GlobalFusion - Schedule of Cover

For GlobalFusion International Medical Insurance.

GlobalFusion International Medical Insurance

Summary Schedule of Cover and Excesses

This Summary Schedule of Cover and Excesses must be read in conjunction with the GlobalFusion Policy Wording (copy available upon request), and all sections and cover are subject to all terms and conditions. Each GlobalFusion sub-plan has a different column to identify the specific limits of cover and sections that are applicable to it.

Your cover is always subject to the overall lifetime maximum sum insured per insured person. Each section of cover is per Insured Person and per Period of Insurance, unless stated otherwise and always subject to the benefits stated for each sub-plan and plan terms, conditions, limitations and exclusions. Please note that sub-limits and Pre-Certification requirements apply within certain benefit sections - refer to the Policy Wording for further details.

All benefit limits and excesses in this Summary Schedule of Cover and Excesses are set in £Sterling, $US Dollar and €Euros. The currency in which you pay your premium being either £Sterling, $US Dollar and €Euros, is the currency that applies to your sub-plan for the purposes of the benefit limits. "Full Cover" means up to the applicable overall Lifetime Maximum Limit per Individual Insured Person shown in the table below, and is based upon Usual, Reasonable and Customary Eligible Charges.

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Global Fusion Benefits

All sub-limit sums insured are the maximum per Person, per Period of Insurance unless otherwise stated

Lifetime Maximum Limit Per Individual Insured Person

In-Patient & Day-Patient Treatment

		Bronze	Silver	Gold Plus
1	Surgery, Surgeons, Consultants, Second Surgical Opinion, Medical Practitioners, Nurses, Treatment, Services and Supplies routinely provided and Ancillary Charges	Full Cover	Full Cover	Full Cover
2	Hospitalisation/Room & Board		Up to $600 / £350 /€400 per day 240 day Maximum
3	Intensive Care Unit		Up to $1,500 / £850 / €1,000 per day – 180 day per event
4	Anaesthetist’s Charges associated with Surgery		20% of Surgery Benefit
5	Diagnostic Tests and Procedures, X-Rays, Pathology, & MRI/CT Scans		Full Cover
6	Dressings and Durable Medical Equipment
7	Reconstructive Surgery-following an accident or following surgery for an eligible condition
8	Cancer Tests, Treatment and Consultants, including cover for Radiotherapy
9	Prescribed Drugs and Medication Including Chemotherapy Combined per Period of Insurance limit for In-Patient/Day-Patient and Out-Patient services	Up to $250,000 / £150,000 / €200,000 per Period of Insurance	Up to $250,000 / £150,000 / €200,000 per Period of Insurance	Up to $250,000 / £150,000 / €200,000 per Period of Insurance
10	Physiotherapy	Full Cover	Full Cover	Full Cover
11	Parental Hospital Accommodation
12	Prosthetic Devices
13	Transplants	$250,000/ £137,500/ €167,500 Per Transplant	$250,000/ £137,500/ €167,500 Per Transplant	$1,000,000/ £550,000/ €670,000 Lifetime Limit
14	State Hospital Cash Benefit	$300 / £165 / €200 Per Night 60 nights	$300 / £165 / €200 Per Night 60 nights	$300 / £165 / €200 Per Night 60 nights
15	Terrorism Coverage	$10,000 / £5,500 / €6,700 Lifetime Limit	$10,000 / £5,500 / €6,700 Lifetime Limit	$10,000 / £5,500 / €6,700 Lifetime Limit

Out-Patient Treatment, Wellness Benefits and Other Coverages

		Bronze	Silver	Gold Plus
1	Out-Patient including: Family Doctor, Treatment and Referrals, Specialists and Consultants, X-Rays, Pathology, Diagnostic Tests and Procedures *not dependent upon admission	No Family Doctor Cover Specialists & Consultants: Up to $500 / £275 / €335 Prior to admission, then up to $500 / £275 / €335 following related Out-Patient Surgery or In-Patient/Day-Patient treatment: for 90 days after leaving hospital Including Pre & Post Hospital: $250 / £140 / €170 X-Ray per Examination Maximum Limit; $300 / £165 / €200 Lab Tests per Examination Maximum Limit	FULL COVER Except: $150 / £85 / €100 Physician Charges Maximum per Visit; Hospital Charge $100 / £55 / €67 Co-Pay unless admitted; Urgent Care Facility - $25 / £15 / €20 Co-Pay; Diagnostic Lab and X-Rays limited to $5,000 / £2,750 / €3,350 per Period of Insurance	Full Cover
2	Emergency Room Illness (Additional $250/£138/€168 Excess if not admitted) (Not applicable to the Bronze sub-plan) Additional Excess waived if admitted as an In- Patient or Day-Patient	Full Cover	Full Cover
3	Emergency Room Accident	Full Cover	Full Cover
4	Supplemental Accident Benefit	No Cover	No Cover	$300 / £165 / €200 per covered accident
5	Out-Patient Surgery	Full Cover	Full Cover	Full Cover
6	MRI, CAT Scan Echocardiography, Endoscopy, Gastroscopy Colonoscopy, Cystoscopy	$600 / £330 /€400 Maximum Per Examination	$600 / £330 /€400 Maximum Per Examination
7	Cancer Tests, Treatment and Consultants, including cover for Radiotherapy	Full Cover	Full Cover
8	Prescribed Out-Patient Dressings and Durable Medical Equipment	Up to $600 / £330 /€400 Following and in relation to In-Patient/Day-Patient Treatment or Out-Patient Surgery: for 90 days after leaving hospital	Full Cover
9	Prescribed Drugs and Medication Including Chemotherapy Combined per Period of Insurance limit for In-Patient/Day-Patient and Out-Patient services	Up to $250,000 / £150,000 / €200,000 per Period of Insurance	Up to $250,000 / £150,000 / €200,000 per Period of Insurance	Up to $250,000 / £150,000 / €200,000 per Period of Insurance
10	Physiotherapy, Homeopathic, Chiropractic Therapy and Osteopathic Therapy	Physiotherapy Only: Relating to In-Patient/Day-Patient Treatment, Out-Patient Surgery Up to $40 / £25 / €30 per visit 10 visit Maximum: for 90 days after leaving hospital	Up to $40 / £25 / €30 per visit 30 visit Maximum	Maximum of 1 visit per day 45 visit maximum Up to $4,000 / £2,500 / €3,000 per Period of Insurance
11	Complementary Medicine Acupuncture, Aroma Therapy, Herbal Therapy, Magnetic Therapy, Massage Therapy, Vitamin Therapy, Traditional Chinese Medicine	No Cover	No Cover	Up to $200 / £110 / €135
12	AIDS/HIV Treatment	No Cover	No Cover	Up to $5,000 / £2,750 / €3,350 per Period of Insurance $50,000 / £27,500 / €33,500 Lifetime Limit
13	Home Nursing Care	30 Days Limit: Up to $150 / £85/ €100 per visit	30 Days Limit: Up to $150 / £85/ €100 per visit	45 Days Limit: Up to $150 / £85/ €100 per visit
14	Rehabilitation	No Cover	No Cover	Full Cover Up to 90 Days
15	Extended Care Facility	No Cover	Full Cover Up to 30 Days	Full Cover Up to 90 Days
16	Hospice Care	No Cover	No Cover	Full Cover Up to 180 Days
17	Adult Wellness and Health Check - includes Hearing Test, Sight Test and Vaccinations/Inoculations (Not subject to Annual Excess or Co-Insurance) - After 12 months continuous coverage		No Cover	Up to $250 / £140 / €170
18	Child Wellness and Health Check (Under 18 years of age) - includes Hearing Test, Sight Test and Vaccinations/Inoculations (Not subject to Annual Excess or Co-Insurance) - After 12 months continuous coverage		3 visits per Period of Insurance Up to $70 / £40 / €50 per visit	Up to $200 /£110 / €135
19a or 19b	Pre-Existing Conditions -Underwriting/Coverage Options Full Medical Underwriting Option*: - After 24 months continuous cover - Declared and Accepted conditions (unless otherwise excluded or terms applied as indicated otherwise in writing) - Flexible Underwriting Option available - Endorsement issued if applicable.		Up to $5,000 / £2,750 / €3,350 $50,000 / £27,500 / €33,500 Lifetime Limit	Up to $5,000 / £2,750 / €3,350 $50,000 / £27,500 / €33,500 Lifetime Limit
19a or 19b	Moratorium Enrolment & Underwriting Option* - After 24 months continuous coverage: subject to 24 months without treatment, symptoms, medication or consultation* - Available to insureds up to age 64		Full Cover	Full Cover
*Coverage in respect of Pre-Existing Conditions is as selected at time of application and identified on your Certificate of Insurance. Refer to Section B for further details and Endorsements issued for full Policy definitions, terms, conditions and restrictions.
20	Newly Diagnosed Chronic Conditions	Covered	Covered	Covered
21	Mental/Nervous - After 12 months continuous coverage	No Cover	Out-Patient Only - See Section B1	Up to $10,000 / £5,500 / €6,700 $50,000 / £27,500 / €33,500 Lifetime Limit

Travel, Transportation and Out Of Area Benefits

Dental Treatment & Vision Care Benefits

		Bronze	Silver	Gold Plus
1a	Emergency Dental Due to Accident	Up to $1,000 / £550 / €670	Up to $1,000 / £550 / €670	Full Cover
2a	Emergency Dental due to Sudden Unexpected Pain To Sound Natural Teeth	No Cover	No Cover	Up to $100 / £55 / €70

		Dental and Vision Optional Add-On Coverage Additional Premium Applies Coverage is issued via a Dental & Visions Care Coverage Endorsement Sections D1a & D2a above are replaced with: Refer To Policy Wording/Endorsement for Full Details & Listing
1b	Emergency Dental Due to Accident	Full Cover
2b	Emergency Dental due to Sudden Unexpected Pain To Sound Natural Teeth	Up to $100 / £55 / €70
3	Non-Emergency Dental Sections D3, D4 & D5 Combined: i) Calendar Year Maximum Sum Insured ii) Dental Annual Excess iii) Maximum Annual Excesses per Family per Calendar Year - After 6 months continuous cover	i) $750 /£425 /€500; ii) $50 / £30 / €35 iii) 2
4	Class I Treatment: - Preventative & Diagnostic - Emergency Palliative Treatment - includes up to two dental check ups per calendar year to include scraping, cleaning and polishing - After 6 months continuous cover Refer To Policy Wording for Full Details & Listing	90% Coverage, Dental Annual Excess Waived
5	Class II Treatment: - Radiographs & X-Rays - Oral Surgery & Extractions - Routine Compound Fillings, Restorations, Re-cementing crowns, inlays and bridges & Prosthetic Repairs - Endodontics & Root Canals - Periodontics & Gum Disease - Minor Restorative Services - After 6 months continuous cover Refer To Policy Wording for Full Details & Listing	70% Coverage, after Dental Annual Excess
6	Class III Treatment: - Prosthodontic Services including: appliances, bridges, full and partial dentures that replace missing natural teeth that were extracted while the person is covered with this Plan. - Major Restorative Treatment including: Crowns, Jackets, gold-related services required when teeth can not be restored using other filling material. - After 6 months continuous cover Refer To Policy Wording for Full Details & Listing	50% Coverage, after Dental Annual Excess
7	Vision Care Not subject to Annual Excess or Co-Insurance (Benefit payable per 24 months)	Exams – up to $100 / £55 / €70 Materials – up to $150 / £85 / €100

Additional Benefits & Services

Maternity

Optional Add-On Coverages

Annual Excess and Co-Insurance

*This Web page contains only a consolidated and summary description of some of the current benefits, conditions, limitations and exclusions. A Policy Wording containing the full terms, conditions and exclusions will be included in the fulfillment kit. IMG Europe reserves the right to issue the most current Policy Wording for this insurance program in the event this Web page, application and/or booklet has expired, is modified, or is replaced with a newer version. Current Policy Wordings are available upon request.

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GlobalFusion International Medical Insurance

Summary Schedule of Cover and Excesses