GLOC Nemwil Smart Choice Plan

IMPORTANT: This Schedule of Benefits should be read in conjunction with the Individual Health Policy and is subject to the definitions, benefit limitations, exclusions and to all other provisions of the Individual Health Policy.Covered medical expenses are based on the usual customary and reasonable charges incurred by you or your Dependents while insured hereunder for Medically Necessary treatment of an Illness or Injury.

IMPORTANT:Failure to pre-certify in accordance with the pre-certification requirement will result in an additional 35% penalty for Preferred Providers, and 50% for Non-Preferred Providers.This penalty is in addition to any other Coinsurance or Deductible stipulated in the Schedule of Benefits and applies in full notwithstanding any applicable maximum out of pocket expenses.

IMPORTANT:The Per Insured and Per Family Deductibles are applied to the covered medical expenses before the Coinsurance factors.The resulting net amount (after applications of Deductibles and Coinsurance) is always subject to any stipulated maximum dollar limit payable by Underwriters for the applicable medical treatment or condition. Family includes the Covered Insured, Spouse and any Dependents.

IMPORTANT:Once the Underwriters limit has been exhausted in respect of a specific treatment or condition then any further expenses relating to that treatment or condition are no longer covered, irrespective of any maximum out of pocket cap.

Schedule of Benefits

 

Non - Preferred Provider

Preferred Provider
USA Worldwide

Preferred Provider
BVI Puerto Rico

Lifetime Maximum

$500,000

Per Insured per year Deductible

$2,000

$1,000

$500

Waived BVI

Family Year Deductible

(2 Family members to satisfy)

$4,000

$2,000

$1,000

Dental  Services per Insured Person per Annual Insurance Period Deductible, if applicable

$200

$200

$200

Dental Services per insured family per Annual Insurance Period Deductible (2 Family members to satisfy) if applicable

$400

$400

$400

 

Co-Insurance factor
BVI and Puerto Rico

See Below

Co-Insurance factor
USA Worldwide

See Below

See Below

Maximum out of pocket cap per individual each year for covered medical treatment

No Cap

$2,000

$1,000

Maximum out of pocket cap per Family

No Cap

$4,000

$2,000

 

Non pre-certification penalty

50%

35%

35%

Covered Medical Expenses and Coinsurance Factors

Percentage of Covered Expenses payable by Underwriters

 

Non-Preferred Provider

Preferred Provider - USA & Worldwide

Preferred Provider –BVI & Puerto Rico

Hospital Treatment including:

Semi-private room - after 60 days of confinement, the Extended Care Facility Benefit applies

Surgeon's / Physicians fees

Assistant Surgeon's fee (20% of Surgeons fee)

Pre-certification Required

 

 

 

50%

 

 

 

80%

 

 

 

80%

Extended Care Facility

After a period of confinement, a maximum of $50 payable per day up to a maximum of 120 days

50%

80%

80%

Subject to a lifetime maximum of $6,000

Rehabilitation Facility

Pre-Certification required

50%

80%

80%

Home Health Care/Hospice Care

After a period of confinement, a maximum of $50 payable per day up to a maximum of 120 days

50%

80%

80%

Subject to a lifetime maximum of $6,000

Emergency Room including

non-emergency treatment in emergency room

50%

80%

80%

Out Patient Diagnostic Testing benefit MRI, CT Scans, Endoscopy, Cardiovascular Studies and any other Diagnostic Procedures 

Pre-certification Required

50%

80%

80%

Subject to a maximum amount of $1,500 per policy year

Prescription per item

50%

60%

60%

 

Subject to a maximum amount of $1,000 per policy year

Doctors and Specialist Visits

50%

60%

60%

Subject to a maximum amount of $1,000 per policy year

Second Surgical Opinion (no deductible)

50%

80%

80%

Preventative Care Services-subject to an overall maximum of $1,000 per policy year for the following services:

  • Annual Routine Medical Exam
  • Screening Mammogram
  • Prostate Cancer Screening
  • Annual Pap Smear
  • Routine Diagnostic Lab Test & Other Routine Screening Exams
  • Vaccinations/Immunizations up to age 5 oldyears

 

 

100%

 

 

100%

 

 

100%

Subject to a maximum amount of $150 per  policy year

100%

100%

100%

Subject to a maximum amount of $300 per  policy year

100%

100%

100%

Subject to a maximum amount of $50 per  policy year

100%

100%

100%

Subject to a maximum amount of $70 per  policy year

80%

80%

80%

100%

100%

100%

Non-Preferred Provider

Preferred Provider - USA & Worldwide

Preferred Provider –BVI & Puerto Rico

Airfare Benefit

100%

100%

100%

Maximum 2 trips per year

Subject to a maximum of $200 per policy year

Private Duty Nursing - $50 per day, maximum of 30 days per year

50%

80%

80%

Pre-certification required

Subject to a maximum amount of $1,500 per policy year

Hearing Test/Examination

Consultation/Office Visit

Hearing Test

Hearing Aid

50%

50%

50%

60%

80%

80%

60%

80%

80%

Organ Transplants including Pre and Post Operative Treatments

50%

80%

80%

Pre-certification Required

Subject to a lifetime maximum amount of $250,000

Air Ambulance

 

100%

100%

100%

Pre-certification required

Subject to a maximum amount of $15,000 per policy year

Ground Ambulance @ $75 per trip

100%

100%

100%

 

Subject to a maximum amount of $150 per policy year

Birth Abnormalities, Congenital Conditions, Premature Birth, or Other Defects in newborn children

50%

80%

80%

 

Subject to a maximum amount for any insured child of $50,000

All Treatment for AIDS, HIV, ARC

50%

50%

80%

Pre-certification Required

Subject to a maximum amount of $5,000 per policy year and lifetime maximum of $15,000

Chemotherapy

Pre-certification Required

50%

 

80%

80%

Subject to a maximum amount of $50,000 per policy year

Radiotherapy

50%

80%

80%

Pre-certification Required

Subject to a maximum amount of $50,000 per policy year

Chronic Conditions

50%

80%

80%

Physical Therapy- up to 20 one hour sessions per annual insurance period – maximum $30 per session 

50%

80%

80%

Psychiatric Care, including prescription drugs - Limited to 20 treatments per annum with a maximum of $20 per office visit

50%

50%

50%

 

Subject to a maximum amount of $10,000 per policy year and lifetime maximum of $25,000

Durable Medical Equipment
By prescription only

50%

80%

80%

Alcoholism and Substance Abuse

50%

80%

80%

 

Subject to a maximum of $2,500 per policy year and lifetime maximum of $10,000

 

Percentage of Covered Expenses payable by Underwriters

Dental Care Benefits:

Diagnostic/preventative   

Basic restorative

Major Replacement

 

80% (deductible waived)

80% (deductible waived)

80% (deductible applies)

Subject to a maximum of $1,000 per policy year per insured person

Orthodontia

 

80% (deductible applies)

Subject to a lifetime maximum benefit payable per member of $1,000

Vision Care Benefits: per person, per year $400

Eye Examination - one per year

Lenses (All types) - one pair per year

Frames - one pair per year

Contact Lenses

80%

80%

80%

80%

 

Subject to a maximum of $400 per policy year per insured person

Maternity Benefits

The Underwriter will pay covered Maternity Benefits for a Covered Insured or Spouse up to a maximum of $4,000 per pregnancy, for services, including doctors fees, Hospital fees and hospitalisation relating to prenatal care, postnatal care, delivery, complication of pregnancy, and charges relating to well baby nursery care.

Percentage of Covered Expenses payable by Underwriters

Pre and Post Natal Care Office visits

Doctors Fees:
Normal delivery
Pre-certification required

Caesarean Section
Pre-certification required

Ectopic or other complications
Pre Certification required

80%

 

80%

80%

80%

 

80%

 

Hospital Fees:
Maternity
Pre-certification required

 

Subject to a maximum of $4,000 per pregnancy