GLOC Nemwil Extended Plan

Schedule of Benefits

IMPORTANT: This Policy is to be used as Secondary Insurance to the Virgin Islands National Health Insurance (NHI).

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: 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.

NEMWIL EXTENDED

(NHI MUST BE USED AS PRIMARY PLAN)

BVI

OVERSEAS

MAJOR MEDICAL LIFETIME MAXIMUM

$2,000,000

Deductible, per Insured per policy year

$     -

$250

Deductible, per family per policy year

(2 family members to satisfy)

$     -

$500

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

No Cap

$4,000

Maximum out of pocket cap per family per policy year

No Cap

$8,000

Pre-certification penalty

35%

35%

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)

Anaesthesiologist (25% of Surgeons fee)

100%

90%

Extended Care Facility

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

                      100%                                         90%  

Subject to a lifetime maximum of $6,000

Rehabilitation Facility

Maximum of $250 payable per day up to 30 days per policy year

Pre-certification Required

                      100%                                         90%  

Home Health Care/Hospice Care

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

                      100%                                         90%  

Subject to a lifetime maximum of $6,000

NEMWIL EXTENDED

(NHI MUST BE USED AS PRIMARY PLAN)

BVI

OVERSEAS

Emergency Room including non-emergency treatment in emergency room

                      100%                                         90%

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

Pre-certification Required

                      100%                                         90%

Prescription per item

                      100%                                         80%  

Annual Maximum - $2,500

Doctors and Specialist Visits

                      100%                                         80%

Second Surgical Opinion (No Deductible)

                      100%                                         90%

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

Annual Maximum of $1,000

100%
100%

Chiropractic Services, maximum of 10 treatments per policy year

Maximum of $50 per visit

                          100%                                           90%

Annual Maximum of $500

Private Duty Nursing - maximum of 30 days per policy year

Maximum of $50 per visit

Pre-certification Required

                          100%                                           90%

Annual Maximum of $1,500

Hearing Test/Examination

Consultation/Office Visit

Hearing Test

                         100%                                            90%

 

Organ Transplants including Pre and Post-Operative Treatments

Pre-certification Required

                           100%                                          90%

Lifetime Maximum of $250,000

Air Ambulance

Pre-certification Required

                           100%                                         100%

Annual Maximum of $20,000

Ground Ambulance

 

                           100%                                         100%

Annual Maximum of $500

Birth Abnormalities, Congenital Conditions, Premature Birth, or other defects in newborn children

                           100%                                           90%

Lifetime Maximum of $100,000 per child

NEMWIL EXTENDED

(NHI MUST BE USED AS PRIMARY PLAN)

BVI

OVERSEAS

All treatment for AIDS, HIV, ARC

Pre-certification Required

                           100%                                           90%

Annual Maximum of $5,000

Lifetime Maximum of $15,000

 

Chemotherapy

Pre-certification Required

                           100%                                           90%

 

Annual Maximum of $100,000

 

Radiotherapy

Pre-certification Required

                           100%                                           90%

 

Annual Maximum of $100,000

 

Dialysis

                           100%                                           90%

Physical Therapy - up to 20 one hour sessions per policy year

Maximum of $50 per visit

                           100%                                           90%

Annual Maximum of $1,000

Psychiatric Care - Limited to 20 visits per policy year

Maximum of $100 per visit

                           100%                                           90%

Annual Maximum of $2,000

Lifetime Maximum of $25,000

Durable Medical Equipment

By Prescription Only

                             90%                                           90%

Alcoholism and Substance Abuse

                           100%                                           90%

Annual Maximum $2,500 - Lifetime Maximum $25,000

Dental Care Benefits

Diagnostic/Preventative

Basic Restorative

Major Replacement

                            100%                                          80%

Annual Maximum of $1,500

Orthodontic 

                            100%                                          80%

Lifetime Maximum of $1,500

Vision Care Benefits

Eye Examination - one per year

Lenses (All types) - one pair per year

Frames - one pair per year

Contact Lenses

Annual Maximum of $500

            100%                                        100%

NEMWIL EXTENDED

(NHI MUST BE USED AS PRIMARY PLAN)

BVI

OVERSEAS

Maternity Benefits

Pre-Natal Care Office visits

Post-Natal Care Office visits

Doctors’ Fees:

Normal delivery

Pre-certification Required

Caesarean Section

Pre-certification Required

Ectopic or other complications

Pre-certification required

Hospital Fees:

Maternity

Pre-certification Required

90%

90%

 

Subject to a maximum of $6,000 per pregnancy

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