1. October 6, 2011
LINEA OPTIMA COVERAGE
NOTES
SUM INSURED AMOUNT. Is the maximum amount that PLAN SEGURO will pay for an ailment as a consequence of an
accident and/or covered illness, which initiated during the policy term.
DEDUCTIBLE. Is the maximum lump sum that the insured has to cover, which corresponds to the first covered expenses.
The deductible is set on the cover page of the policy and it is applied one time per condition. Once the covered expense
has exceeded this amount, the obligation by PLAN SEGURO begins.
COINSURANCE. The amount that the insured has to cover, resulting from applying the percentage stipulated on the
cover page of the insurance policy to the total covered Medical Expenses after applying the deductible. Coinsurance will
apply to each claim including additional costs, regardless of whether the first claim has been compensated by direct
payment. There is a stop Coinsurance of $30,000.00 pesos.
HOSPITAL LEVEL. These are categories that define national standards for trauma care in hospitals. Plan Seguro offers the
top level of Hospitals in Mexico.
PREVENTIVE CAMPAIGNS
- Mastography. You pay only Mx$220.00 pesos
- Cervicouterine Cancer, Breast Cancer, Dislipidemias, Prostate Cancer, Diabetes, and Osteoporosis with no cost for you
AMBULATORY COVERAGE
- Ambulatory Medical Consults – You pay only Mx$129.00 pesos with appointments made with doctors inside the
network. Outside the network you pay 40% of the cost.
- Laboratory tests, cabinet and office imaging inside of the network. You pay 40% of the cost.
- Medical checkups. You pay only Mx$404.00 pesos
AMBULATORY COVERAGE EXCLUSIONS
- Pregnancy control consults childbirth, postpartum and related complications, weight control, and dental
procedures.
- Medications.
- Doctors, hospitals and laboratories outside the network.
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2. MAJOR MEDICAL INSURANCE
- Hospital Expenses
- Standard private hospitalization and meals with a maximum of 180 days per condition.
- General nursing attention.
- Operating room, recovery, and recuperation.
- All cost incurred and related to the condition for which the claim was submitted.
- Extra hospital bed for a companion.
- Physicians fees.
- Medications included.
- Medical – surgical fees
- Anesthetist’s fees
- Assistant’s fees
- Home nursing fees
- Laboratory, cabinet, and hospital imaging
- Chiropractic
- Declared pre-existing conditions
- Prosthesis, orthopedics, medical equipment
- Emergency air ambulance
- Ground ambulance
- Medical consults
- Oxygen consumption
- Physiotherapy and rehabilitation (3 months or 30 sessions per condition).
- Ozonotherapy (20 sessions and up to 1 SMGM each, maximum.
- Blood Transfusions and Application.
- Radiotherapy and Chemotherapy Treatment.
- Dental Treatment, Alveolar or Gingival (Sum Insured 10 SMGM, applying policy’s deductible and coinsurance).
- Reconstructive Treatments due to an accident.
- Nose disease or paranasal sinus derivated from an accident (applying deductible and 50% coinsurance).
- Organ Transplant (heart, lung, liver or kidney, up to 800 SMGM or contracted SA, whichever is less costly).
- Dangerous Sports (occasional or vacational practice, performed twice a month as a maximum).
- Psychiatric Damage (covered accident, terminal illness, assault, kidnapping or rape).
- Palpebral Ptosis.
- Parenteral Feeding (20 sessions per condition).
- Breast Expanders.
- Lessions suffered by the insured when traveling as a passenger in commercial airlines.
- External Equipment for Medication Application.
- HIV Testing (Preoperative Protocol)
PLAN SEGURO PROVIDES THE FOLLOWING AMOUNT OF MONEY TO SUPPORT WHEN
- Cardiac valvular prosthesis, endoprosthesis, and stents: Mx$71,800.00 pesos per condition
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3. - Pacemakers: Mx$ 26,925.00 pesos
- Hip prosthesis, knee, shoulder, elbow, ocular prosthesis, and artificial limbs, osteosynthesis material: Mx$52,055.00
pesos per concept
- Rental or purchase of orthopedic equipment such as crutches, wheelchairs, artificial lungs or other similar devices:
Mx$52,055.00 pesos per concept
WAITING PERIODS
10 MONTHS
- PREGNANCY COMPLICATIONS, DELIVERY, CESAREAN SECTION OR POSTPARTUM (SA 65 SMGM, deductible and
coinsurance apply).
- DELIVERY AND CESAREAN SECTION (SA 15 SMGM, no deductible or coinsurance).
- ABORTION AND DILATION AND CURETTAGE (SA 5 SMGM, no deductible or coinsurance).
- NEWBORNS.
- CONGENIAL DISORDERS (IF THE MOTHER IS INSURED).
12 MONTHS
- ADEINOIDECTOMY AND TONSILLECTOMY.
- INCISIONAL HERNIAS, HERNIAS, HEMORRHOIDS, AND ANORECTAL DISEASES.
- CHOLECYSTITIS, BILIARY LITHIASIS, BILIARY VESICULAR LITHIASIS.
- PERIPHERAL VENOUS INSUFFICIENCY, VARICOCELE, LOWER LIMB VARICES.
- RENAL AND GENITOURINARY LITHIASIS.
- PROSTHATIC DISEASE (EXCEPT CANCER).
- ACID PEPTIC DISORDERS.
- DIVERTICULAR ILLNESS, POLYPS, AND DIVERTICULOSIS.
- NOSE DISEASE OR PANASAL SINUS DERIVATED FROM AN ILLNESS (applying deductible and 50% coinsurance).
- TUMORS (EXCEPT CANCEROUS).
2 YEARS
- PROSTATECTOMY.
- CATARACTS.
- ILLNESSES RELATED TO THE PERONEUS, HALLUX VALGUS (BUNIONS).
- ANY KIND OF PROLAPSE.
- GYNECOLOGICAL DISEASE.
- ANY KNEE OR VERTEBRAL COLUMN DISEASE.
- CANCER.
4 YEARS
- HIV
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4. CONDITIONS TO BE DENIED THE POLICY
- Heart diseases with exception of Hypertension if it is under control (periodically checkups and ongoing treatments).
- Combination of Hypertension and Diabetes.
- Brain diseases.
- Cancer in less than 10 years.
DENTAL SERVICES
- One check up, one cleaning, four fillings, and two extractions per year.
EMERGENCIES ABROAD
- Coverage in the United States and Canada for Emergencies up to the limit of $50,000.00 USD.
GENERAL EXCLUSIONS
1. Pre-existing conditions omitted on the application
2. For lesions or illnesses caused as a consequence of serving in the military service, insurrection, war, natural
catastrophe, riots, rebellion or fights.
3. For intentional criminal acts of the insured.
4. Self inflicted injury, voluntary mutilation, auto medication, and suicide attempt, even when these are caused by
mental illness.
5. Injuries resulting from participating as a passenger on any racing vehicle, race, tryouts or competitions,
resistance or speed in autos, mononautics or motorless flying.
6. Injuries resulting as a consequence of professional or amateur practice of any sport, as well as participation on
official races and exhibitions.
7. Injuries resulting as a consequence of professional or amateur practice of the following dangerous sports:
mountaineering, climbing, rappelling, scuba diving, rodeos, skiing, bull fighting, motorcycling, go karts, boxing,
Greco Roman wrestling, wrestling, hunting, caving, hockey, horseback riding, football, martial arts, karate, sky
diving or any other air sport practiced as an amateur.
8. Injuries sustained when traveling as a pilot, mechanic or crew member of an aircraft that does not belong to a
legally established commercial airline.
9. Conditions and treatments to correct mental diseases, hysteria, neurosis or psychosis, all kinds of psychological
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5. disease, psychiatric or nervous, psychomotor, related to language and speech, learning disability, anxiety,
depression, anguish, senile dementia, and cognitive disorders, irrespective of their clinical manifestations except
what is specified as Covered Medical Expenses on Psychiatric Damage.
10. Condition as a result of the use of alcohol, drugs, barbiturate, stimulant, sleeping pills or similar.
11. Pregnancy conditions except as covered in subsection Pregnancy Complications, delivery, and cesarean section
or postpartum; also excluded are pregnancy complications as a consequence of infertility and sterility
treatments.
12. Costs incurred in diagnostics, medical or surgical treatment and/or complications for the treatment of infertility,
sterility, sexual dysfunction and birth control.
13. Vision exam, eye glasses, contact lenses, intraocular lenses or hearing aids.
14. Dental exams and consultations, alveolar, gingival, maxillary or any other kind, except the ones required for
reconstruction, as a result of an accident.
15. Treatments or surgical interventions of aesthetic or plastic nature including keloid scars, except reconstructive
indispensable for functioning as a consequence of an accident or illness.
16. Medical or surgical treatment and/or complications related to alopecia, obesity, weight reduction, tobacco
abuse, and lower limb sclerotherapy.
17. Rectoabdominal muscle diastasis, regardless of the cause.
18. Malformations and congenial disease and consequences suffered by insureds who were born outside the policy
term.
19. Circumcision regardless of the cause, except as indicated on Covered Medical Expenses.
20. Rest cures or checkups, except expenses covered on Ambulatory Coverages.
21. Physiological expenses of a newborn.
22. Replacement of orthopedic or prosthetic devices existent at the policy issue date.
23. Purchase or rental of shoes or orthopedic shoe inserts, hospital bed or similar devices.
24. Expenses for insured’s companions during hospitalization, except extra bed.
25. Treatments not recognized by medical scientific practice, experimental treatments or treatments of uncertain
benefits for the patient.
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6. 26. Treatments that require the use of an hyperbaric chamber.
27. Any complication arising from conditions expressly excluded from this contract.
28. Intrahospital specialized nurse.
29. Medical fees when the doctor is the one insured or is related to the insured.
30. Treatment for presbyopia, hypermetropia, astigmatism, myopia, strabismus, regardless of the cause.
31. Palpebral ptosis except for complications of a medical covered expense.
32. Expenses related to blood transfusions:
- ABO and Rh (identification of blood type of potential donors)
- COMPATIBILITY TESTS
- IRREGULAR ANTIBODIES
- BLOOD CHARGE OR SUPPLY RECOVERY
33. Parenteral feeding except in case of hospitalization.
34. Pigmented skin lesions such as nevus or moles, warts, seborrheic keratosis, acne, rosacea, congenital disease, as
well as treatments based on hypnosis, cryotherapy, and chelation.
35. Breast expanders (except if required as part of the reconstructive treatment of breast cancer covered by PLAN
SEGURO). Breast prosthesis and ailments and/or complications caused by placement of them.
36. Menopause, climacterium, osteoporosis (densitometry), tobacco abuse, sleep control.
37. Any kind of immunization.
38. Supplements or vitamin complexes and alimentary, as well as any kind of infant formula (milk).
39. HIV care for newborns.
40. Regarding organ transplant of any kind, presurgical and postsurgical expenses are excluded on a living donor
post- transplant, and any complication of the living donor derived from the event, as well as any gratification or
compensation that he/she receives, except the ones mentioned on Covered Medical Expenses.
41. Acupuncture, naturopathic, homeopathic or any other kind of treatment of alternative medicine.
42. Expenses not related to the disease and/or accident claimed will not be covered, as well as services, rental or
purchase of equipment or devices to provide comfort and personal recreation.
43. Treatment to correct behavioral and learning problems, short stature, growth, development, gigantism and its
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7. complications, early stimulation, speech therapy, impaired growth and development.
44. The following are not covered:
- Epidemics officially declared by health authorities.
- Nuclear or radioactive explosions.
- Radioactive pollution.
- Terrorist acts as a result of the direct participation of the insured on intentional criminal acts.
45. Civil, criminal or any other kind of responsibility derived from a service received from a provider.
46. Any condition of which symptoms or signs have been manifested and/or initiated on any open period, as well as
any expense incurred over the above mentioned period.
47. Medical and/or surgical treatment with Focus Exablate.
48. Correction of sleep disorders, sleep apneas, and snoring, even the ones resulting from covered illnesses or
accidents.
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