Global International Health insurance


Please read the Insurance Product Information Document for the insurance plan you wish to purchase before proceeding.

Insurance Product Information Document (IPID)



 

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.

Click the blue headers for further information.

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
Bronze Silver Gold Plus
Lifetime Maximum Limit Per Individual Insured Person $2,500,000
£1,375,000
€1,675,000 		$5,000,000
£2,750,000
€3,350,000 		$5,000,000
£2,750,000
€3,350,000
A
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
B
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
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
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
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 		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
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
C
Travel, Transportation and Out Of Area Benefits
Bronze Silver Gold Plus
1 Emergency Local Ambulance Up to $1,500 /£825 / €1000 per event Not subject to Annual Excess or Co-Insurance Up to $1,500 /£825 / €1000 per event Not subject to Annual Excess or Co-Insurance Full Cover
2 Emergency Evacuation and Transportation To the Nearest Suitable Hospital Facility Up to $50,000 / £27,500 / €33,500 Not subject to Annual Excess or Co-Insurance Up to $50,000 / £27,500 / €33,500 Not subject to Annual Excess or Co-Insurance FULL COVER Not subject to Annual Excess or Co-Insurance
3 Accompanying Relative, Travel and Accommodation No Cover No Cover $10,000 / £5,500 / €6,700 Lifetime Limit
4 Cremation/Burial or Return of Mortal Remains $10,000 / £5,500 / €6,700 Lifetime Limit Not subject to Annual Excess or Co-Insurance $25,000 / £13,750 / €16,750 Lifetime Limit Not subject to Annual Excess or Co-Insurance $25,000 / £13,750 / €16,750 Lifetime Limit Not subject to Annual Excess or Co-Insurance
7 Worldwide Accident & Emergency Out of Area Coverage (USA Treatment Must Be within PPO Network) 15 Days Maximum 30 Days Maximum 30 Days Maximum
D
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
E
Additional Benefits & Services
Bronze Silver Gold Plus
2 Recreational Scuba No Cover No Cover Full Cover
5 24 Hour Emergency Helpline Included Included Included
F
Maternity
Bronze Silver Gold Plus
Maternity - Only available to Female Insureds - After 10 months of continuous cover

*All benefits reduced by 50% for births occurring in the 11th or 12th month of continuous coverage 		Optional Add-On Coverage
Additional Premium Applies*
Maternity Annual Excess Section F1 & F2 : Not subject to Annual Excess or Co-Insurance
Lifetime Limit *$50,000 / £27,500 / €33,500 Lifetime Limit
1 Normal Delivery - Including Premature Birth Treatment, Pre, Post and Routine Natal Care *Up to $5000 / £2750 /€3350
2 C-Section *Up to $7500 / £4125 / €5025
3 New Born Baby Wellness
- Not subject to Annual or Annual Maternity Excess or Co-Insurance
- for the first 12 months of life 		$200 /£110 / €134
4 Cover for New Borns including non-hereditary birth defects and congenital abnormalities *Up to $250,000 / £137,500 / €167,500 for the first 31 days
Optional Add-On Coverages
(Upon selection at initial Application and subject to additional premium) Bronze Silver Gold Plus
Sports Coverage* Coverage Add-On
i) Listed Extreme Sports
ii) Amateur Sports *Non-Professional
(Gold Plus Plan Only) 		Not Applicable i) $25,000 / £13,750 / €16,750 Lifetime Limits
ii) $10,000 / £5,500 / €6,700 Lifetime Limit
Annual Excess and Co-Insurance
Bronze Silver Gold Plus
Annual Excess Options
- Per Insured Person, Per Period of Insurance 		Nil
$250 to $10,000/
£138 to £5,500/
€168 to €6,700
50% waived (up to a maximum reduction of $2,500 / £1,375 / €1,675) for: USA PPO Out-Patient & Emergency In-Patient Treatment & Non-Emergency In-Patient USA Medical Concierge Provider Treatment
Co-Insurance within the USA & Canada PPO Network No Co-Insurance
Co-Insurance outside the USA & Canada No Co-Insurance
Co-Insurance Payable by Insured inside the USA & Canada

– When treatment is taken outside the USA & Canada PPO Network*

– (*No Co-Insurance for Non-Emergency In-Patient Treatment when utilising a USA Medical Concierge Provider) 		20% of the next $5,000 / £2,750 / €3,350 / eligible expenses after the Annual Excess, then No Co-Insurance to the overall maximum per Period of Insurance

* 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.