TABLE OF BENEFITS. Description of Disablement Percentage of Sum Covered (%) Accidental Death 100% Loss of Limbs (two limbs) 100% Loss of both hands, or of all fingers and both thumbs 100% Total paralysis 100% Total insanity 100% Injuries resulting in being permanently bedridden 100% Any other injury causing Permanent Total Disablement 100% Loss of arm at shoulder 100% Loss of arm between shoulder and elbow 100% Loss of arm at elbow 100% Loss of arm between elbow and wrist 100% Loss of hand at wrist 100% Loss of leg at hip 100% between knee and hip 100% below knee 100% Eye: Loss of whole eye 100% Sight 100% Sight, except perception of light 50% lens 50% Loss of four fingers and thumb of one hand 50% Loss of four fingers 40% Loss of thumb both phalanges 25% one phalanx 10% Loss of index finger three phalanges 10% two phalanges 8% one phalanx 4% Loss of middle finger three phalanges 6% two phalanges 4% one phalanx 2% Loss of ring finger three phalanges 5% two phalanges 4% one phalanx 2% Loss of little finger three phalanges 4% two phalanges 3% one phalanx 2% Loss of metacarpals first or second (additional) 3% third, fourth or fifth (additional) 2% Loss of toes All phalanges 15% two great, both phalanges 5% great one phalanges 2% other than great, if more than one toe lost, each 1% Loss of Hearing both ears 75% one ear 15% Loss of Speech 50% Where the Bodily Injury is not specified, We reserve the right to adopt a percentage of sum covered based on the disablement, which, in Our opinion, is consistent with the provisions of the above Table of Benefits. “Loss” of limb or member or part thereof shall mean loss by actual physical severance or total and permanent Loss of Use. Loss of Use of body member shall be treated as loss of body member. The aggregate of all percentages payable in respect of any one (1) Accident shall not exceed 100%. In the event a total of 100% is paid, all coverage hereunder shall immediately cease to be in force. All other losses less than 100% if having been paid shall reduce the coverage under Benefit A or B by that amount from the date of Accident until the expiry of the Certificate of Takaful.
TABLE OF BENEFITS. If the insured does not contact USA Medical Services before their treatment, the insurer cannot make a direct payment to the pro- vider. The insurer will then reimburse the policyholder in accordance with the usual, customary, and reasonable fees for that geographical area. • Any diagnostic or therapeutic procedure, treat- ment, or benefit is covered only if resulting from a condition covered under this policy. • Insureds are asked to notify USA Medical Services prior to beginning any treatment. • All benefits are subject to any applicable deductible, unless otherwise stated. • The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America and, solely with respect to the insurer, where otherwise prohibited by the laws in the United Kingdom and/or Denmark. Please contact USA Medical Services for more information about this restriction. Maximum coverage per insured, per policy year No limit In-patient benefits and limitations Coverage Hospital services 100% Hospital room and board (standard private/semi private) • In Bupa hospital network • In other hospitals, per day 100% US$2,000 Intensive care unit • In Bupa hospital network • In other hospitals, per day 100% US$4,000 Medical and nursing fees 100% Mental Health while in-patient (must be pre-approved) 100% Drugs prescribed while in-patient 100% Diagnostic procedures (pathology, lab tests, X-rays, MRI/CT/PET scan, ultrasound, and endoscopies) 100% Accommodation charges for companion of a hospitalized child, per day US$400 Guest meals, per day US$50 BENEFITS | 3 Out-patient benefits and limitations Coverage Ambulatory surgery 100% Physicians and specialists visits 100% Prescription drugs: • Following hospitalization or out-patient surgery (for a maximum of 6 months) • Per policy year thereafter • Out-patient or non-hospitalization (with 20% co-insurance) 100% US$3,000 US$2,000 Diagnostic procedures (pathology, lab tests, X-rays, MRI/CT/PET scan, ultrasound, and endoscopies) 100% Physical therapy and rehabilitation services (must be pre-approved) 100% Home health care (must be pre-approved) 100% Routine health checkup • No deductible applies US$1,000 Vaccines (medically required) • No deductible applies • Subject to 20% of coinsurance 80% Urgent Care Facilities or Walk-in Clinics in the U.S.A. Expenses derived from treatment in e...
TABLE OF BENEFITS. Type of incident Cover • Natural or Accidental Death • Accidental Total and permanent disablement • Total and permanent loss of sight in both eyes as a result of an accident • Total loss by physical severance of total and permanent loss of the following parts, as a result of an accident: a) Two limbs b) Both hands c) Arm above the elbow d) Leg above the knee 100% of the credit outstanding up to an aggregate maximum of LKR 2,000,000 per credit cardholder Policy Exclusions
TABLE OF BENEFITS. The table in this agreement that sets out the benefits covered by each plan. Temporary trip A trip for business and/or recreational purposes, which has a defined return date and is for a period that is no longer than the maximum duration specified for your USA cover option. If your treatment extends beyond the end of your trip's specified return date, your cover will cease at the end of the term defined in your USA cover option wording. For example, if you have selected the USA-45 option and you are on a 30-day trip to the United States of America, which becomes extended to 60 days, your cover in the United States of America will cease 45 days after your date of entry to the United States of America. Terminal medical condition A condition that has become incurable and all the treatments given are to prolong life. Treatment Surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury. Unused premium The amount of premium that is attributable to the period from the date after the date of cancellation, up to the date before the next premium due date. In the event of a refund of unused premium being eligible, the unused premium amount refunded (using an annually paid plan as an example) will be the annual premium paid divided by 12 and multiplied by the number of whole calendar months remaining in the period of cover. If the plan is cancelled part way through a month, an additional amount, equal to one twelfth of the annual premium paid, multiplied by the proportion of days without cover in the calendar month of cancellation will also be paid. For example, if the annual premium for an insured person is US$3,000, the period of cover is 1st January to 31st December 2020, and the insured person leaves the plan on 27th September 2020, the unused premium will be US$775, as: - • ((US$3,000 / 12) x 3) = US$750 for the three whole months without cover (October, November and December); added to -
TABLE OF BENEFITS. Unless otherwise stated and subject to any sub-limit as stated in any Section, the maximum liability in respect of each of the Insured Persons is shown under the Table of Benefits below:
TABLE OF BENEFITS. Description of Disablement Percentage of Sum Covered (%) Accidental Death 100% Loss of Limbs (one (1) or both limbs) - loss by physical separation at or above the wrist or ankle joint 100% Total paralysis 100% Injuries resulting in being permanently bedridden 100% Any other Bodily Injury causing Permanent Total Disablement 100% Eye: Loss of one (1) or both eyes including Loss of Sight 100%
TABLE OF BENEFITS. INSURANCE GUARANTEES CEILING Subject to the eligibility conditions and exclusions detailed in this Information Notice 1 / CANCELLATION • Death following Covid-19 infection • Serious illness or disease following Covid-19 infection • Infection with Covid-19 • Refusal of boarding by the means of transport reserved following temperature measurement • Case of Contact with Covid-19 2/ LATE ARRIVAL • Serious illness or disease following Covid-19 infection • Infection with Covid-19 • Refusal of boarding by the means of transport reserved following temperature measurement • Case of Contact with Covid-19 3 / INTERRUPTION OF STAY • Interruption of stay following illness or death due to a Covid-19 infection during the stay. 4/ HOTEL EXPENSES FOLLOWING QUARANTINE FOR DISEASE • extension of stay following quarantine Maximum compensation of 20 000 € / file Without deductible Maximum 3 days of refundable rental Deductible of one day Maximum compensation of 20 000 € / file Deductible of one day Hotel fee 80 € per file / Max 7 nights l Gritchen Affinity 27, rue Xxxxxxx Xxxxxx CS70139 - 18021 Bourges Cedex xxx.xxxxxxxx.xx
TABLE OF BENEFITS. Insured Event Sum Protected Section 1 - Personal Accident Benefits Principal Sum Protected $25,000 Accidental Death 100% of the Principal Sum Protected Permanent Partial Disability % of the Principal Sum Protected as per scale. Permanent Total Disability 100% of the Principal Sum Protected Section 2 - Medical and Related Benefits Emergency Medical Evacuation Included in Emergency Medical Expenses Assistance Department Covered Repatriation of Remains $7,000 Section 4 - Additional Optional Coverage: Hazardous Sports Benefits Terrorism Extension Amount noted for the applicable above cover under Section 1 and Section 2 and 4.4.1 HAZARDOUS SPORTS BENEFITS as above. Amount noted for the applicable cover under Section 1 and Section 2 as above or $100,000 whichever is less Section 3 - Travel Inconvenience Benefits Baggage Loss (Common Carrier) Refer to 4.3.1 Per Bag Per Item $1,000 $500 $50 Family includes Participant, Spouse and unlimited number of Children. Children are charged only 50% of the premium charged for adults. Children are covered for 10% of the Participant’s Sum Protected and up to a maximum of $10,000 under Accidental Death. Baggage Delay (Pays for actual expenses incurred due to the delay and up to the limit stated) Refer to 4.3.2 Excess $50 per hour up to $500 4 Hours Travel Delay (Pays for actual expenses in- curred due to the delay and up to the limit stated) Refer to 4.3.3) Excess $50 per hour up to $500 4 Hours
TABLE OF BENEFITS. 8.1 Medical Services in a Physician's Office. These are Health Services provided by or through a Physician in the Physician's office. A Physician’s office may be located in a clinic or Hospital. Covered Health Services exclude preventive medical care such as routine physical examinations, vision and hearing screenings, voluntary family planning, and immunizations.
TABLE OF BENEFITS. The Table of Benefits (1) outlines the Co-payment and/or Co-insurance that a Covered Person is required to pay for Health Services (2) describes any maximum Benefit that may apply (3) any Waiting Periods that must be satisfied prior to eligibility for Benefits. Health Services Covered under the Policy are described in Section 8, "Covered Health Services." Network Benefits are subject to the payment of any Co-payment and/or Co-insurance listed in the Table of Benefits. Network Benefits include Medically Necessary Emergency Health Services and referral Health Services received from non-Network Providers as described in Section 6. Non-Network Benefits are subject to the payment of Co-payment and/or Coinsurance listed in the Table of Benefits and subject to Reasonable and Customary limitations. Covered Health Services must be prior authorized by the Company. Note: Not all Health Services may be available as Non-Network Benefits. Non-Network Benefits that are subject to prior approval are mentioned in section 7. Failure to obtain prior approval may require payment by the Primary Insured of all charges for such Health Services.
