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As specified under The Health Insurance Act 1970 and its regulations, orders and rules |
| Ancillary Hospital Services Bermuda Hospitals Board Fee Schedule |
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| Surgical, Obstetrical, Anaesthetic, Diagnostic and Medical Care Bermuda Fee Schedule |
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| Ground Ambulance to Home As specified under The Health Insurance Act |
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| Chronic Disease Management Programme 80% | $2,880 maximum per policy year |
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| Medical Alarm Device 80% | $200 maximum per policy year |
Medical Nutritional Therapy (Provider must be a registered Dietitian approved by Argus):
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Diabetes Prevention Programme (Programme & provider must be pre-approved by Argus):
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Diabetes Reversal Programme:
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Annual Foot Exam: For persons with type I or II diabetes or diabetic neuropathy $150, maximum 1 exam per policy year |
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| Allergy testing: Our Fee Schedule, $600 per lifetime |
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| Allergy Injections: $20 per injection and serum combined |
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| Annual Health Exam: Maximum 1 exam per policy year
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Annual Specialist / Gynaecologist Exam (all ages): $225, maximum 1 exam per policy year |
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| Routine Diagnostic Testing in conjunction with Annual Exams: Bermuda Fee Schedule |
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| Well-Baby Routine Health exam (under 2 years): $107, maximum 6 exams per policy year |
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| Annual Eye Exam: $115, maximum 1 exam per policy year Routine Diagnostic Testing in conjunction with Annual Eye Exam (Provider must be approved by the Bermuda Health Council): $200 per policy year |
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| Immunisations and Injections: $30 per injection |
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| Diagnostic Services in Private Testing Facilities: Includes Genetic Testing and Sleep Studies (These services must be pre-certified by Argus): Bermuda Fee Schedule. |
General Practitioner
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Specialist
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Telemedicine Office Visit (Services must be pre-certified by Argus) $125 |
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In Office Medical / Surgical Treatment: Bermuda Fee Schedule |
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Physical & Occupational Therapy/TENS:
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| Chiropractic: $75, maximum 6 visits per policy year |
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| Chiropody / Podiatry: $75, maximum 6 visits per policy year |
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| Behavioural Therapies for Autism Spectrum & Attention Deficit Disorders (Services must be pre-certified by Argus): Individual and family applied behavioural therapies 100% of billed charges, $2,500 per policy year |
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| Psychiatrist: $190, maximum 6 visits per policy year Clinical Psychologist/Group Therapy Session: $140, maximum 6 visits per policy year Counselling Services:
Smoking Cessation Counselling
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| Sclerotherapy: Bermuda Fee Schedule $1,000 per policy year |
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| Lymphedema Treatment: $110, 28 visits policy year |
| Major Medical Benefits are applicable to overseas treatment and services. Eligible Expenses are payable at a percentage of the lesser of Usual and Customary Charges, claim amounts reduced by the Argus claims editing process or Discounted Rates. |
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| All Insured Persons other than Dependent Children noted below: Policy Year: $500,000 Lifetime: $1,500,000 |
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| Dependent Children over age 19 and under age 26 who are not full-time students: Policy Year: $500,000 Lifetime: $500,000 |
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| Emergency Treatment: Insured calls Argus Health within 48 hours of incident: 100% Coinsurance Insured does not contact Argus Health within 48 hours of incident: 10% Coinsurance for inpatient facility only and all other services will not be eligible. |
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| Treatment not Available in Bermuda in Bermuda not specified below: Insured must call Argus in advance and treatment must be pre-certified by Argus and obtained within the Argus Preferred Provider Network in order to receive 100% coinsurance; otherwise, benefits will be payable at 10% for inpatient facility only, and all other services will not be eligible. |
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| Treatment Available in Bermuda: 10% for inpatient facility only, and all other services will not be eligible. |
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| Neonatal Treatment, Congenital Birth Defects & High-Risk Pregnancy: Charges related to neonatal, congenital birth defects and high-risk pregnancy will only be payable at 100% if they are pre-certified by Argus and treatment is obtained within the Argus Canada Network; otherwise benefits will be payable at 10% for inpatient facility only, and all other services will not be eligible. |
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| Spinal Treatment: Charges related to spinal care, services and treatment will only be payable at 100% if they are pre-certified by Argus and obtained within the Argus Spinal Care Network; otherwise, benefits will be payable at 10% for inpatient facility only, and all other services will not be eligible. Spinal care, services and treatment are subject to a mandatory second opinion review. |
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| Paediatric Assessment of Autism Spectrum & Attention Deficit Disorders: Charges related to paediatric assessment of autism spectrum and attention deficit disorders will only be payable at 100% if they are pre-certified by Argus and obtained in an Argus Preferred Provider Facility; otherwise, benefits will be payable at 10% for inpatient facility only, and all other services will not be eligible. |
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| Specialty Prescription Drugs: Physician and facility charges related to the administration of specialty prescription drugs will only be payable at 100% if they are tier one drugs, pre-certified by Argus and obtained within the Argus Specialty Prescription Drug Network; otherwise, benefits will be payable at 10% for inpatient facility only, and all other services will not be eligible. |
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| Psychiatric Disorders & Substance Abuse Disorders: Charges related to psychiatric and substance abuse disorders will only be payable at 100% if they are pre-certified by Argus and obtained within the Argus Psychiatric & Substance Abuse Disorders Network; otherwise, benefits will be payable at 10% for inpatient facility only, and all other services will not be eligible. |
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The following services are payable at a percentage of the lesser of Usual & Customary charges, claim amounts reduced by the Argus claims editing process or Discounted Rates, and must be pre-certified by Argus in order to receive maximum reimbursement. Airfare and accommodation are only eligible for Psychiatric & Substance Abuse services, Emergency Treatment and treatment which is not available in Bermuda and must be pre-certified by Argus in order to be eligible: |
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| Inpatient Care: Semi-private accommodation |
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| Intensive Care, Outpatient and Emergency Care: Unlimited |
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| Surgical, Obstetrical, Anaesthetic, Diagnostic and Medical Care: Unlimited |
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| Physician Services - Home or Office Visit: Unlimited |
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| Rehabilitation / Skilled Nursing Facility: Semi-private up to 60 days per policy year |
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| Home Health Care: Unlimited |
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| Transplant Services: Unlimited |
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| Psychiatric & Substance Abuse Disorders (Must be pre-certified by Argus in order to be eligible and receive maximum reimbursement): Inpatient Care: Unlimited Psychiatric Professional Services: Unlimited |
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Hotel or Rental Accommodation:**
Commercial Economy Airfare:** (Per Insured Person or per Insured Minor and Parent/Guardian jointly. Excludes preferred/priority seating and baggage fees) Combined Maximum with Hotel or Rental Accommodation: $15,000 per policy year |
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The following services must be pre-certified by Argus in order to be eligible: |
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| Ground Ambulance and Air Ambulance: Unlimited (if Medically Necessary) |
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| Behavioural Therapies for Autism Spectrum & Attention Deficit Disorders: Individual and family applied behavioural therapies 100% of billed charges, $2,500 maximum per policy year |
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| Cardiac Rehabilitation/Exercise Programme: $2,000 per policy year |
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| Telemedicine Office Visit: Unlimited |
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| Genetic Testing: Unlimited |
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| Repatriation of remains (inclusive of cremation): Unlimited for return of remains or ashes |
| Vision Care Benefits are applicable Worldwide.** Prescription Eye Glasses or Contact Lenses: $400 per policy year payable at 100% |
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| Elective Surgical Treatment for Vision Correction: $2,000 per lifetime payable at 100% **Airfare and accommodation do not apply to Worldwide Treatment and Services |
| Benefits are payable in accordance with the Bermuda Dental Fee Schedule. Amounts charged by a provider which exceed the scheduled amounts are your responsibility. Please obtain a pre-estimate of benefits from your dentist prior to undergoing extensive dental procedures. Basic Dental Services (DE01): Preventive and Diagnostic: 100% of Fee Schedule Policy Year: Unlimited Lifetime: Unlimited |
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| Exams, Consultations, Polishing, Scaling or Root Planing, Fluoride: 100% of Fee Schedule Policy Year: $1,400 Lifetime: Unlimited |
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| Surgical and Minor Restorative: 100% of Fee Schedule Policy Year: Unlimited Lifetime: Unlimited |
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| Endodontics: 100% of Fee Schedule Policy Year: Unlimited Lifetime: Unlimited |
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| Periodontics: 50% of Fee Schedule Policy Year: $2,000 Lifetime: Unlimited |
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Major Restorative Services (DE02): 50% or 80% of Fee Schedule Policy Year: $5,000 Lifetime: Unlimited |
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Orthodontic Services (DE03): Only Insured Persons up to age 19 are covered 50% of Fee Schedule Policy Year: N/A Lifetime: $4,000 **Airfare and accommodation do not apply to Worldwide Treatment and Services |
| Prescription Benefits are applicable Worldwide.** Prescription Drugs, Birth Control, Medicines and Sera available only by prescription: 80% for brand name drugs 100% for generic drugs $7,500 maximum per policy year **Airfare and accommodation do not apply to Worldwide Treatment and Services |
| Specialty Prescription Drugs (Must be pre-certified by Argus) (High cost drugs, biologic and biosimilar drugs and specialty drugs approved by Argus to treat complex or chronic medical conditions) 100% for tier one drugs 50% for tier two drugs |
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