Liberty
Maximum Benefit
$2,000,000
Eligibility
75 years
Renewal
Lifetime
Coverage Area
Worldwide – 100% within the Loyal USA Medical Services
80% out of Network
Medical Treatment for Accidents and Emergencies outside of the Network
100% within the Loyal USA Medical Services network / Preferred Providers
Deductible Options
– Per Policy Year
I. $500/$1,000 II. $1,000/$2,000 III. $2,000/$3,000 IV.$5,000 V.$10,000 VI. $20,000 / ($50,000)
Co-Insurance
Does not apply
Waiting Period
90 Days / 3 Months
Reduction of Deductible after 3 years of no claims
Options I, II, III: Elimination of deductible for 1 year, after the 3rd year without claims
Options IV, V, VI: 50% reduction of deductible for 1 year, after the 3rd year without claims
Free coverage for Dependents after the death of the Policyholder
8 months of Premium waived
HOSPITALIZATION
Medical and Surgical Services
100% within the Loyal USA Medical Services Network / Preferred Providers
Physician Fees
100% within the Loyal USA Medical Services Network / Preferred Providers
Room and Board
– Private and Semi-Private room only
100% within the Loyal USA Medical Services network
$1,000 out of Network
Intensive Care Unit
100% within the Loyal USA Medical Services network / Preferred Providers
Cancer Treatment (Chemotherapy and Radiation), Dialysis
100% within the Loyal USA Medical Services network / Preferred Providers
Diagnostic Services (Laboratory, X-Rays, MRIs, CT Scans, and Echos)
100% within the Loyal USA Medical Services network
$1,500 out of Network
Options I, II
Physical Therapy and Rehabilitation
100% within the Loyal USA Medical Services network / Pre-approved / Preferred Providers
Hospital accommodation charges for Companion of a Hospitalized child
$150 per night, maximum of 30 nights
Reduction in risk of cancer or prophylactic surgery / waiting period apply
$8,000 per lifetime / 36 months waiting period / Options I, II
Bariatric Surgery, Gastric Bypass and any type of surgical procedure for loss weight, its complications or treatments / Waiting period apply
$4,000 / 36 months waiting period in Network of Loyal USA Medical Services / Preferred Providers
Medically necessary Reconstructive Surgery in case of Accident or any malformation of the nasal septum
100% Loyal USA Medical Services / Pre-approved / Preferred Providers
Emergency Room / after deductible
100% within the Loyal USA Medical Services Network / Pre-notification
OUT-PATIENT SERVICES
Out-Patient Surgery
100% within the Loyal USA Medical Services Network
Medical and Surgical Services, Medication and Physician’s Fees
100% within the Loyal USA Medical Services Network
Cancer Treatment (Chemotherapy and Radiation), Dialysis
100% within the Loyal USA Medical Services Network
Options I, II
Diagnostic Services (Laboratory, X-Rays, MRIs, CT Scans, and Echos)
100% within the Loyal USA Medical Services Network
Options I, II
Physical Therapy and Rehabilitation
$10,000 within the Loyal USA Medical Services Network
SPECIALIZED / ALTERNATIVE TREATMENTS
Speech Therapy
$1,500 within the Loyal USA Medical Services Network
Psychiatric Therapy
Total of 10 visits a year within the Loyal USA Medical Services Network
PREVENTIVE SERVICES / COVERAGE
Routine Adult Health checkup
– No Deductible
Maximum of $250 per Insured within the Loyal USA Medical Services Network
Routine Child Well Care/Immunizations
– No Deductible
< 1 year = 5 visits up to $75 per visit
1 to 17 years = $150 per policy year
Dental Exam
– 12 months waiting period
– No Deductible
$75 Routine checkup benefit / within the Loyal USA Medical Services Network
Hearing Aids – waiting period
– Pre-Authorization required
$500 lifetime / 36 months waiting period / within the Loyal USA Medical Services Network
MATERNITY COVERAGE
Maternity Services – Per covered pregnancy – Waiting period – No Deductible
Normal delivery:
– 100% within the Network of Loyal USA Medical Services
– $5,000 out of Network
– Waiting period 18 months
– Options: I, II
Cesarean delivery $6,000 / within the Loyal USA Medical Services Network
Maternity Complications – Deductible apply – Excludes conditions treated as a result of infertility treatments.
Rider: $150,000 Lifetime
– 18 months waiting period
– Options I, II
Stem Cell extraction and preservation
– per newborn child from a covered pregnancy
$1,000 within the Loyal USA Medical Services Network
– Options I, II
Maternity services for dependents 18 yrs to 24 yrs
Normal delivery:
– In Network $1,000 / Loyal USA Medical Services
– Out of Network: N/A
– 18 months waiting period
– Options I, II Cesarean: $800 / Within the Network of Loyal USA Medical Services
Automatic addition of Newborn to the policy – If notified within 90 days of birth -Only newborns from a Covered Maternity
No risk assessment
TRANSPORTATION SERVICES
Ground Ambulance
– No deductible
100% within the Loyal USA Medical Services Network
Air Ambulance Services
– No deductible
– Pre-authorization required
$45,000 within the Loyal USA Medical Services Network
Repatriation of Mortal Remains or Cremation services
– Pre-Authorization required
$10,000 Must be pre-approved and coordinated by Loyal USA Medical Services
Return Travel Assistance to Country of Residence if evacuated by Air Ambulance
– For the patient and 1 companion
$1,000 per person / Within the Loyal USA Medical Services Network
OTHER COVERAGE / SERVICES
Risk and/or Professionals activities
100% (professional and/or amateur) within the Loyal USA Medical Services Network
Emergency Dental treatment after an accident – Deductible apply
100% within the Loyal USA Medical Services Network
Congenital and/or Hereditary conditions diagnosed before the age of 18 from a Loyal covered maternity
$50,000 Lifetime / Within the Loyal USA Medical Services Network
Congenital and/or Hereditary Disorders diagnosed after 18 years of age
$100,000 Lifetime / Within the Loyal USA Medical Services Network
Transplant Procedures
$200,000 (per Lifetime Diagnosis)
$30,000 (maximum per donor preparation)
– Option: I
Including Rider: Options: II, III, IV, V. VI
Medical equipment and Orthopedic Devices
– Pre-Authorization required
$8,000 within the Loyal USA Medical Services Network
ADDITIONAL COVERAGE (RIDER)
Term Life – Principal Insured and Spouse
Principal Insured: $150,000 – $100,000
Spouse: $150,000 – $100,000
All Plans – 10 years Term / Age limit: 60 years old