Policy Number
GLM N18221871
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This plan is provided by Cultural Insurance Services International and underwritten by Ace American Insurance Company
GLM N18221871
Coverages and Services | Maximum Limits |
---|---|
Accidental Death and Dismemberment: | |
Per Insured | $10,000 |
Aggregate Limit Per Accident | $1,000,000 |
Medical Expenses (per Accident or Sickness): | |
Deductible | $0 (zero) |
Basic Medical | $200,000 @ 100% |
Accidental Dental | 100% of Covered Expenses, up to policy limits |
Dental Palliative | Up to $500 max, $250 per tooth |
Pre-existing Conditions Coverage Limit | Up to $10,000 primary, secondary thereafter up to policy max |
Mental and Nervous | Inpatient up to $5,000, Outpatient up to $2,500 |
Prescription Drugs (Inpatient/Outpatient) | 100% |
Nursery Newborn covered child | Up to $500 |
Pregnancy | Treated as any other illness |
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 | $250,000 |
Repatriation/Return of Mortal Remains | $50,000 |
Security Evacuation Comprehensive | $100,000 ($2.5M aggregate limit) |
Emergency Medical Reunion | $3,000 (300/day,10-day max) Hospitalized after 5 days. Immediate coverage for Felonious Assault. |
Quarantine Coverage | $2,000 |
Trip Delay | $500(12 hours, $100/day) |
Trip Cancelation | $2,000 |
Trip Interruption | $1,500 |
24/7 Team Assist Package (AXA) & CISI Crisis Team | Included |
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).