GLOC Nemwil Overseas Plan

Schedule of Benefits

IMPORTANT: Medical expenses incurred in the British Virgin Islands are not covered under this Plan. Such medical expenses should be submitted to the Virgin Islands National Health Insurance office for appropriate reimbursement.

IMPORTANT: This Schedule of Benefits should be read in conjunction with the Certificate of insurance and is subject to the definitions, terms, conditions, warranties, limitations, exclusions and to all other provisions of the Certificate of insurance. Covered Medical Expenses are based on the lesser of the Usual, Customary and Reasonable fees or the rates negotiated by Underwriters for the Medically Necessary treatment of an Illness or Injury covered under the Certificate.

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 Co-insurance or Deductible stipulated in the Schedule of Benefits and applies in full notwithstanding any applicable Maximum Out of Pocket Expenses Cap.

IMPORTANT: The per Insured Person and per Family Deductibles are applied to the Covered Medical Expenses before the Co-insurance factors. The resulting net amount (after applications of Deductibles and Co-insurance) is always subject to any stipulated maximum dollar limit payable by Underwriters for the applicable Covered Medical Expense. Any stipulated per Insured Person or per Family Out of Pocket Expenses Cap amount is always in addition to any stipulated per Insured Person or per Family Deductible amount.Supplementary.

IMPORTANT: Once the Underwriters limit has been exhausted in respect of a specific benefit then any further expenses relating to any treatment or condition falling under that benefit are no longer covered, irrespective of any Maximum Out of Pocket Expenses Cap.

IMPORTANT: All potential or actual claims that may result in a Covered Medical Expense under this Certificate, even if such Covered Medical Expense falls wholly or partly within the applicable Deductible, must be submitted to the Agent or Third Party Administrator in accordance with the “Submission of a Claim” condition within the Certificate. Failure to comply with this condition will lead to denial of the claim.

Non - Preferred Provider

Preferred Provider USA Worldwide

Preferred ProviderPuerto Rico

Lifetime Maximum

$2,000,000.00

Per Insured per year Deductible

$500

$250

$250

Waived

Family Year Deductible

(2 Family members to satisfy)

$1,000

$500

$500

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 -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

70%

90%

90%

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

70%

90%

90%

Subject to a lifetime maximum of $6,000

Rehabilitation Facility

Pre-certification Required

70%

90%

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

70%

90%

90%

Subject to a lifetime maximum of $6,000

Emergency Room including non-emergency treatment in emergency room

70%

90%

90%

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

70%

90%

90%

 

Prescription per item

70%

80%

80%

Subject to a maximum amount of $2,500 per policy year

Doctors and Specialist Visits

70%

80%

80%

Second Surgical Opinion (no deductible)

70%

90%

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

 

 

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

90%

90%

90%

100%

100%

100%

Non-Preferred Provider

Preferred Provider - USA & Worldwide

Preferred Provider -Puerto Rico

Chiropractic Services, maximum of 20 treatments per year.

70%

90%

90%

Subject to a maximum amount of $320 per policy year

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

70%

90%

90%

Pre-certification Required

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

Hearing Test/Examination

Consultation/Office Visit

Hearing Test

Hearing Aid

70%

70%

70%

80%

90%

90%

80%

90%

90%

Organ Transplants including Pre and Post Operative Treatments

70%

90%

90%

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 $20,000 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

70%

90%

90%

Subject to a maximum amount for any insured child of $100,000

All Treatment for AIDS, HIV, ARC

70%

90%

90%

Pre-certification Required

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

Chemotherapy

Pre-certification Required

70%

90%

90%

Subject to a maximum amount of $100,000 per policy year

Radiotherapy

70%

90%

90%

Pre-certification Required

Subject to a maximum amount of $100,000 per policy year

Chronic Conditions

70%

90%

90%

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

70%

90%

90%

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

70%

90%

90%

Alcoholism and Substance Abuse

70%

90%

90%

Subject to a maximum of $2,500 per policy year and lifetime maximum of $25,000

 

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 $1,500 per policy year per insured person

Orthodontia

80% (deductible applies)

Subject to a lifetime maximum benefit payable per member of $1,500.00

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 $6,000 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

90%


90%


90%

90%


90%

Hospital Fees:
Maternity
Pre-certification Required

Subject to a maximum of $6,000 per pregnancy

Download PDF