 100% | 80% | 100% |
| Emergency Medical Evacuation Lifetime maximum: $1,000,000 for insured under age 65. Insured persons under 65 years of age. Approved in advance and coordinated by the company | 100% | 100% | 100% |
| Emergency Reunion Lifetime maximum: $10,000. Maximum days: 15. Maximum meal limit per day: $25. Reasonable and necessary travel costs and accommodations. Approved in advance by the company | 100% | 100% | 100% |
| Inter-Facility Ambulance Transfer Transfer must be the result of an inpatient hospital admission | 100% | 100% | 100% |
| Return of Mortal Remains Maximum limit per insured person: $25,000. Local burial/cremation maximum limit: $10,000. Return of insured person's mortal remains to home country. Approved in advance by the company | 100% | 100% | 100% |
| Vision Care NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Routine Eye Examination Available after 12 months of continuous coverage | Maximum limit every 24 months: $100 | ||
| Corrective Lenses, Contacts, Frames Available after 12 months of continuous coverage | Maximum Limit every 24 months: $150 | ||
| Other Services NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Amateur Sailboat Racing Subject to deductible and coinsurance. Bodily injury as a result of an accident while participating in amateur sailboat racing | 100% | 80% | 100% |
| Crew Member Return Maximum limit: $2,500 | 100% | 100% | 100% |
| Emergency Dental Subject to deductible and coinsurance. Accident-related | 80% | 80% | 100% |
| Traumatic Dental Injury Treatment at a hospital facility due to an accident. Additional treatment for the same injury rendered by a dental provider will be paid at 100% | 100% | 80% | 100% |
| Hospital Indemnity International only. Benefit is not available when the inpatient hospital treatment is part of the medical travel management benefit. Inpatient hospitalization only | Not Applicable | Not Applicable | Overnight maximum limit: $100 Maximum overnight limit: 20 Maximum limit: $5,000 |
| Medical Travel Management Must be approved in advance by the company | The company will offer medical travel as a means to manage the costs of medically necessary non-emergency treatment, including hospitalization and surgery for approved procedures. If medical travel is approved, the company will reimburse 10% of the cost savings, up to a maximum of $7,500 back to the insured person where such savings arise from treatment outside of the United States. Meal allowance maximum: $100. Refer to the Medical Travel Management provision for further details and requirements. | ||
| Non-Emergency Medical Evacuation Lifetime maximum: $1,000,000. Insured persons under age 65. Approved in advance and coordinated by the company | 100% | 100% | 100% |
| Recreational Underwater Activities Subject to deductible and coinsurance. Injuries that occur while engaging in recreational underwater activities | 100% | 80% | 100% |
| Supplemental Accident Benefit Maximum limit per covered accident: $300 | 100% | 100% | 100% |
Dental Benefits Summary
| Coverage Limit/Maximum Amount for Eligible Dental Expenses | ||
|---|---|---|
| Calendar year maximum limit per person | $1,500 | |
| Deductible Applies to minor restorative, major restorative, and orthodontia services | $50 | |
| Family deductible Maximum 3 deductibles per family | $150 | |
| Routine Services NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | ||
| Benefit | Coinsurance | |
| Diagnostic and Preventative Services Preventative visits and cleanings: 2 (one every six months) Radiographic examinations (including posterior bitewings): 2 (one every six months). Fluoride treatment: 1 for children under age 19 | Plan pays 100% | Insured pays 0% |
| Emergency Palliative Treatment | Plan pays 100% | Insured pays 0% |
| Minor Restorative Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | ||
| Radiographs Radiograph: 1 every 3 years. Full mouth X-rays including panographic X-rays | Plan pays 80% | Insured pays 20% |
| Oral Surgery | Plan pays 80% | Insured pays 20% |
| Endodontics | Plan pays 80% | Insured pays 20% |
| Periodontics Root planing: 1 every 2 years Periodontal surgery: 1 every 3 years | Plan pays 80% | Insured pays 20% |
| Minor Restorative Services Refer to the Eligible Dental Expenses provision for further details and requirements | Plan pays 80% | Insured pays 20% |
| Major Restorative Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | ||
| Major Restorative Services Crowns, jackets, inlays (on same tooth): 1 every 5 years. Limitations apply for children under age 12. Refer to the Eligible Dental Expenses provision for further details and requirements | Plan pays 50% | Insured pays 50% |
| Prosthodontics Dentures/bridges: 1 every 5 years Replacement of denture base material or reline: 1 every 3 years Refer to the Eligible Dental Expenses provision for further details and requirements | Plan pays 50% | Insured pays 50% |
| Orthodontia Services Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | ||
| Orthodontia Children less than 19 years of age | Plan pays 50% | Insured pays 50% |
Group Life Insurance
- Group Life benefit includes:
- Term Life Insurance Benefit
- Accidental Death Benefit
- Dismemberment Benefit
- 10 or fewer employees:
- $10,000 minimum required
- Automatically approved up to $100,000 if member is approved for the IMMI medical plan
- Additional underwriting $100,001 - $250,000
- Group Life can be issued as a flat amount (e.g. $50,000) or by salary (e.g. 2 x salary)
- Group Life Reduction Schedule
- Less than age 65: Full amount payable
- Ages 65-69: 35% reduction
- Ages 70-74: 55% reduction
- Ages 75-79: 70% reduction
- Age 80+: 80% reduction
Medical Management Without BoundariesSM
The ability to access quality healthcare is essential when a medical emergency arises abroad. From routine medical care and check-ups to complex case management and medical evacuations, we are there to offer our expertise and unique blend of services, including:
Medical Travel Management
The Medical Travel Management benefit offers the member who is contemplating non-emergency medical treatment in the United States the opportunity to be financially compensated for having that care rendered by a qualified medical provider(s) outside of the U.S.
First, a designated nurse case manager will evaluate the cost effectiveness of an international medical travel case to assess whether the minimum savings required can be achieved as defined by the plan. The case manager will then assist the member in identifying a qualified medical provider to provide the specified care, while also negotiating medical fees. Upon approval, the case manager will coordinate the necessary services including patient care, travel, scheduling, and housing. The case manager will also assist with coordination of a medical follow-up visit upon returning home, when needed.
When treatment is received outside of the U.S. and there is cost savings greater than $10,000 to the plan, the member will personally share in any cost savings that are realized. The cost savings are calculated using the average U.S. cost of the medical service compared to the actual cost of the medical procedure and associated medical travel costs performed by the non-U.S.-based provider(s).
International Comprehensive Care Management
Critically ill or injured crew have enough to worry about—let us ease the administrative workload and communications that come with complex international medical case management. Our experienced medical management team can assist with meeting the patient's health and care needs to deliver the best possible outcome. Our medical staff will help coordinate care for your members who have highly complex cases requiring detailed management. These services may include assisting with:
- Concurrent review and monitoring of services for medical necessity
- Coordination of the hospitalization and any necessary post-discharge care
Customizable Solutions
We are confident that IMMI will provide quality medical coverage specific to your organization and group member's needs. For groups of a certain size, IMMI also offers the flexibility to customize benefits. Please contact us for more information. Our reputation for excellence has been built on providing top-tier programs to organizations like yours around the world, and we will work closely with you to design a benefits package to meet your unique needs.
Platinum Medical Benefits
| Period of coverage | Maximum limit: 365 days | ||
|---|---|---|---|
| Calendar year maximum limit | Unlimited | ||
| Benefit Levels | United States In-Network | United States Out-of-Network | International International |
| Deductible options | $0 | $0 | $0 |
| Deductible per family Maximum three deductibles per family | $0 | $0 | $0 |
| Coinsurance | Plan pays 100%, Member pays 0% | Plan pays 80%, Member pays 20% | Plan pays 100%, Member pays 0% |
| Out-of-pocket maximum | $0 | $1,000 | $0 |
| Pre-certification | |||
| |||
| Pre-existing Conditions | |||
| Pre-existing conditions are covered the same as any other illness or injury | |||
Travel Intelligence & Member Tools
It's easy to access and manage your accounts any time, anywhere, from any device. With Travel Intelligence, you can get location-specific alerts across 10 threat categories that span health, transporation, security, and weather. Leverage location-specific travel intelligence like travel tips, tools, and key insights from local analysts.
Additional features include:
- Claims submission and management
- ID card and insurance documents access
- Pre-certification process initiation
- Explanation of Benefits (EOB) access
- Customer Care live chat and contact information
- Find a Doctor locator
| Inpatient or Outpatient Services Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
|---|---|---|---|
| Benefit | In-Network | Out-of-Network | International |
| Eligible Medical Expenses | 100% | 80% | 100% |
| Physician Visits/Services | 100% | 80% | 100% |
| Hospital Emergency Room: United States Injury: Not subject to Emergency Room Deductible Illness: Subject to $250 deductible for each emergency room visit for treatment that does not result in a direct hospital admission Hospital Emergency Room: International | 100% | 80% | 100% |
| Hospitalization/Room & Board Average semi-private room rate. Includes nursing, miscellaneous, and ancillary services | 100% | 80% | 100% |
| Intensive Care | 100% | 80% | 100% |
| Outpatient Surgical/Hospital Facility | 100% | 80% | 100% |
| Laboratory | 100% | 80% | 100% |
| Radiology/X-rays | 100% | 80% | 100% |
| Chemotherapy/Radiation Therapy | 100% | 80% | 100% |
| Pre-admission Testing | 100% | 80% | 100% |
| Surgery | 100% | 80% | 100% |
| Reconstructive Surgery Surgery is incidental to and follows surgery that was covered under the plan | 100% | 80% | 100% |
| Assistant Surgeon 20% of the primary surgeon’s eligible fee | 100% | 80% | 100% |
| Second Surgical Opinion Payable at 100% if requested by the company. 50% reduction of eligible medical expenses for failure to obtain a second surgical opinion when requested by the company | 100% | 80% | 100% |
| Anesthetists | 100% | 80% | 100% |
| Pregnancy & Newborn Care After 10 months of continuous coverage. Result of natural insemination. Newborn routine care, diagnostic tests, and routine immunizations for the first 31 days of life | 100% | 80% | 100% |
| Pregnancy Complications After 10 months of continuous coverage | 100% | 80% | 100% |
| Durable Medical Equipment | 100% | 80% | 100% |
| Podiatry Care Maximum limit: $750 | 100% | 80% | 100% |
| Chiropractic Care Not subject to deductible. Maximum limit per visit: $75. Maximum visits: 20. Physician order not required | 50% | 50% | 50% |
| Chiropractic Care Must be part of a recovery treatment plan for a covered illness or injury. Medical order or treatment plan required | 50% | 50% | 50% |
| Physical Therapy Maximum limit per visit: $75. Medical order or treatment plan required | 100% | 80% | 100% |
| Extended Care Facility Upon direct transfer from acute care facility | 100% | 80% | 100% |
| Home Nursing Care Provided by a home healthcare agency. Upon direct transfer from an acute care facility | 100% | 80% | 100% |
| Transplant Lifetime maximum: $1,000,000. Per period of coverage transplant maximum limit: 1. Organ procurement and harvesting costs lifetime maximum: $10,000. Travel and lodging lifetime maximum expenses: $5,000. Covered transplants: cornea, heart, heart/lung, lung, kidney, kidney/ pancreas, liver, allogeneic or autologous bone marrow. Subject to Transplant Pre-certification provision and only when treatment is provided within the company's approved independent managed transplant system network | 100% | 80% | 100% |
|
Preventative Care NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Adult Preventative Care Ages 19 and over. Maximum limit: $250. Refer to the Preventative Care provision for further details and requirements | 100% | 70% | 100% |
| Child Preventative Care Ages 18 and younger. Maximum limit: $250. Refer to the Preventative Care provision for further details and requirements | 100% | 70% | 100% |
| Prescriptions Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| United States Retail Pharmacy Not subject to deductible and coinsurance Copayments are per 30-day supply Dispensing maximum: 90 days per prescription | Universal Rx (URX) Prescription Drug Card MUST be utilized for all outpatient prescription drugs in the United States. Retail Pharmacy Copayments: Generic: $5 Higher-cost generic and brand: $15 Non-preferred brand name: $30 | ||
| International Prescriptions Dispensing maximum: 90 days per prescription | Coinsurance: 100% | ||
| International Prescriptions Copayments are per 30-day supply Dispensing maximum: 180 days per prescription | Expatriate Prescription Services Program: Generic: $5 Non-preferred brand name: $15 Prescription submission: Email (scan prescription): [email protected] or fax: +1.540.777.7184 Questions/concerns: Phone: +1.540.777.1450 Email: [email protected] | ||
| Vision Care Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Routine Eye Examination Available after 12 months of continuous coverage | Maximum limit every 24 months: $100 | ||
| Corrective Lenses, Contacts, Frames Available after 12 months of continuous coverage | Maximum limit every 24 months: $150 | ||
| Mental or Nervous, Substance Abuse, and Counseling Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Lifetime Maximum | $20,000 | ||
| Inpatient Mental or Nervous/Substance Abuse Maximum limit: $10,000 | 100% | 80% | 100% |
| Outpatient Mental or Nervous/Substance Abuse Maximum limit per visit: $100 Maximum visits per calendar year: 52 | 50% | 50% | 50% |
| Emergency Services NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Emergency Local Ambulance Subject to deductible and coinsurance Injury/illness resulting in an inpatient hospital admission | 100% | 80% | 100% |
| Emergency Medical Evacuation Lifetime maximum: $1,000,000 for insured under age 65 Insured persons under 65 years of age Approved in advance and coordinated by the company | 100% | 100% | 100% |
| Return of Mortal Remains Maximum limit per insured person: $25,000 Local burial/cremation maximum limit: $10,000 Return of insured person’s mortal remains to home country Approved in advance by the company | 100% | 100% | 100% |
| Emergency Reunion Lifetime maximum: $10,000. Maximum days: 15. Maximum meal limit per day $25. Reasonable and necessary travel costs and accommodations. Approved in advance by the company | 100% | 100% | 100% |
| Inter-facility Ambulance Transfer Transfer must be the result of an inpatient hospital admission | 100% | 100% | 100% |
| Other Services NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | |||
| Amateur Sailboat Racing Subject to deductible and coinsurance. Bodily injury as a result of an accident while participating in amateur sailboat racing | 100% | 80% | 100% |
| Crew Member Return Maximum limit: $2,500 | 100% | 100% | 100% |
| Emergency Dental Subject to deductible and coinsurance. Accident-related | 100% | 100% | 100% |
| Traumatic Dental Injury Treatment at hospital facility due to an accident. Additional treatment for the same injury rendered by a dental provider will be paid at 100% | 100% | 80% | 100% |
| Hospital Indemnity International only. Benefit is not available when the inpatient hospital treatment is part of the Medical Travel Management benefit. Inpatient hospitalization only | Overnight maximum limit: $50 Maximum overnight limit: 20 Maximum limit: $1,000 | ||
| Medical Travel Management Must be approved in advance by the company | Medically necessary non-emergency treatment, including hospitalization and surgery for approved procedures, the company will offer medical travel as a means to manage the costs. If medical travel is approved, the company will reimburse 10% of the cost savings, up to a maximum of $7,500 back to the insured person where such savings arise from treatment outside of the United States. Meal allowance maximum: $100. Refer to the Medical Travel Management provision for further details and requirements. | ||
| Non-Emergency Medical Evacuation Lifetime maximum: $1,000,000. Insured persons under age 65. Approved in advance and coordinated by the company | 100% | 100% | 100% |
| Recreational Underwater Activities Subject to deductible and coinsurance. Injuries that occur while engaging in recreational underwater activities | 100% | 80% | 100% |
| Supplemental Accident Benefit Maximum limit covered per accident: $500 | 100% | 100% | 100% |
Dental Benefits Summary
| Coverage Limit/Maximum Amount for Eligible Dental Expenses | ||
|---|---|---|
| Calendar year maximum limit | $1,500 | |
| Deductible Applies to minor restorative, major restorative, and orthodontia services | $50 | |
| Family deductible Maximum 3 deductibles per family | $150 | |
| Routine Services NOT subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | ||
| Benefit | Coinsurance | |
| Diagnostic and Preventative Services Preventative visits and cleanings: 2 (one every six months) Radiographic examinations (including posterior bitewings): 2 (one every six months) Fluoride treatment: 1 for children under age 19 | Plan pays 100% | Insured pays 0% |
| Emergency Palliative Treatment | Plan pays 100% | Insured pays 0% |
| Minor Restorative Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | ||
| Radiographs Radiograph: 1 every 3 years. Full mouth X-rays including panographic X-rays | Plan pays 80% | Insured pays 20% |
| Oral Surgery | Plan pays 80% | Insured pays 20% |
| Endodontics | Plan pays 80% | Insured pays 20% |
| Periodontics Root planing: 1 every 2 years Periodontal surgery: 1 every 3 years | Plan pays 80% | Insured pays 20% |
| Minor Restorative Services Refer to the Eligible Dental Expenses provision for further details and requirements | Plan pays 80% | Insured pays 20% |
| Major Restorative Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | ||
| Major Restorative Services Crowns, jackets, inlays (on same tooth): 1 every 5 years. Limitations apply for children under age 12. Refer to the Eligible Dental Expenses provision for further details and requirements | Plan pays 50% | Insured pays 50% |
| Prosthodontics Dentures/bridges: 1 every 5 years Replacement of denture base material or reline: 1 every 3 years Refer to the Eligible Dental Expenses provision for further details and requirements | Plan pays 50% | Insured pays 50% |
| Orthodontia Services Subject to deductible and coinsurance unless otherwise noted Eligible medical expenses are limited to usual, reasonable, and customary Maximum limits per calendar year, or, if indicated, per lifetime | ||
| Orthodontia Children less than 19 years of age | Plan pays 50% | Insured pays 50% |
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the "Insurance Contract"). The Insurance Contract is the only source of the actual benefits provided.
Administrator
IMGP.O. Box 88509
2960 North Meridian Street
Indianapolis, IN 46208-0509 USA
FOR ADDITIONAL INFORMATION
Insubuy®, Inc.4200 Mapleshade Ln, Suite 200
Plano, TX 75093
Toll Free:
+1 (866) INSUBUY
Phone:
+1 (972) 985-4400
Fax:
+1 (972) 767-4470
Website:
www.insubuy.com
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
Version:
CM00500702A190514
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