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UltraCare International Schools

Table of benets 2017
UltraCare UltraCare UltraCare
International International International
Schools Bronze Schools Silver Schools Gold
1 Overall plan limit
Reasonable costs will be paid for you up to the overall plan limit in each plan year,
subject to the terms and conditions of the plan. We will not pay any more than the overall
plan limit for any one or more claims on any one or more of the benefits below. Where
1.1 a benefit limit is shown as Paid in full, this is subject to the overall plan limit. $1,000,000 $2,000,000 $3,000,000
You must request pre-authorisation for some of the benefits, see your Claims
procedures and benefit condition BC2 in the Plan guide for more information.

2 Cancer care
All treatment for cancer, including bone marrow transplants. This benefit covers
treatment aimed to cure cancer, treatment of a cancer which is diagnosed as a
2.1 Paid in full Paid in full Paid in full
chronic medical condition, palliative treatment and care during the end stages of
a cancer.

In-patient and daycare treatment of acute medical conditions and stabilisation of acute episodes of chronic medical conditions
3
(see section 23 for deductibles)
Medical costs including intensive care costs, theatre costs, hospital accommodation,
3.1 specialists and medical practitioners fees, anaesthetists fees, nursing fees and
prescribed drugs and dressings.
3.2 MRI, PET and CT scans, X-rays, pathology and other diagnostic tests and procedures.
Reconstructive surgery following an accident or following surgery for an eligible medical
3.3
condition that first occurred after your date of joining. Paid in full Paid in full Paid in full
3.4 Prostheses surgically implanted to form permanent parts of your body.
Medical services of a nurse as part of your in-patient or daycare treatment when
3.5
these are received in your home instead of in hospital.
Hospital accommodation costs for a parent or legal guardian to stay with an insured
3.6
child, under the age of 18, when the child is receiving in-patient treatment.

4 Out-patient post-hospitalisation treatment of acute medical conditions (see section 23 for deductibles)
Out-patient treatment for a period of 90 days following in-patient or daycare
treatment related to the same acute medical condition. This benefit covers
4.1 medical practitioners and specialists fees, surgical procedures, prescribed drugs Paid in full Paid in full Paid in full
and dressings, MRI, PET and CT scans, X-rays, pathology and other diagnostic tests
and procedures.

Out-patient treatment of acute medical conditions and stabilisation of acute episodes of chronic medical conditions
5
(see section 23 for deductibles)
5.1 Surgical procedures. Paid in full Paid in full
Out-patient pre-operative tests up to 72 hours before in-patient or daycare treatment
Paid up to
5.2 of acute medical conditions and stabilisation of acute episodes of chronic medical
$1,000 Paid up to
conditions. Paid in full
$6,500
Medical practitioners and specialists fees, prescribed drugs and dressings, X-rays,
5.3
pathology and diagnostic tests and procedures. Not covered
5.4 MRI, PET and CT scans. Paid in full

6 Physiotherapy and complementary medicine for acute and chronic medical conditions (see section 23 for deductibles)
6.1 Physiotherapy by a physiotherapist, as part of in-patient or daycare treatment. Paid in full Paid in full Paid in full
Post-hospitalisation out-patient physiotherapy by a physiotherapist for any one or
more medical conditions in each plan year. This benefit is available for a period of Paid up to
6.2
90 days following any in-patient or daycare treatment related to the same medical $300 Paid up to Paid up to
condition. $450 $850
Out-patient physiotherapy by a physiotherapist, when referred by a medical
6.3
practitioner or specialist.
Out-patient complementary medicine and treatment, when referred by a medical
Not covered
6.4 practitioner or specialist. This benefit covers podiatry, osteopathic and chiropractic Paid up to Paid up to
treatment only. $450 $850
6.5 Out-patient traditional Chinese medicine, acupuncture and homeopathic treatment.
 UltraCare UltraCare UltraCare
International International International
Schools Bronze Schools Silver Schools Gold
7 Psychiatric treatment for acute and chronic medical conditions (see section 23 for deductibles)
7.1 In-patient psychiatric treatment and psychotherapy for up to 30 days. Not covered Not covered
Out-patient psychiatric treatment and psychotherapy, available after you have had Not covered Paid up to Paid up to
7.2 12 months continuous cover from the date that the benefit was first introduced on
$1,700 $2,600
your plan.

8 Maintenance of chronic medical conditions (see section 23 for deductibles)

In-patient and daycare treatment to maintain the symptoms of chronic medical
8.1
conditions.
8.2 Kidney dialysis for the maintenance of chronic medical conditions. Paid up to Paid up to
Not covered a lifetime limit of a lifetime limit of
Out-patient treatment to maintain the symptoms of chronic medical conditions. $75,000 $150,000
This benefit covers medical practitioners and specialists fees, surgical procedures,
8.3
prescribed drugs and dressings, MRI, PET and CT scans, X-rays, pathology and other
diagnostic tests and procedures.
8.4 If a medical condition becomes terminal, it will only be covered under section 10.

9 Congenital abnormalities (see section 23 for deductibles)

All treatment aimed to cure a congenital abnormality, treatment of a congenital
abnormality which is diagnosed as a chronic medical condition, palliative
treatment and care for a congenital abnormality which is diagnosed as terminal,
and treatment for any related medical condition:
if the congenital abnormality is not inherited;
if you did not have signs or symptoms of the congenital abnormality before your
Paid up to
date of joining; and
9.1 Not covered Not covered a lifetime limit of
the congenital abnormality is diagnosed after your date of joining.
$35,000
This benefit covers medical practitioners and specialists fees, surgical procedures
including prostheses surgically implanted to form permanent parts of your body,
physiotherapy, prescribed drugs and dressings, MRI, PET and CT scans, X-rays, pathology
and other diagnostic tests and procedures. This benefit does not extend to
psychiatric treatment or psychotherapy, complementary medicine, traditional Chinese
medicine, acupuncture or homeopathic treatment.

10 Terminal care
Palliative treatment and care for a medical condition which is diagnosed as
10.1 Not covered Paid in full Paid in full
terminal.

11 Medical evacuation and repatriation

The costs to transport you to the nearest location within your area of cover where
appropriate medical facilities are available. This benefit, including emergency
11.1
treatment you receive during the journey, will only be paid if we agree appropriate
treatment for your eligible medical condition is not available locally.
Economy class travel costs for you to go back to the country where you live, Paid in full
11.2 when needed for
following your medical evacuation.
in-patient
Costs of your dependants, a close family member or business colleague having Paid in full Paid in full
treatment, daycare
to accompany you for a medical evacuation. This benefit will only become available if treatment or any
your medical condition is critical. We will cover: cancer treatment
11.3 return economy class travel costs, including taxi transfers to and from the hotel on
arrival and departure;
reasonable overnight accommodation costs, to include breakfast; and
a taxi from the hotel to the hospital, and back, once a day.

12 Local ambulance
Costs of appropriate ambulance transport to the nearest available and appropriate local
12.1 Paid in full Paid in full Paid in full
hospital because of an emergency or due to medical necessity.

13 Out-patient dental treatment (see section 23 for deductibles)

Restoration of natural teeth including treatment of accidental damage to natural
teeth. This benefit covers X-rays, fillings, extractions, root-canal treatment, gum Paid up to Paid up to
13.1 treatment, permanent bridges and semi-precious crowns, and is available after you Not covered 75% of 75% of
have had 182 days continuous cover from the date that the benefit was first introduced $850 $1,300
on your plan.
 UltraCare UltraCare UltraCare
International International International
Schools Bronze Schools Silver Schools Gold
14 Wellness
Members aged 18 and over: routine health checks including cancer screening,
14.1
cardiovascular examinations, neurological examinations, vital sign tests and vaccinations.
14.2 Members aged 0-17: well-child tests and vaccinations.
Preventative dental services: checkups to include scraping, cleaning and polishing Not covered Not covered Not covered
14.3
only.
Preventative services for sight and hearing: one sight examination and one hearing
14.4
examination in each plan year.

15 Organ transplants (see section 23 for deductibles)

Transplants of kidney, liver, heart, lung or heart and lung and any related treatment that Paid up to Paid up to Paid up to
15.1
you need as a result of an eligible medical condition. $500,000 $500,000 $500,000
15.2 If the medical condition is a congenital abnormality, the cost of organ transplants and any related treatment will only be covered under section 9.

16 HIV or AIDS (see section 23 for deductibles)

All treatment, including palliative treatment and care, for HIV or AIDS and all Paid up to Paid up to
16.1 related medical conditions, available after you have had four years continuous cover Not covered a lifetime limit of a lifetime limit of
from the date that the benefit was first introduced on your plan. $85,000 $85,000

Maternity care - available after you have had 12 months continuous cover from the date that the benet was rst introduced
17
on your plan
Antenatal checkups and treatment, delivery costs, nursing fees, hospital
accommodation costs and postnatal checkups, for a normal uncomplicated pregnancy
and normal uncomplicated childbirth.
This benefit covers no more than one 2D ultrasound scan in each trimester of a normal
uncomplicated pregnancy. This benefit also covers 12 routine antenatal visits during a
normal uncomplicated pregnancy.
Paid up to
This benefit covers the following for the newborn child:
17.1 Not covered Not covered 80% of
one physical examination; $8,500
vitamin K, hepatitis B and BCG vaccinations;
routine blood tests for PKU, congenital hypothyroidism and G6PD;
one hearing examination; and
reasonable accommodation costs for no more than four nights, if the mother is
admitted and not suffering any complications.
(see section 23 for deductibles)
Treatment of a medical complication that happens due to a medical condition during
the antenatal period of a pregnancy or childbirth.
Paid up to Paid up to
17.2 If the pregnancy is resulting from assisted conception, any medical complication arising $4,250 $8,500
during the antenatal period or childbirth will be limited to the amounts shown in section
17.1. Paid in full
Hospital accommodation costs for a newborn child to stay with its mother when she is
17.3
receiving in-patient treatment for a medical condition covered under section 17.2. Paid in full Paid in full
17.4 Terminating a pregnancy when medically necessary.
Treatment of birth defects, including birth trauma, for 12 months from the date of
diagnosis. This benefit is available for each pregnancy covered under sections 17.1 or Paid up to
17.5
17.2 if the newborn child is added to the plan before they are 30 days old and the birth $35,000
defects are diagnosed in the first six months after birth.
Treatment of congenital abnormalities for 12 months from the date of diagnosis. Paid up to Paid up to
This benefit is available for each pregnancy covered under sections 17.1 or 17.2: $35,000 $35,000
Covered in the
if the newborn child is added to the plan before they are 30 days old;
17.6 benefit limit shown
the congenital abnormalities are diagnosed in the first six months after birth; and
in section 9
the congenital abnormalities are not inherited.
(see section 23 for deductibles)

18 Hormone replacement therapy

Paid up to Paid up to
18.1 Hormone replacement therapy for symptoms of the menopause. Not covered
$260 $500
 UltraCare UltraCare UltraCare
International International International
Schools Bronze Schools Silver Schools Gold
19 Hospital cash
$450 $450 $450
Cash payment made to you, for up to 30 nights in each plan year, when you receive
19.1 paid to you for paid to you for paid to you for
in-patient treatment and hospital accommodation free of charge.
each night each night each night

20 Compassionate emergency visit

Costs you have to pay for an economy class return travel ticket from a country within
your area of cover to visit a close family member if their medical condition is
20.1 Not covered Paid in full Paid in full
critical, or for you to attend their burial or cremation following their death. You are
limited to one return journey in each plan year.

21 Mortal remains
Reasonable costs of preparing and transporting your body, mortal remains or ashes
21.1 to your home country, or preparing your body or mortal remains for local burial or Paid in full Paid in full Paid in full
cremation. This benefit is only available if you die outside your home country.

22 Emergency treatment outside area of cover (see section 23 for deductibles)

Paid up to Paid up to
22.1 Emergency treatment outside your area of cover. Not covered
$70,000 $100,000

23 Deductibles
Out-patient treatment excess on sections 4, 5, 6.2, 6.3, 6.4, 6.5, 7.2, 8.3, 9, 16 and
23.1 $50.00 $50.00 $50.00
17.6. This deductible is applied for each medical condition in each plan year.
Only Only Only
applied if applied if applied if
a voluntary excess a voluntary excess a voluntary excess
In-patient, daycare and out-patient treatment excess on sections 3, 4, 5, 6, 7, 8,
has been chosen. has been chosen. has been chosen.
23.2 9, 15, 16, 17.6 and 22. This deductible is applied for each medical condition in each
This replaces the This replaces the This replaces the
plan year.
standard excess standard excess standard excess
shown in shown in shown in
section 23.1 section 23.1 section 23.1
Out-patient dental treatment co-insurance on section 13. This deductible is
23.3 Not applicable 25% 25%
applied to each claim.
Normal uncomplicated pregnancy and normal uncomplicated childbirth co-insurance on
23.4 Not applicable Not applicable 20%
section 17.1. This deductible is applied to each claim.

24 red24 security services

AdviceLine - 24/7 personal security information and advice for all your travel safety Included Included
24.1
queries. Please contact red24 or visit www.red24.com/interglobal with your plan with your plan
Included
ActionResponse - 24/7 international rescue and response service for you in a potentially with your plan
Not included Not included
24.2 life-threatening, non-medical event. Please contact red24 or visit
with your plan with your plan
www.red24.com/interglobal

Some words and phrases used in this Table of benefits have specific meanings that are relevant to your plan. We have highlighted them in bold print and defined them in
the Definitions section of your Plan guide.

InterGlobal Insurance Company Limited has changed its name to Aetna Insurance Company Limited. The company will continue to trade under the InterGlobal brand
until further notice. InterGlobal Limited has changed its name to Aetna Global Benefits (UK) Limited.
Whenever coverage provided by any insurance policy would be in violation of any US, UN or EU economic or trade sanctions, such coverage shall be null and void.
For example, we cannot pay for health care services provided in a country under sanction by the United States unless permitted under a written Office of Foreign
Asset Control (OFAC) license. Learn more on the US Treasurys website at: www.treasury.gov/resource-center/sanctions.
Plans are underwritten by Aetna Insurance Company Limited, registered in England (Company Registration No. 5956141), which is authorised by the Prudential Regulation
Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority (Firm Reference No. 458505). Plans are administered on behalf of the
insurer by Aetna Global Benefits (UK) Limited, registered in England (Company Registration No. 3554885), which is authorised and regulated by the Financial Conduct
Authority (Firm Reference No. 312279). Both companies are registered at 50 Cannon Street, London, EC4N 6JJ, United Kingdom. M004-18E-010117