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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 |
| 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:: Policy Year: $500,000 Lifetime: $1,500,000 |
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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 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: No benefits are payable. |
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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 within the Argus Preferred Provider 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 Hospital or Substance Abuse Treatment Facility (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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| Genetic Testing: Unlimited |
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| Cardiac Rehabilitation/Exercise Programme: $2,000 per policy year |
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| Repatriation of remains (inclusive of cremation): Unlimited for return of remains or ashes |
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