Policy Number
GLM N14286494
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This plan is provided by Cultural Insurance Services International and underwritten by Ace American Insurance Company
GLM N14286494
Coverages and Services | Maximum Limits |
---|---|
Accidental Death & Dismemberment: | $10,000 ($1M aggregate limit) |
Medical Expense (per Accident or Sickness): | |
Deductible | $0 (zero) |
Basic Medical | $100,000 |
Accidental Dental | Up to $1500 |
Palliative Dental (relief of pain) | Up to $500 |
Pre-existing Conditions Coverage Limit | Up to policy max |
Mental and Nervous | Inpatient up to $5,000, Outpatient up to $1,500 |
Prescription Drugs (Inpatient/Outpatient) | 100% |
Physiotherapy | If recommended by a Physician and administered by a licensed physiotherapist |
Specified Therapies and Spinal Manipulation, including acupuncture and physiotherapy: | |
Outpatient Limit | Max of $50/visit; maximum of 10 visits; $500 overall maximum |
Emergency Medical Evacuation | $100,000 |
Repatriation/Return of Mortal Remains | $50,000 |
Security Evacuation Comprehensive | $100,000 ($1M aggregate limit) |
24/7 Team Assist Package & CISI Crisis Team | Included |
Trip Delay | $500 (more than 12 hours, up to 5 days, $100/day) |
Quarantine Benefit | Up to $1,000 |
Trip Cancellation | Up to $4,000 |
Trip Interruption | Up to $1,500 |
Please contact the Team Assist line by phone at +1 312-935-1703 (collect calls accepted) or email medassist-usa@axa-assistance.us. The TeamAssist Emergency Assistance Provider is AXA Assistance.
Non-Emergency questions may be directed to CISI at 203-399-5130 (toll free 800-303-8120).