Atlas Travel
| Benefits | Atlas Travel |
| Policy Maximum | $50,000, $100,000, $200,000, $500,000 or $1,000,000
(Ages 70 to 79: $50,000 or $100,000 limit; Ages 80+: $10,000 Limit) |
| Deductible | $0, $100, $250, $500, $1,000 or $2,500
The deductible is due once per certificate period |
| ER Co-Pay | $200 if not admitted to the hospital as an in-patient. Waived for Emergency treatment of injury. Only applies to Claims incurred in U.S. or Canada. |
| Urgent Care Co-Pay | $50 per visit, then coinsurance will apply — Not subject to the deductible. Only applies to Claims incurred in U.S. or Canada. |
| Provider Network | Coventry Provider Network |
| Coinsurance
- Out of Network inside the USA/ Canada |
80% Coverage up to $5,000
100% after up to Policy Maximum |
| Coinsurance
- Outside the USA/ Canada - In Network inside the USA |
100% Coverage |
| The following benefits are all subject to the deductible and coinsurance, unless otherwise stated: | |
| Hospital Room & Board | Average Semi-Private Room Rate |
| Local Ambulance | URC when results in hospitalization |
| Hospital Indemnity | $100 per day in addition to all other benefits |
| Intensive Care Unit | URC |
| Outpatient Treatment | URC |
| Acute onset of a Pre-existing Condition | Overall Maximum Limit
$25,000 Lifetime Maximum for Emergency Medical Evacuation |
| Prescription Medication | URC |
| Physical Therapy | $50 Maximum per day |
| All other medical expenses | URC |
| Terrorism | $50,000 limit for medical expenses only |
| The following benefits are not subject to the deductible or coinsurance, unless otherwise stated: | |
| Emergency Dental | Accident – URC
Acute onset of pain – $250 Maximum |
| Medical Evacuation | $1,000,000 limit |
| Emergency Reunion | $50,000 limit, Maximum of 15 days |
| Bedside Visit | $1,500 limit |
| Return of Minor Children | $50,000 limit |
| Political Evacuation | $10,000 limit |
| Accidental Death and Dismemberment | Principal sum – $50,000 (18-69 years old) |
| Common Carrier Accidental Death | $50,000 per member (18-69 years old)
Maximum $250,000 for any one family/ group |
| Repatriation of Remains | Overall Maximum Limit |
| Local Burial or Cremation | $5,000 |
| Natural Disaster Benefit | Maximum $100 for 5 days |
| Trip Interruption | $5,000 limit |
| Travel Delay | Maximum $100 a day, max 2 days after a 12-hour delay period requiring an unplanned overnight stay |
| Lost Checked Luggage | $500 limit |
| Pet Return | $1,000 to return a pet home if member is hospitalized |
| Crisis Response | $10,000 Maximum benefit per Certificate Period |
| Personal Liability | $10,000 lifetime maximum |
| Sports | Non-contact, leisure, recreational and fitness sports included, along with selected hazardous sports |
| Hospital Pre-notification Penalty | 50% of eligible expenses |
Atlas America —Travel to the USA
| $50k | $100k | $200k | $500k | $1 million | |
| 14d-17y | $1.36/ day | $1.73/ day | $1.90/ day | $2.28/ day | $2.52/ day |
| 18-29 | $1.36/ day | $1.73/ day | $1.90/ day | $2.28/ day | $2.52/ day |
| 30-39 | $1.85/ day | $2.56/ day | $2.95/ day | $3.00/ day | $3.22/ day |
| 40-49 | $2.73/ day | $3.42/ day | $3.81/ day | $4.29/ day | $4.78/ day |
| 50-59 | $4.07/ day | $5.13/ day | $6.29/ day | $6.77/ day | $7.25/ day |
| 60-64 | $4.75/ day | $6.23/ day | $8.20/ day | $8.49/ day | $9.06/ day |
| 65-69 | $5.38/ day | $6.89/ day | $9.15/ day | $9.44/ day | $10.07/ day |
| 70-79 | $7.75/ day | $9.92/ day | N/A | N/A | N/A |
| 80+* | $12.34/ day | N/A | N/A | N/A | N/A |
The following list contains a summary of the plan exclusions. Charges for the following treatments and/or services and/or supplies and/or conditions are excluded from coverage:
- Routine pre-natal care, Pregnancy, child birth, and post natal care.
- Chargesfortreatmentofanycondition(s)whenthepurposeof departing the Home Country was to obtain treatment in the destination country/countries.
- ChargesnotpresentedtoUnderwritersforpaymentwithin 60 days beginning on the last day of the Certificate Period.
- Treatment not administered by or under the supervision of a Physician.
- Investigational, Experimental or for Research purposes.
- Treatment of obesity or weight modification.
- HIV, AIDS or ARC, and all diseases caused by and/or related to HIV.
- Dental Treatment, except for Emergency Dental Treatment as covered under the plan.
- Vision and hearing tests and examinations.
- Diagnosis, testing or treatment of the temporomandibular joint.
- Medical expenses for Injury or Illness resulting from Amateur Athletics, Contact Sports, intercollegiate, interscholastic, intramural, extreme and club sports or athletic activities and Professional Sports including practice.
- Injury sustained that is due wholly or partially to the effects of intoxication or drugs.
- Self-inflictedInjuryorIllness.
- Sexually Transmitted Diseases and conditions.
- Routine medical examinations.
- Diagnosis or treatment by a chiropractor.
- Charges resulting from or occurring during the commission of a violation of law by the Member.
- Diagnosis, testing, treatment or supplies for the feet.
- Diagnostic testing or procedures, services, supplies, and treatment for hair loss.
- Pre-existing Conditions, except as covered under the table of benefits.
- Organ or Tissue Transplants or related services.
- Diagnosis, testing or treatment for skin conditions.
- Diagnosis, testing, or treatment of all forms of cancer / neoplasm.
Please view the full plan certificate on our website for a complete list of benefits and exclusions.
