Basic Long Term Insurance Coverage | Print |

Benefits

Global Mission Basic® covers the Usual, Reasonable and Customary (URC) charges for eligible expenses in the area where you receive treatment. Each insured person will only need to satisfy their deductible once per period of coverage (12 months), with a maximum of three deductibles per family. For eligible expenses incurred in the U.S. and Canada (if applicable): once the deductible is met, Global Mission Basic® pays 80% of the next US$5000 in eligible expenses, then 100% of eligible expenses up to the policy maximum. For eligible expenses incurred outside of the U.S. and Canada: once the deductible is met, Global Mission Basic® will pay 100% of eligible expenses up to the policy maximum.

MEDICAL INSURANCE
BENEFIT
Subject to deductible and
coinsurance
Coverage Area
 Two options: Worldwide or worldwide excluding U.S. and Canada

Policy Maximum Per Individual US$5,000,000 lifetime
   
Hospital Room & Board US$600 per day
(maximum of 240 consecutive days per covered event)
   
Intensive Care Unit US$1,500 per day (maximum of 180 consecutive days per covered event)
   
Inpatient or outpatient surgery URC up to lifetime maximum benefit
   
Anesthetist's charges associated with surgery 20% of the surgery benefit payable
   
Laboratory tests, X-rays, & other treatment associated with an inpatient covered event URC up to lifetime maximum benefit
   
Emergency medical evacuation US$50,000 per period of coverage(not subject to deductible or coinsurance)
   
Local ground ambulance US$1,500 per covered event (not subject to deductible or coinsurance)
   
Emergency room treatment due to an accident URC up to lifetime maximum benefit
   
Emergency dental due to an accident US$1,000 per period of coverage
   
Well child care
Only available after 12 months of continuous coverage 		3 visits per period of coverage (maximum limit of $70 per visit)
   
Outpatient visits or exams
25 visits per insured person per period of coverage reimbursed to the maximum limit as outlined below:
  
• Physician US$70 per visit/exam
• Specialist US$70 per visit/exam
• Psychiatrist US$60 per visit/exam
• Chiropractor US$50 per visit/exam
• Surgical intervention consultation US$500 per visit/exam
   
Outpatient X-rays US$250 per exam maximum limit
   
Outpatient lab tests US$300 per exam maximum limit
Pre-existing conditions
Only available after 24 months of continuous coverage 		US$50,000 lifetime maximum benefit
(maximum of US$5,000 per period of coverage)
Prescription medication related to a covered event URC up to lifetime maximum benefit
Extended care facility services Limited to the first 30 days of convalescent confinement
Home nursing care services Limited to 30 days per covered event
Inpatient hospice care Limited to the first 30 days of hospice confinement
Chemotherapy & radiation therapy URC up to lifetime maximum benefit
Physical therapy 30 visits per period of coverage (maximum limit of $40 per visit)
MRI, CAT scan, endoscopy, echocardiography, gastroscopy, colonoscopy & cystoscopy US$600 per exam maximum limit
   
Transplants
Certain precertification provisions must be met 		US$250,000 all inclusive per transplant
Return of mortal remains US$25,000 lifetime maximum (not subject to deductible or coinsurance)
Optional Maternity Rider
US$50,000 lifetime maximum
Benefits include: •Pre- and post-natal care •Maximum of US$5,000 for normal delivery for each pregnancy •Maximum of US$7,500 for C-section delivery for each pregnancy •Well baby care and treatment of newborn for first 31 days •Child wellness benefits of up to US$200 maximum per period of coverage (not subject to deductible or coinsurance) for eligible newborn children for the first 12 months

• The Rider must be selected at time of initial purchase of plan. • Benefits available after 10 months of continuous coverage • Eligible newborn children may be added without evidence of insurability as long as an application form is submitted within 31 days of birth • Benefits will be reduced by 50% for births that occur the 11th or 12th month of continuous coverage • See the application form for the cost of this optional rider
The foregoing list is only a summary of available benefits and coverages, and is subject to the specific terms and conditions of the plan concerning eligible benefits, limitations, eligibility and exclusions. Please refer to the Certificate Wording for a complete description, which is available upon request.

Exclusions

Pre-existing conditions and exclusions


After coverage has been in effect for 24 continuous months, Global Mission Basic® provides a US$50,000 lifetime benefit for eligible pre-existing conditions that existed at or prior to the effective date, subject to a maximum of US$5,000 per period of coverage. This benefit is payable whether or not you have received consultation or treatment for the condition(s) during the 24-month period. This is important since few pre-existing conditions remain free from ongoing consultation or treatment, and often do not qualify for coverage in standard plans. Global Mission Basic® does not rider or charge additional premium for pre-existing conditions. If you properly disclose a pre-existing condition at the time of application, and are accepted into the plan, you will be covered for eligible medical expenses after 24 months of continuous coverage, subject to the foregoing limits and the other terms of the plan.*

The following illnesses which exist, manifest themselves or are treated or have treatment recommended prior to or during the first 180 days of coverage from the initial effective date are considered pre-existing conditions under the plan, and are subject to the waiting period and other limitations of coverage described above: asthma, allergies, tonsillectomy, back conditions, adenoidectomy, hemorrhoids or hemorrhoidectomy, disorders of the reproductive system, hysterectomy, hernia, gall stones or kidney stones, any condition of the breast, and any condition of the prostate.




OTHER EXCLUSIONS & LIMITATIONS*
  • Maternity and newborn care (unless the maternity rider is purchased - see details under the Benefits section)
  • Inpatient mental and nervous
  • Routine physical exams
  • Dental treatment unless accident related
  • Organized amateur or professional sports
  • Treatment not ordered or received by a physician
  • Treatment or supplies not medically necessary
  • Investigational, experimental or research procedures
  • Custodial care
  • Weight modification
  • Elective cosmetic or plastic surgery
  • Treatment of impotency
  • Contraceptive medication or treatment
  • Drug and alcohol abuse treatment
  • Organ transplants not specifically listed
  • Devices to correct sight or hearing
  • Routine foot care
  • Treatment by a relative or family member
  • Treatment as a result of war or riot
  • Treatment resulting from illegal activities
  • Speech therapy
  • Persons HIV+ at effective date
  • Services and treatment eligible for payment by any government or other insurance


    • * See Certificate Wording for a definition of pre-existing conditions and a complete list of exclusions and limitations, and for all other specific terms and conditions of the plan. Certificate Wording is available upon request.
     

    Premiums

    New Business Rates through 31-Oct-2008 (Includes 2.5% surplus lines tax where applicable)

    WORLDWIDE COVERAGE - ANNUAL PREMIUMS
      $250.00
    deductible     		$500.00
    deductible     		$1,000.00
    deductible     		$2,500.00
    deductible     		$5,000.00
    deductible     		$10,000.00
    deductible
     
    Age M F M F M F M F M F M F
     
    14 Days-9** First 2 Free*, Then 310 First 2 Free*, Then 270 First 2 Free*, Then 210 First 2 Free*, Then 184 First 2 Free*, Then 169 First 2 Free*, Then 150
     
    10-18** 317 282 233 217 204 180
    * The first two Dependent Children between the ages of 14 days to 9 years are free only when both parents or guardians are insured under the Global Mission Basic plan. **Dependent child rates are only available when at least one parent or guardian is insured under the Global Mission Basic plan. Children applying with no parent or guardian insured by Global Mission Basic must use the Male 19-24 rates.
     
    19-24 718 895 622 881 484 675 422 588 331 473 294 407
     
    25-29 758 1,020 662 991 515 764 449 663 352 551 313 433
     
    30-34 848 1,128 730 1,063 566 823 496 718 389 576 345 490
     
    35-39 950 1,333 770 1,182 596 918 522 793 408 661 364 516
     
    40-44 1,202 1,463 976 1,273 647 997 567 873 542 676 482 602
     
    45-49 1,339 1,614 1,098 1,373 850 1,062 741 925 605 730 538 650
     
    50-54 1,635 1,796 1,386 1,548 1,071 1,201 935 1,068 794 886 706 789
     
    55-59 1,976 1,976 1,718 1,718 1,330 1,328 1,159 1,159 976 984 868 876
     
    60-64 2,909 2,738 2,651 2,480 2,235 1,973 2,024 1,816 1,691 1,502 1,505 1,337
     
    65-69 6,075 5,271 5,814 5,041 5,439 4,591 4,181 3,412 3,656 3,274 3,254 2,914
     
    70 - 74 Please contact IMG or your agent for premium information concerning this age bracket
    Rates expire on 31-Oct-2008

    New Business Rates through 31-Oct-2008 (Includes 2.5% surplus lines tax where applicable)

    WORLDWIDE COVERAGE EXCLUDING U.S/CANADA - ANNUAL PREMIUMS
      $250.00
    deductible     		$500.00
    deductible     		$1,000.00
    deductible     		$2,500.00
    deductible     		$5,000.00
    deductible     		$10,000.00
    deductible
     
    Age M F M F M F M F M F M F
     
    14 Days-9** First 2 Free*, Then 232 First 2 Free*, Then 203 First 2 Free*, Then 158 First 2 Free*, Then 138 First 2 Free*, Then 127 First 2 Free*, Then 112
     
    10-18** 238 212 175 163 153 134
    * The first two Dependent Children between the ages of 14 days to 9 years are free only when both parents or guardians are insured under the Global Mission Basic plan. **Dependent child rates are only available when at least one parent or guardian is insured under the Global Mission Basic plan. Children applying with no parent or guardian insured by Global Mission Basic must use the Male 19-24 rates.
     
    19-24 539 671 466 660 363 506 317 441 248 355 221 306
     
    25-29 569 766 497 744 385 572 336 498 264 413 234 326
     
    30-34 636 846 548 798 424 618 372 538 291 432 259 369
     
    35-39 714 1,000 578 888 447 689 392 595 307 496 273 387
     
    40-44 901 1,098 731 955 486 748 425 655 407 510 362 451
     
    45-49 1,004 1,211 823 1,030 638 797 556 694 453 548 404 487
     
    50-54 1,226 1,347 1,040 1,161 803 901 702 801 595 665 530 592
     
    55-59 1,482 1,482 1,288 1,288 997 996 869 869 731 738 651 657
     
    60-64 2,182 2,054 1,988 1,860 1,676 1,480 1,518 1,363 1,268 1,127 1,129 1,003
     
    65-69 4,556 3,953 4,361 3,781 4,080 3,443 3,136 2,559 2,742 2,456 2,441 2,185
     
    70 - 74 Please contact IMG or your agent for premium information concerning this age bracket
    Rates expire on 31-Oct-200