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As specified under The Health Insurance Act 1970 and its regulations, orders and rules |
| Ancillary Hospital Services 100%, Bermuda Hospitals Board Fee Schedule |
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| Surgical, Obstetrical, Anaesthetic, Diagnostic and Medical Care 100%, 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):
Diabetes Rewind Programme (Programme & provider must be pre-approved by Argus):
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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: $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: 100%, 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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| Laboratory & Diagnostic Services in Private Testing Facilities: Includes Genetic Testing and Sleep Studies (Must be pre-approved by Argus): covered by approved fee schedule. COVID-19 Testing (Approved Tests at Approved Facilities) 100%, Bermuda Fee Schedule |
General Practitioner
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Specialist
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Telemedicine
(Services & providers must be pre-certified/approved by Argus; refer to FAQ’s) |
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In Office Medical / Surgical Treatment: 100%, Bermuda Fee Schedule |
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In-Office COVID-19 Sample Collection (and associated charges relating to evaluation and management, PPE and handling) 50%, Bermuda Fee Schedule or as otherwise directed by the Bermuda Health Council guidelines |
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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-approved by Argus): Individual and family applied behavioural therapies 100% of billed charges, $10,000 per policy year |
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| Psychiatrist: $190, maximum 6 visits per policy year Psychologist/Group Therapy Session: $140, maximum 6 visits per policy year Counselling Services (Includes Addiction, Art, Play & Equestrian Therapies):
Smoking Cessation Counselling
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| Neuropsychological Testing (Services must be pre-approved by Argus): 100%, Bermuda Fee Schedule. Maximum 1 test every 2 policy years |
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| Sclerotherapy: 100%, 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, Birth Defects & High-Risk Pregnancy: Charges related to neonatal, 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 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 & 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 eligible for airfare and accommodation and must be pre-approved by Argus in order to receive maximum reimbursement. Airfare and accommodation are only eligible for Psychiatric and Substance Abuse services, Emergency Treatment and Treatment which is not available in Bermuda: |
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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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| COVID-19 Testing (Approved Tests): 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-approved by Argus in order to be eligible and receive maximum reimbursement): Inpatient Care: Unlimited Psychiatric Professional Service: $5,500 combined maximum per policy year |
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Hotel or Rental Accommodation:** Insured Person or or Insured Minor and Parent/Guardian jointly: $200 per day Without Hotel or Rental Accommodation: 50% of above amount Combined Maximum with commercial Economy Airfare: $15,000 per policy year 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-approved 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 Virtual 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 |
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| The following services are payable at 100% of the lesser of Usual and Customary charges, claim amounts reduced by the Argus claims editing process or Discounted Rates. Airfare and accommodation do not apply to these services, consultations and second opinions. Pre-certification of these services is not required: |
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| COVID-19 Vaccination: Unlimited |
| 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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