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GlobalFusion 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 one of the sections from the list to view each of the benefits category:

A.  In-Patient & Day-Patient Treatment

B.  Out-Patient Treatment, Wellness Benefits and Other Coverages

C.  Travel, Transportation and Out of Area Benefits

D.  Dental Treatment

E.  Additional Benefits & Services

F.  Maternity

Optional Add-On Coverages

Annual Excess and Co-Insurance

 

GLOBAL FUSION BENEFITS ALL SUB-LIMIT SUMS INSURED ARE THE MAXIMUM PER PERSON, PER PERIOD OF INSURANCE UNLESS OTHER WISE STATED

A.  In-Patient & Day-Patient Treatment

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Silver

                     

Gold
(1st 36 months of continuous coverage)
Gold
(Beginning the 1st day of the 37th month)
Gold Plus Platinum
1 Surgery, Surgeons, Second Surgical Opinion, Medical Practitioners, Nurses, Treatmenht, Services and Supplies routinely provided and Ancillary Charges Full Cover Full Cover Full Cover Full Cover Full Cover
2 Hospitalization/Room & Board Up to $600 / £350 / €400 per day 240 day Maximum Up to $2,250 / £1,250 / €1,500 per day Full Cover
3 Intensive Care Unit Up to $1,500 / £850 / €1,000 per day - 180 day per event Up to $4,000 / £2,500 / €3,000 per day
4 Anaesthetist's Charges associated with Surgery 20% of Surgery Benefit 20% of Surgery Benefit
5 Diagnostic Tests and Procedures, X-Rays, Pathology, & MRI/CT Scans Full Cover Full Cover
6 Prescribed Drugs, Dressings and Durable Medical Equipment
7 Reconstructiver Surgery - following an accident or following surgery for an eligible condition
8 Cancer Tests, Drugs, Treatment and Consultants, including cover for Chemotherapy and Radiotherapy FULL COVER Except:  Radiation & Chemotherapy Treatments (In and Out-Patient) limited to $10,000 / £5,500 / €6,700 with a $50,00 £27,500 / €33,500 Lifetime Limit
9 Physiotherapy  
10 Parental Hospital Accommodation
11 Prosthetic Devices
12 Transplants $250,000 / £137,500 / €16,500 Per Transplant $1,000,000 / £550,000 / €670,000 Lifetime Limit $5,00,000 / £275,000 / €335,000 Lifetime Limit $1,000,000 / £550,000 / €670,000 Lifetime Limit $2,000,000 / £1,100,000 / €1,340,000 Lifetime Limit

B.  Out-Patient Treatment, Wellness Benefits and Other Coverages

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    Silver Gold
(1st 36 months of continuous coverage)
Gold
(Beginning the 1st day of the 37th month)
Gold Plus Platinum
1 Out-Patient including: Family Doctor, Treatment and Referrals, Specialists and Consultants, X-Rays, Pathology, Diagnostic Tests and Procedures 25 Visit Maximum Maximums Per Visit/Examination: $70/ £40 / €50 Doctor/Specialist; $60 / £35 / €40 Psychiatrist; $50 / £30 / €35 Chiropractor; $250 / £140 / €170 X-Ray per Examination Maximum Limit; $500 / £275 / €335 Surgery Intervention Consultation; $300 / £165 / €200 Lab Tests per Examination Maximum Limit Full Cover 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 Full Cover
2 Emergency Room Illness, Waived if admitted as an In-Patient or Day-Patient (Additional $250/£138/€168 Excess if not admitted) Full Cover Full Cover
3 Emergency Room Accident
4 Supplemental Accident Benefit No Cover $300 / £165 / €200 per covered accident $300 / £165 / €200 per covered accident $300 / £165 / €200 per covered accident $500 / £275 / €335 per covered accident
5 Supplemental Accident Benefit Out-Patient Surgery Full Cover Full Cover Full Cover Full Cover Full Cover
6 MRI, CAT Scan Echocardiography, Endoscopy, Gastroscopy Colonoscopy, Cystoscopy $600 / £330 /€400 Maximum Per Examination
7 Cancer Tests, Drugs, Treatment and Consultants, including cover for Chemotherapy and Radiotherapy   FULL COVER Except: Radiation & Chemotherapy Treatments (in and out-patient) limited to $10,000 / £5,500 / €6,700 with a $50,000 / £27,500 / €33,500 Lifetime Limit
8 Prescribed Out-Patient Drugs, Medicines, Dressings and Durable Medical Equipment Up to $5,000 / £2,750 / €3,350 Outside U.S. : FULL COVER Inside U.S. : FULL COVER and must use the Out-Patient Prescription Drug Card. A Co-Pay:$20 for generic, $40 for brand name where generic is not available and Not Subject to Annual Excess or Co-Insurance when using the Out-Patient Prescription Drug Card. No coverage if the Out-Patient Prescription Drug Card is not used
9 Physiotherapy, Homeopathic and Osteopathic Therapy Up to $40 / £25 / €30 per visit 30 visit Maximum Up to $50 / £30 / €35 per visit Maximum of 1 visit per day 45 visit Maximum Up to $50 / £30 / €35 per visit Maximum of 1 visit per day 30 visit Maximum Up to $1,000 / £550 / €670 per Period of Insurance $10,000 / £5,500 / €6,700 Lifetime Limit Up to $50 / £30 / €35 per visit Maximum of 1 visit per day 45 visit Maximum Up to $50 / £30 / €35 per visit Maximum of 1 visit per day 60 visit Maximum
10 Complementary Medicine Acupuncture, Aroma Therapy, Herbal Therapy, Magnetic Therapy, assage Therapy, Vitamin, Therapy, Traditional Chinese Medicine No Cover Up to $200 / £110 / €135 Up to $200 / £110 / €135 Up to $200 / £110 / €135 Up to $200 / £110 / €135
11 AIDS/HIV Treatment No Cover Up to $5,000 / £2,750 / €3,350 per Period of Insurance $50,000 / £27,500 / €33,500 Lifetime Limit Up to $5,000 / £2,750 / €3,350 per Period of Insurance $50,000 / £27,500 / €33,500 Lifetime Limit Up to $5,000 / £2,750 / €3,350 per Period of Insurance $50,000 / £27,500 / €33,500 Lifetime Limit Up to $5,000 / £2,750 / €3,350 per Period of Insurance $50,000 / £27,500 / €33,500 Lifetime Limit
12 Home Nursing Care 30 Days Limit: Up to $150 / £85/ €100 per vi 45 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 60 Days Limit : Up to $150 / £85/ €100 per visit
13 Rehabilitation No Cover Full Cover Up to 90 Days Full Cover Up to 45 Days Full Cover Up to 90 Days Full Cover Up to 180 Days
14 Extended Care Facility Full Cover Up to 30 Days Full Cover Up to 90 Days
15 Hospice Care No Cover Full Cover Up to 180 Days Full Cover Up to 180 Days
16 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 (6 months on Platinum)
Up to $250 / £140 / €170 Available for those 30 years of age and over Up to $250 / £140 / €170 Available for those 30 years of age and over Up to $250 / £140 / €170 Available for those 30 years of age and over Up to $500 / £275 / €335 Available for those 18 years of age and over
17 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 (6 months on Platinum)
3 visits per Period of Insurance Up to $70 / £40 / €50 per visit Up to $200 /£110 / €135 Up to $200 /£110 / €135 Up to $200 /£110 / €135 Up to $400 / £220 / €270
18 Pre-Existing Medical Conditions Standard Underwriting: - After 24 months continuous cover - Declared and Accepted conditions (unless otherwise excluded or terms applied as indicated otherwise in writing)

- Flexible Underwriting Option available – refer GlobalFusion Flexible Undewritingfor detail.
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 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 Full Cover No requirement for 24 months continuous cover
19 Newly Diagnosed Chronic Conditions Covered Covered Covered Covered Covered
20 Mental/Nervous - After 12 months continuous coverage Out-Patient Only - See Section B1 Up to $10,000 / £5,500 / €6,700 $50,000 / £27,500 / €33,500 Lifetime Limit Up to $2,500 / £1,375 / €1,675 25 days In-Patient Limit 20 visit Out-Patient Limit at 70% eligible expenses, up to $75 / £42 / €51 per visit; $30,000 / £16,500 / €20,100 Lifetime Limit Up to $10,000 / £5,500 / €6,700 $50,000 / £27,500 / €33,500 Lifetime Limit Up to $50,000 / £27,500 / €33,500 Lifetime Limit
C

Travel, Transportation and Out Of Area Benefits

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    Silver Gold
(1st 36 months of continuous coverage)
Gold
(Beginning the 1st day of the 37th month)
Gold Plus Platinum
1 Emergency Local Ambulance Up to $1,500 /£825 / €1000 per event Not subject to Annual Excess or Co-Insurance Full Cover Up to $100 / £55 / €70 per event Not subject to Annual Excess or Co-Insurance Full Cover 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 FULL COVER Not subject to Annual Excess or Co-Insurance Up to $250,000 / £137,500 / €167,500 FULL COVER 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 $10,000 / £5,500 / €6,700 Lifetime Limit $10,000 / £5,500 / €6,700 Lifetime Limit $10,000 / £5,500 / €6,700 Lifetime Limit $10,000 / £5,500 / €6,700 Lifetime Limit
4 Cremation/Burial or Return of Mortal Remains $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 $15,000 / £8,250 / €10,050 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 $50,000 / £27,500 / €33,500 Lifetime Limit Not subject to Annual Excess or Co-Insurance
5 Remote Transportation - for additional transport for on-going Treatment once stabilised No Cover No Cover No Cover No Cover Up to $5,000 / £2,750 / €3,350 $20,000 / £11,000 / €13,400 Lifetime Limit
6 Security & Political Evacuation & Repatriation   $10,000 / £5,500 / €6,700 Lifetime Limit
7 Worldwide Accident & Emergency Out of Area Coverage (USA Treatment Must Be within PPO Network) 30 Days Maximum 30 Days Maximum 30 Days Maximum 30 Days Maximum 30 Days Maximum
D

Dental Benefits

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    Silver Gold
(1st 36 months of continuous coverage)
Gold
(Beginning the 1st day of the 37th month)
Gold Plus Platinum
1 Emergency Dental Due to Accident Up to $1,000 / £550 / €670 Full Cover Up to $500 / £275 / €345 Full Cover Full Cover
2 Emergency Dental due to Sudden Unexpected Pain To Sound Natural Teeth   No Cover  Up to $100 / £55 / €70 Up to $100 / £55 / €70 Up to $100 / £55 / €70 See Non-Emergency Dental Benefits
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 No Cover No Cover No Cover i) $750 /£425 /€500; ii) $50 / £30 / €35 iii) 2
4 Class I Treatment*: - Preventative & Diagnostic - Emergency Palliative Treatment. - 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
E

Additional Benefits & Services

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    Silver Gold
(1st 36 months of continuous coverage)
Gold
(Beginning the 1st day of the 37th month)
Gold Plus Platinum
1 High School Sports Injury No Cover No Cover No Cover No Cover Up to $20,000 / £11,000 / €13,400
2 Recreational Scuba No Cover Full Cover Full Cover Full Cover
3 Vision Care

Not subject to Annual Excess or Co-Insurance

(Benefit payable per 24 months)
No Cover No Cover No Cover Exams – up to $100 / £55 / €67 Materials – up to $150 / £85 / €100
4 Medical Information Service Not Applicable Not Applicable Not Applicable Not Applicable Included
5 Global Concierge & Assistance Services
F

Maternity

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    Silver Gold
(1st 36 months of continuous coverage)
Gold
(Beginning the 1st day of the 37th month)
Gold Plus Platinum
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*
Optional Add-On Coverage

Additional Premium Applies*
Optional Add-On Coverage

Additional Premium Applies*
Optional Add-On Coverage

Additional Premium Applies*
Maternity Coverage Included – See Below
Maternity Annual Excess Section F1 & F2 : Not subject to Annual Excess or Co-Insurance Section F1 & F2 : Not subject to Annual Excess or Co-Insurance Section F1 & F2 : Not subject to Annual Excess or Co-Insurance Section F1 & F2 : Not subject to Annual Excess or Co-Insurance $1,000 / £550 / €670 Maternity Annual Excess

(Annual Excess Does Not Apply)
Lifetime Maximum *$50,000 / £27,500 / €33,500 Lifetime Limit *$50,000 / £27,500 / €33,500 Lifetime Limit *$50,000 / £27,500 / €33,500 Lifetime Limit *$50,000 / £27,500 / €33,500 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 *Up to $5000 / £2750 /€3350 *Up to $5000 / £2750 /€3350 *Up to $5000 / £2750 /€3350 Included within and up to Lifetime Limit
2 C-Section *Up to $7500 / £4125 / €5025 *Up to $7500 / £4125 / €5025 *Up to $7500 / £4125 / €5025 *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 $200 /£110 / €134 $200 /£110 / €134 $200 /£110 / €134 $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 *Up to $250,000 / £137,500 / €167,500 for the first 31 days *Up to $250,000 / £137,500 / €167,500 for the first 31 days *Up to $250,000 / £137,500 / €167,500 for the first 31 days *Up to $250,000 / £137,500 / €167,500 for the first 31 days

Optional Add-On Coverages

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  (Upon selection at initial Application and subject to additional premium) Silver Gold
(1st 36 months of continuous coverage)
Gold
(Beginning the 1st day of the 37th month)
Gold Plus Platinum
Terrorism Coverage Add-On
Increases coverage from $10,000 / £5,500 / €6,700 Lifetime Limit to:
Not Applicable Not Applicable Not Applicable Not Applicable $50,000 / £27,500 / €33,500 Lifetime Limit
Sports Coverage* Coverage Add-On
i) Listed Extreme Sports
ii) Amateur Sports *Non-Professional
Not Applicable Not Applicable Not Applicable 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

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    Silver Gold
(1st 36 months of continuous coverage)
Gold
(Beginning the 1st day of the 37th month)
Gold Plus Platinum
Annual Excess Options
- Per Insured Person, Per Period of Insurance
$250 to $10,000, £138 to £5,500, €168 to €6,700 $250 to $10,000, £138 to £5,500, €168 to €6,700 $250 to $10,000, £138 to £5,500, €168 to €6,700 $250 to $10,000, £138 to £5,500, €168 to €6,700 $100 to $10,000, £55 to £5,500, €67 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
Family Maximum Annual Excesses 3 x Individual Annual Excess 3 x Individual Annual Excess 3 x Individual Annual Excess 3 x Individual Annual Excess 2 x Individual Annual Excess
Annual Excess Carry Forward - If prior Annual Excess not met, then last 30 days Expenses from the previous Period of Insurance are carried forward and applied towards satisfying the Annual Excess for the next Period of Insurance YES YES YES YES YES
Co-Insurance within the USA & Canada PPO Network No Co-Insurance No Co-Insurance No Co-Insurance No Co-Insurance No Co-Insurance
Co-Insurance outside the USA & Canada No Co-Insurance No Co-Insurance No Co-Insurance No Co-Insurance 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 utilizing 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 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 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 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 10% 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

 

>>  Download Summary Schedule of Cover and Excess

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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