LLOYD’S Superior 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.

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 Provider

Puerto Rico

Lifetime Maximum

$2,000,000

Annual Deductible Per Insured Person

 

$250

$250

$250

Waived

Family Annual DeductibleK
(2 Family members to satisfy)

$500

$500

$500

Waived

Dental Annual Deductible,  if applicable

 

$50

$50

$50
Waived

Dental Annual Deductible, if applicable
(2 Family members to satisfy)

 

$100

$100

$100
Waived

Co-Insurance

See Below

See Below

See Below

Maximum Out of Pocket Expenses Cap

per Insured Person per year for Covered

Medical Expenses

$10,000

$4,000

$2,500

 

Maximum Out of Pocket Expenses Cap

per Family each year for Covered Medical

Expenses

$20,000

$8,000

$5,000

 

Non Pre-certification penalty 

50%

35%

35%

Covered Medical Expenses and Coinsurance Factors

Percentage of Covered Medical Expenses payable by Underwriters

Non-Preferred

Provider

Preferred Provider

USA & Worldwide

Preferred Provider

Puerto Rico

Hospital Treatment Benefit including:

Semi-private room – after 60 days of Confinement, the Rehabilitation Facility benefit applies Surgeon, Physician and anaesthesiologist’s fees, Assistant Surgeon’s fees (limited to 20% of Surgeon’s fees)

Pre-certification Required

 

75%

 

80%

 

90%

Rehabilitation Facility Benefit 

Maximum of $400 per day

Pre-certification Required

75%

80%

90%

 

Subject to a maximum amount of $12,000 per year

Emergency Room Benefit including:

Non-emergency treatment in an emergency room

75%

80%

90%

Diagnostic Testing Benefit

MRI, CT Scans, Endoscopy, Cardiovascular studies and other diagnostic procedures.

75%

80%

90%

Pre-certification Required

Prescription Drugs Benefit

75%

80%

90%

Physician Visits Benefit

75%

80%

90%

Second Surgical Opinion Benefit

Pre-certification Required

75%

80%

90%

Annual Physical Exam Benefit, including Pap Smear, Mammogram, Immunisations, Vaccinations and other Routine Diagnostic Studies

100%

100%

100%

Subject to a maximum amount of $1,000 per year for each Insured Person

Organ Transplant Benefit including pre and post-

operative treatments

75%

80%

90%

Pre-certification Required

Subject to a lifetime maximum amount of $250,000

Air Ambulance Benefit

100%

100%

100%

Pre-certification Required

Subject to a maximum amount of $30,000 per year for each Insured Person

Air Travel Benefits

Limited to $300 per ticket. Treatment must be medically necessary. Maximum of 3 tickets per year

Pre-certification Required

 

100%

 

100%

 

100%

Ground Ambulance Benefit @ $300 per trip

Pre-certification Required

100%

100%

100%

Subject to a maximum amount of $600 per year for each Insured Person

 

 

Percentage of Covered Medical Expenses payable by Underwriters

Non-Preferred

Provider

 

Preferred Provider

USA & Worldwide

Preferred Provider

Puerto Rico

Birth Abnormalities, Congenital Conditions, Premature Birth, or Other Defects in Newborn ChildrenThe benefit only applies if the newborn is covered by the Maternity Benefit of this Certificate on the date the Certificate Holder acquires the newborn child.

75%

80%

100%

Pre-certification Required

Subject to a maximum amount for any newborn Insured Person of $50,000

AIDS, HIV and ARC Benefit

75%

80%

90%

Pre-certification Required

Subject to a maximum amount of $5,000 per year, lifetime maximum of $25,000

Radiotherapy Benefit 

75%

80%

90%

Pre-certification Required

Chemotherapy Benefit

Pre-certification Required

75%

80%

90%

Mental and Nervous Disorders Benefit

Maximum $50 per visit per year
Outpatient Visits limited to 20 per year
Hospitalization stay limited to 60 days per year

75%

80%

90%

Physical Therapy Benefit – 25 one hour sessions per year – maximum of $50 per session 

Pre-certification Required

75%

80%

90%

Subject to a maximum amount of $1,250 per year for each Insured Person

Occupational Therapy Benefit – maximum of $50 per session

Pre-certification Required

75%

80%

90%

Speech Therapy Benefit – maximum of $50 per session

Pre-certification Required

75%

80%

90%

Extended Care Facility Benefit

Pre-certification Required

75%

80%

90%

Subject to a maximum of $10,000 per year for each Insured Person

Home Health Care Benefit and Hospice Care Benefit

Pre-certification Required

75%

80%

90%

Subject to a maximum of $10,000 per year for each Insured Person

Chiropractic Services Benefit - maximum 25 treatments per year, maximum $40 per treatment

Pre-certification Required

75%

80%

90%

Subject to a maximum amount of $1,000 per year for each Insured Person

Private Duty Nursing Benefit –30 days per year

75%

80%

90%

Pre-certification Required

Subject to a maximum amount of $1,500 per year for each Insured Person

                                               

 

Percentage of Covered Medical Expenses payable by Underwriters

Dental Benefits:

Class 1 Diagnostic/Preventative (no Deductible)
Class 2 Basic Restorative
Class 3 Major Replacement

 

100%
75%
75%

 

Orthodontic

Subject to a maximum of $2,000 per year for each Insured Person 75% (deductible applies)

Subject to a maximum of $2,000 per lifetime for each Insured Person

Vision Care Benefits: per Insured Person, per year

Eye examination – one
Lenses (All types) – one pair
Frames – one pair
Contact Lenses

 

 

80%

 

Subject to a maximum of $600 per year for each Insured Person

Maternity Care Benefit:

The Underwriter will pay Covered Maternity Benefits for the pregnancy of the Certificate Holder or the Certificate Holder’s spouse up to a maximum of $7,500 per pregnancy for Medically Necessary treatment, care and services, including Physicians’ fees and Hospital fees relating to prenatal care, postnatal care, delivery, complications of pregnancy, and charges relating to Well Baby Care.

IMPORTANT: The pregnancy of any Insured Person other than the Certificate Holder or the Certificate Holder’s spouse is not covered under this Certificate.

IMPORTANT: There is a 12 month Waiting Period for Maternity Care benefits.

 

 

Percentage of Covered Medical Expenses payable by Underwriters

Maternity Care Benefit

Non-Preferred Provider

Preferred Provider – USA & Worldwide

Preferred Provider –Puerto Rico

Physician and Hospital fees:
Normal delivery
Caesarean section
Ectopic or other complications
Medically Necessary abortion

Pre and post natal care office visits:
Well Baby Care:

Elective abortions are not covered

Pre-certification Required

 

90%

 

90%

 

90%

 

90%

 

90%

 

90%

 

Subject to a maximum of $7,500 per pregnancy

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