Summary of Benefits – Standard Plan
| Maximum Limit | Student – $500,000 per period of coverage Dependent – $100,000 per period of coverage |
|---|---|
| Per Illness/Injury Maximum | Student – $300,000 Dependent – $100,000 |
| Deductible | $100 per illness/injury Student Health Center: $5 copay per visit |
| Coinsurance | Outside the US & Canada: Company pays 100% In PPO Network or Student Health Center within U.S. or Canada: No coinsurance Out of PPO Network if within U.S. or Canada: 80% of eligible expenses up to $5,000; then 100% thereafter |
| Hospital Room and Board | Average semi-private room rate, including nursing service |
| Intensive Care | URC (Usual, Reasonable, Customary) |
| Emergency Room Injury | URC |
| Emergency Room Illness resulting in hospitalization | URC |
| Emergency Room Illness without In-patient Admission | URC; Subject to additional $250 deductible |
| Mental & Nervous Disorders and Substance Abuse | Out-patient – $50 per day; $500 lifetime maximum In-patient – URC up to $10,000 lifetime maximum Student Health Center Treatment – $0 |
| Prescription Drugs | In-patient URC Out-patient – 50% of actual charges |
| Physical Therapy | URC – limit 1 visit per day |
| Local Ambulance | Per Injury – up to $350 $350 per illness only if admitted as In-patient |
| Dental | Injury due to a covered accident – $500 maximum per accident Sudden & Unexpected Pain to natural teeth – $350 maximum |
| Eligible Medical Expenses | URC |
| Emergency Medical Evacuation | $500,000 lifetime maximum |
| Emergency Reunion | $50,000 lifetime maximum |
| Return of Mortal Remains | $50,000 maximum |
| Political Evacuation and Repatriation | $10,000 lifetime maximum |
| Intercollegiate/Interscholastic/Intramural or Club Sports | $5,000 maximum per Injury/Illness |
| Incidental Trip Coverage | Up to a cumulative 14 days (available for non-U.S. residents only) |
| Pre-existing Conditions | Charges excluded until after 12 months of continuous coverage |
| Terrorism | $50,000 lifetime maximum |
| AD&D | Student – $25,000 principal sum Spouse – $10,000 principal sum Dependent Child – $5,000 principal sum Accidental Dismemberment percentage of the principal sum |
| Personal Liability (Secondary to any other insurance) | $10,000 combined maximum limit Injury to third person’s property: subject to a $100 per damage deductible Damage to third person’s property: subject to a $100 per damage deductible |
| Treatment Period | 60-day minimum |
Summary of Benefits – Platinum Plan
| Maximum Limit | Student – $1,000,000 per period of coverage Dependent – $100,000 per period of coverage |
|---|---|
| Per Illness/Injury Maximum | Student- $500,000 Dependent- $100,000 |
| Deductible | For treatment received outside the US & Canada: $25 per illness or injury For treatment received inside the U.S./Canada: PPO Provider: $25 per illness or injury Non-PPO Provider: $50 per illness or injury Student Health Center: $5 copay per visit |
| Coinsurance | Outside the US & Canada: No coinsurance In PPO Network or Student Health Center within U.S. or Canada: No coinsurance Out of PPO Network if within U.S. or Canada: 80% of eligible expenses up to $5,000; then 100% thereafter |
| Hospital Room and Board | Average semi-private room rate, including nursing service |
| Intensive Care | URC |
| Maternity | $5,000 maximum limit. The benefit includes newborn routine care during the first 31 days of life after the deductible is met, the company pays 60% of eligible expenses out-of-network (U.S.), 80% in-network (U.S.) and 100% internationally |
| Routine Newborn Care | $750 maximum per period of coverage |
| Emergency Room Injury | URC |
| Emergency Room Illness resulting in hospitalization | URC |
| Emergency Room Illness without In-patient Admission | URC; Subject to additional $250 deductible |
| Mental & Nervous Disorders and Substance Abuse | Out-patient – $50 per day; $500 lifetime maximum In-patient – URC up to $10,000 lifetime maximum Student Health Center Treatment – $0 |
| Prescription Drugs | In-patient URC Out-patient – 50% of actual charges |
| Physical Therapy | URC – limit 1 visit per day |
| Local Ambulance | Per Injury – up to $750 $750 per illness only if admitted as In-patient |
| Dental | Injury due to a covered accident – $500 maximum per accident Sudden & Unexpected Pain to natural teeth – $350 maximum |
| Eligible Medical Expenses | URC |
| Emergency Medical Evacuation | $500,000 lifetime maximum |
| Emergency Reunion | $50,000 lifetime maximum |
| Return of Mortal Remains | $50,000 maximum |
| Political Evacuation and Repatriation | $10,000 lifetime maximum |
| Intercollegiate/Interscholastic/Intramural or Club Sports | $5,000 maximum per Injury/Illness |
| Incidental Trip Coverage | Up to a cumulative 14 days (available for non-U.S. residents only) |
| Pre-existing Conditions | Charges excluded until after 6 months of continuous coverage |
| Terrorism | $50,000 lifetime maximum |
| AD&D | Student – $25,000 principal sum Spouse – $10,000 principal sum Dependent Child – $5,000 principal sum Accidental Dismemberment percentage of the principal sum |
| Personal Liability (Secondary to any other insurance) | $10,000 combined maximum limit Injury to third person’s property: subject to a $100 per damage deductible Damage to third person’s property: subject to a $100 per damage deductible |
| Treatment Period | 60-day minimum |
Adventure Sports Rider
The Adventure Sports Rider is available for those up to the age of 65. All such activities must be carried out in strict accordance with the rules, regulations, and guidelines of the applicable Governing Body or Authority of each such activity. The following activities are covered to the lifetime maximum amounts listed below as long as they are engaged solely for leisure, recreation, or entertainment purposes: abseiling, BMX, bobsledding, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, hot air ballooning, inline skating, jet skiing, jungle zip lining, kayaking, mountain biking, parachuting, paragliding, parascending, piloting a non-commercial aircraft, rappelling, rock climbing or mountaineering (ropes and guides to 4500m from ground level), scuba diving (to 50m), skydiving, snorkeling, snowmobiling, spelunking, surfing, trekking, whitewater rafting (to Class V), and wildlife safaris, and windsurfing.
Age / Maximum Limit
- Through age 49 / $50,000
- 50-59 / $30,000
- 60-64 / $15,000
* This Web page contains only a consolidated and summary description of all current benefits, conditions, limitations, and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions, and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate Wording for this insurance plan in the event this Web page, application, and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.
