BUPA CHOICE PREMIUM RATES

B U PA C H O I C E
P R E M I U M R AT E S
E F F EC T I V E J A N UA RY 1, 2 013
BUPA CHOICE
PREMIUM RATES
EFFECTIVE JANUARY 1, 2012
Administrative notes
• Rates are in U.S. dollars and don’t include taxes.
• An annual $75 administration fee per policy applies.
• One deductible applies per insured, per policy year up to a maximum of
the out-of-country deductible. If the in-country deductible has already
been met, and treatment is later received out of country, the difference
between both deductibles will be the insured’s responsibility. A maximum
of two deductibles per policy, per policy year applies, up to a maximum
of two out-of-country deductibles.
• Maximum age to apply: 74 years old.
• For ages 65 and older, a Treating Physician Statement is required when
applying for coverage.
• Available payment modes: annually, semiannually, and quarterly.
• The insurer, USA Medical Services, and/or any of their applicable related
subsidiaries and affiliates will not engage in any transactions with any
parties or in any countries where otherwise prohibited by the laws in the
United States of America. Please contact USA Medical Services for
more information about this restriction.
• Coinsurance: After meeting the deductible, 80% of the first US$5,000 in
approved charges is covered; then 100% of approved charges up to US
$1,000,000. One coinsurance per insured, per policy year applies.
• Bupa reserves the right to correct any errors or omissions.
2
BUPA CHOICE
FOLLETO DE TARIFAS
EFECTIVAS EL 1 DE ENERO DE 2012
Notas administrativas
• Las tarifas están expresadas en dólares de los Estados Unidos de
América y no incluyen impuestos.
• Se aplica una tarifa administrativa anual de US$75 por póliza.
• Se aplica un deducible por asegurado, por año póliza hasta el máximo
del deducible fuera del país de residencia. Si ya se ha cubierto el
deducible dentro del país de residencia, y luego el asegurado recibe
tratamiento fuera de su país de residencia, la diferencia entre ambos
deducibles será responsabilidad del asegurado. Se aplica un máximo de
dos deducibles por póliza, por año póliza, hasta un máximo de dos
deducibles fuera del país de residencia.
• Edad máxima para solicitar cobertura: 74 años.
• Para solicitantes de 65 o más, se requiere incluir el formulario
Declaración del Médico Tratante al solicitar la cobertura.
• Opciones de pago disponibles: anual, semestral y trimestral.
• Ni la aseguradora, ni USA Medical Services, ni ninguna de sus filiales o
subsidiarias pertinentes relacionadas participarán en transacciones con
cualquier parte o país donde dichas transacciones estén prohibidas por
las leyes de los Estados Unidos de América. Por favor comuníquese con
USA Medical Services para obtener más información sobre esta
restricción.
• Coaseguro: Después de satisfacer el deducible, se cubre el 80% de los
primeros US$5,000 en gastos aprobados; luego, el 100% de gastos
aprobados hasta un máximo de US$1,000,000. Aplica un coaseguro por
asegurado, por año póliza.
• Bupa se reserva el derecho de corregir cualquier error u omisión.
3
BUPA CHOICE
PREMIUM RATES
EFFECTIVE JANUARY 1, 2012
ZONE 2
ZONE 3
ZONE 4
Central America
Belize, Caribbean Islands, French
Guiana, Guyana, Suriname
Bolivia, Colombia, Peru
Deductibles
Plan
Plan
In country of
residence
US$500
US$2,500
Out of country
of residence
Age
Ecuador
Venezuela
Plan
Plan
Plan
US$500
US$500
US$500
US$500
US$2,500
US$2,500
US$2,500
US$2,500
Annual
Semiannual
Annual
Semiannual
Annual
Semiannual
Annual
Semiannual
Annual
Semiannual
1 child
$860.16
$455.88
$741.44
$392.96
$659.68
$349.63
$600.32
$318.17
$515.20
$273.06
2 children
1,360.80
721.22
1,173.76
622.09
1,039.36
550.86
948.64
502.78
816.48
432.73
3 or more children
1,972.32
1,045.33
1,703.52
902.87
1,512.00
801.36
1,377.60
730.13
1,183.84
627.44
19-25
2,094.40
1,110.03
1,816.64
962.82
1,618.40
857.75
1,480.64
784.74
1,280.16
678.48
26-29
2,404.64
1,274.46
2,085.44
1,105.28
1,853.60
982.41
1,693.44
897.52
1,467.20
777.62
30-34
2,727.20
1,445.42
2,364.32
1,253.09
2,102.24
1,114.19
1,923.04
1,019.21
1,660.96
880.31
35-39
3,037.44
1,609.84
2,633.12
1,395.55
2,338.56
1,239.44
2,135.84
1,132.00
1,843.52
977.07
40-44
3,444.00
1,825.32
2,982.56
1,580.76
2,652.16
1,405.64
2,421.44
1,283.36
2,089.92
1,107.66
45-49
4,012.96
2,126.87
3,475.36
1,841.94
3,091.20
1,638.34
2,822.40
1,495.87
2,433.76
1,289.89
50-54
4,404.96
2,334.63
3,814.72
2,021.80
3,389.12
1,796.23
3,095.68
1,640.71
2,670.08
1,415.14
55-59
5,227.04
2,770.33
4,524.80
2,398.14
4,021.92
2,131.62
3,669.12
1,944.63
3,164.00
1,676.92
60-64
6,931.68
3,673.79
6,006.56
3,183.48
5,355.84
2,838.60
4,887.68
2,590.47
4,202.24
2,227.19
65-69
9,356.48
4,958.93
8,100.96
4,293.51
7,239.68
3,837.03
6,604.64
3,500.46
5,673.92
3,007.18
70-74
13,630.40
7,224.11
11,747.68
6,226.27
10,515.68
5,573.31
9,589.44
5,082.40
8,239.84
4,367.12
75-79
17,064.32
9,044.09
14,703.36
7,792.78
13,160.00
6,974.80
12,000.80
6,360.42
10,309.60
5,464.09
80+
22,552.32
11,952.73
19,436.48
10,301.33
17,502.24
9,276.19
15,960.00
8,458.80
13,708.80
7,265.66
$125
$66.25
$125
$66.25
$125
$66.25
$125
$66.25
$125
$66.25
250
132.50
250
132.50
250
132.50
250
132.50
250
132.50
Additional coverage
Private pilot
Transplant procedures
4
BUPA CHOICE
FOLLETO DE TARIFAS
EFECTIVAS EL 1 DE ENERO DE 2012
ZONE 2
ZONE 3
ZONE 4
Centroamérica
Belice, Guayana Francesa,
Guyana, Islas del Caribe, Surinam
Bolivia, Colombia, Perú
Ecuador
Venezuela
Plan
Plan
Plan
Plan
Plan
Dentro del país
de residencia
US$500
US$500
US$500
US$500
US$500
Fuera del país
de residencia
US$2,500
US$2,500
US$2,500
US$2,500
US$2,500
Deducibles
Edad
Anual
Semestral
Anual
Semestral
Anual
Semestral
Anual
Semestral
Anual
Semestral
1 hijo
$860.16
$455.88
$741.44
$392.96
$659.68
$349.63
$600.32
$318.17
$515.20
$273.06
2 hijos
1,360.80
721.22
1,173.76
622.09
1,039.36
550.86
948.64
502.78
816.48
432.73
3 hijos o más
1,972.32
1,045.33
1,703.52
902.87
1,512.00
801.36
1,377.60
730.13
1,183.84
627.44
19-25
2,094.40
1,110.03
1,816.64
962.82
1,618.40
857.75
1,480.64
784.74
1,280.16
678.48
26-29
2,404.64
1,274.46
2,085.44
1,105.28
1,853.60
982.41
1,693.44
897.52
1,467.20
777.62
30-34
2,727.20
1,445.42
2,364.32
1,253.09
2,102.24
1,114.19
1,923.04
1,019.21
1,660.96
880.31
35-39
3,037.44
1,609.84
2,633.12
1,395.55
2,338.56
1,239.44
2,135.84
1,132.00
1,843.52
977.07
40-44
3,444.00
1,825.32
2,982.56
1,580.76
2,652.16
1,405.64
2,421.44
1,283.36
2,089.92
1,107.66
45-49
4,012.96
2,126.87
3,475.36
1,841.94
3,091.20
1,638.34
2,822.40
1,495.87
2,433.76
1,289.89
50-54
4,404.96
2,334.63
3,814.72
2,021.80
3,389.12
1,796.23
3,095.68
1,640.71
2,670.08
1,415.14
55-59
5,227.04
2,770.33
4,524.80
2,398.14
4,021.92
2,131.62
3,669.12
1,944.63
3,164.00
1,676.92
60-64
6,931.68
3,673.79
6,006.56
3,183.48
5,355.84
2,838.60
4,887.68
2,590.47
4,202.24
2,227.19
65-69
9,356.48
4,958.93
8,100.96
4,293.51
7,239.68
3,837.03
6,604.64
3,500.46
5,673.92
3,007.18
70-74
13,630.40
7,224.11
11,747.68
6,226.27
10,515.68
5,573.31
9,589.44
5,082.40
8,239.84
4,367.12
75-79
17,064.32
9,044.09
14,703.36
7,792.78
13,160.00
6,974.80
12,000.80
6,360.42
10,309.60
5,464.09
80+
22,552.32
11,952.73
19,436.48
10,301.33
17,502.24
9,276.19
15,960.00
8,458.80
13,708.80
7,265.66
$125
$66.25
$125
$66.25
$125
$66.25
$125
$66.25
$125
$66.25
250
132.50
250
132.50
250
132.50
250
132.50
250
132.50
Cobertura adicional
Piloto privado
Procedimientos de
trasplante
5
HOW IS THE PREMIUM PAID?
Procedure for domestic wire transfers
Wells Fargo Bank
200 South Biscayne Blvd, FL6011
Miami, FL 33131
Account # 2000037371881
ABA # 121000248
Account Name: Bupa Worldwide Premium Trust
Reference: Policyholder Name and Policy Number
Bupa must receive payment before the coverage can take
effect. Please submit payment with your application. You
can choose among the following payment options:
Online payment by credit card through our
website www.bupalatinamerica.com
Credit card MasterCard, VISA, American Express, or Diners Club
Personal check in U.S. dollars drawn on an American
bank, cashier’s check, money order, traveler’s check
Procedure for international wire transfers
Wells Fargo Bank
200 South Biscayne Blvd, FL6011
Miami, FL 33131
Account # 2000037371881
ABA # 121000248
CHIPS # 0407
SWIFT # WFBIUS6S
Account Name: Bupa Worldwide Premium Trust
Reference: Policyholder Name and Policy Number
Bank transfer:
Procedure for ACH’s
Wells Fargo Bank
200 South Biscayne Blvd, FL6011
Miami, FL 33131
Account # 2000037371881
ABA # 067006432
Account Name: Bupa Worldwide Premium Trust
Reference: Policyholder Name and Policy Number
6
CÓMO PAGAR LA PRIMA
Transferencia bancaria doméstica
Wells Fargo Bank
200 South Biscayne Blvd, FL6011
Miami, FL 33131
Número de cuenta: 2000037371881
ABA #: 121000248
Nombre de la cuenta: Bupa Worldwide Premium Trust
Referencia: nombre del asegurado principal y número de póliza
Bupa debe recibir el pago de la prima para que la cobertura entre en
vigencia. Por favor efectúe su pago al momento de presentar la
solicitud. Usted puede elegir cualquiera de las siguientes opciones de pago:
Pago online mediante tarjeta de crédito a través de nuestro sitio web
www.bupalatinamerica.com
Tarjeta de crédito MasterCard, VISA, American Express, o Diners Club
Cheque personal en dólares de los Estados Unidos de América
pagadero contra un banco estadounidense, cheque de caja, giro postal,
cheque de viajero
Transferencia bancaria internacional
Wells Fargo Bank
200 South Biscayne Blvd, FL6011
Miami, FL 33131
Número de cuenta: 2000037371881
ABA #: 121000248
CHIPS # 0407
SWIFT # WFBIUS6S
Nombre de la cuenta: Bupa Worldwide Premium Trust
Referencia: nombre del asegurado principal y número de póliza
Transferencia bancaria:
Cobranza de Cámara de Compensación Automatizada (CCA)
Wells Fargo Bank
200 South Biscayne Blvd, FL6011
Miami, FL 33131
Número de cuenta: 2000037371881
ABA #: 067006432
Nombre de la cuenta: Bupa Worldwide Premium Trust
Referencia: nombre del asegurado principal y número de póliza
7
7001 S.W. 97th Avenue
Miami, Florida 33173
Tel. +1 (305) 398 7400
Fax +1 (305) 275 8484
www.bupalatinamerica.com
[email protected]
Bupa Diamond Care
Bupa Complete Care
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