Atlas America

MEDICAL & REPATRIATION EXPENSES

Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions and restrictions contained in this provision, we will pay the following expenses incurred while this insurance is in effect.

MEDICAL EXPENSES

YOU ARE COVERED FOR:
1. Charges made by a hospital for:

a. Daily room and board and nursing services not to exceed the average semi-private room rate; and
b. Daily room and board and nursing services in Intensive Care Unit; and
c. Use of operating, treatment, or recovery room; and
d. Services and supplies which are routinely provided by the hospital to persons for use while inpatients; and
e. Emergency treatment of an injury, even if hospital confinement is not required; and
f. Emergency treatment of an illness; subject to emergency room co-pay as outlined in the Schedule of Benefits and Limits. ER co-payment is waived when you are directly admitted to the hospital as inpatient for further treatment of that illness.

2. Surgery at an outpatient surgical facility, including services and supplies.
3. Charges made by a physician for professional services, including virtual physician visits and surgery. Charges for an assistant surgeon are covered up to 20% of the usual, reasonable and customary charge of the primary surgeon, but standby availability will not be deemed to be a professional service and therefore is not covered.
4. Dressings, sutures, casts, or other supplies which are medically necessary and administered by or under the supervision of a physician, but excluding nebulizers, oxygen tanks, diabetic supplies, other supplies for use or application at home, and all devices or supplies for repeat use at home, except durable medical equipment.
5. Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included).
6. Artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof.
7. Reconstructive surgery when the reconstructive surgery is directly related to a surgery which is covered.
8. Hemodialysis and the charges by the hospital for processing and administration of blood or blood components but not the cost of the actual blood or blood components.
9. Oxygen and other gasses and their administration by or under the supervision of a physician.
10. Anesthetics and their administration by a physician.
11. Drugs which require prescription by a physician for treatment of a covered injury or illness, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of sixty (60) days per each prescription.
12. Care in a licensed extended care facility upon direct transfer from an acute care hospital.
13. Home nursing care in bed by a qualified licensed professional, provided by a home health care agency upon direct transfer from an acute care hospital and only in lieu of medically necessary inpatient hospitalization.
14. Emergency local ambulance transport necessarily incurred in connection with injury or illness resulting in inpatient hospitalization.
15. Emergency dental treatment necessary to 1) resolve pain; or 2) restore or replace teeth lost or damaged in a covered accident.
16.Emergency Eye Exam if your prescription corrective lenses are lost or damaged due to a covered loss and an exam is required to obtain a lens prescription for medically necessary correction lenses, but not for the replacement cost of prescription corrective lenses or contact lenses.
17.Medically necessary rental of durable medical equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.
18.Outpatient physical therapy or chiropractic care for treatment of a covered injury or illness.
19.Injury or illness resulting from participation in sports or athletic activities not otherwise excluded under this insurance.

YOU ARE NOT COVERED IF:
1. Expenses arise directly or indirectly from anything in the General Exclusions.

Claims incurred in U.S.
Emergency Room Co-Payment - You shall be responsible for a $200 co-payment for the emergency room facility fee for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury.

Urgent Care Center Co-Payment - For each visit, you shall be responsible for a $15 co-payment. Not subject to deductible. Co-payment is waived for members with a $0 deductible.