bupa critical care premium rates - ASA International Insurance

BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
BUPA CRITICAL CARE
PREMIUM RATES
EFFECTIVE JANUARY 1, 2013
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BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013

BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
Administrative notes
• Rates are in U.S. dollars and don’t include taxes.
• An annual US$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 amount
of two out-of-country deductibles.
• Maximum age to apply: 74 years old.
• Premium rates are based on the country of residence. See
separate premium rates for Puerto Rico and the U.S. Virgin
Islands.
• 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.
• For a quote, take the older person as the policyholder and
refer to the rate sheet under the corresponding age group.
• Bupa reserves the right to correct any errors or omissions.
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BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
ZONE 1
MEXICO
Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6
In country of
residence
Out of country
of residence
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
Age Annual Annual Annual Annual Annual Annual
Under 50
Single rate US$1,261.00 US$1,096.00 US$941.00 US$719.00 US$505.00 US$282.00
Two-party rate 2,301.00 1,959.00 1,705.00 1,291.00 894.00 475.00
Family rate 3,342.00 2,822.00 2,471.00 1,866.00 1,286.00 670.00
50 or older
Single rate 1,623.00 1,409.00 1,205.00 921.00 642.00 349.00
Two-party rate 2,663.00 2,274.00 1,971.00 1,490.00 1,030.00 545.00
Family rate 3,704.00 3,134.00 2,738.00 2,065.00 1,421.00 739.00
ZONE 2
Chile, Haiti, Honduras, Peru
Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6
In country of
residence
Out of country
of residence
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
Age Annual Annual Annual Annual Annual Annual
Under 50
Single rate US$1,013.00 US$821.00 US$714.00 US$566.00 US$423.00 US$270.00
Two-party rate 1,785.00 1,398.00 1,231.00 951.00 685.00 404.00
Family rate 2,553.00 1,982.00 1,745.00 1,339.00 948.00 533.00
50 or older
Single rate 1,283.00 1,034.00 896.00 699.00 514.00 315.00
Two-party rate 2,052.00 1,610.00 1,410.00 1,085.00 775.00 448.00
Family rate 2,826.00 2,194.00 1,924.00 1,470.00 1,038.00 578.00
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BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
ZONE 3
Costa Rica, El Salvador
Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6
In country of
residence
Out of country
of residence
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
Age Annual Annual Annual Annual Annual Annual
Under 50
Single rate US$1,184.00 US$1,029.00 US$884.00 US$676.00 US$477.00 US$264.00
Two-party rate 2,159.00 1,837.00 1,599.00 1,213.00 842.00 448.00
Family rate 3,137.00 2,644.00 2,315.00 1,748.00 1,207.00 631.00
50 or older
Single rate 1,524.00 1,324.00 1,133.00 866.00 606.00 327.00
Two-party rate 2,498.00 2,131.00 1,847.00 1,402.00 968.00 513.00
Family rate 3,475.00 2,937.00 2,565.00 1,938.00 1,334.00 693.00
ZONE 4
Belize, Guatemala, Guyana,
Nicaragua, Suriname, Uruguay,
rest of the CARIBBEAN (a)
Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6
In country of
residence
Out of country
of residence
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
Age Annual Annual Annual Annual Annual Annual
Under 50
Single rate US$943.00 US$762.00 US$666.00 US$529.00 US$397.00 US$248.00
Two-party rate 1,660.00 1,302.00 1,146.00 886.00 640.00 367.00
Family rate 2,374.00 1,841.00 1,621.00 1,244.00 884.00 486.00
50 or older
Single rate 1,193.00 962.00 831.00 653.00 480.00 290.00
Two-party rate 1,908.00 1,500.00 1,313.00 1,010.00 723.00 407.00
Family rate 2,623.00 2,037.00 1,787.00 1,371.00 968.00 528.00
(a) Excluding Trinidad & Tobago
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BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
ZONE 5
Ecuador, Venezuela
Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6
In country of
residence
Out of country
of residence
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
Age Annual Annual Annual Annual Annual Annual
Under 50
Single rate US$1,092.00 US$950.00 US$814.00 US$625.00 US$443.00 US$249.00
Two-party rate 1,985.00 1,690.00 1,473.00 1,117.00 778.00 415.00
Family rate 2,882.00 2,432.00 2,129.00 1,610.00 1,113.00 582.00
50 or older
Single rate 1,403.00 1,220.00 1,045.00 797.00 557.00 307.00
Two-party rate 2,299.00 1,960.00 1,702.00 1,289.00 896.00 475.00
Family rate 3,193.00 2,701.00 2,357.00 1,782.00 1,227.00 642.00
ZONE 6
Argentina, Colombia,
Panama, Paraguay
Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6
In country of
residence
Out of country
of residence
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
Age Annual Annual Annual Annual Annual Annual
Under 50
Single rate US$921.00 US$746.00 US$652.00 US$515.00 US$387.00 US$250.00
Two-party rate 1,618.00 1,269.00 1,116.00 866.00 625.00 368.00
Family rate 2,314.00 1,794.00 1,580.00 1,214.00 862.00 487.00
50 or older
Single rate 1,164.00 937.00 813.00 638.00 468.00 291.00
Two-party rate 1,859.00 1,463.00 1,279.00 985.00 705.00 408.00
Family rate 2,558.00 1,987.00 1,744.00 1,335.00 943.00 526.00
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BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
ZONE 7
Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6
In country of
residence
Out of country
of residence
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
Age Annual Annual Annual Annual Annual Annual
Under 50
Single rate US$1,528.00 US$1,318.00 US$1,129.00 US$860.00 US$603.00 US$331.00
Two-party rate 2,797.00 2,363.00 2,053.00 1,554.00 1,075.00 565.00
Family rate 4,066.00 3,404.00 2,980.00 2,249.00 1,547.00 801.00
50 or older
Single rate 1,967.00 1,696.00 1,451.00 1,104.00 766.00 414.00
Two-party rate 3,237.00 2,741.00 2,376.00 1,797.00 1,237.00 649.00
Family rate 4,505.00 3,781.00 3,301.00 2,492.00 1,710.00 885.00
ZONE 8
TRINIDAD & TOBAGO
Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6
In country of
residence
Out of country
of residence
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000
Age Annual Annual Annual Annual Annual Annual
Under 50
Single rate US$881.00 US$712.00 US$622.00 US$494.00 US$371.00 US$232.00
Two-party rate 1,551.00 1,217.00 1,071.00 828.00 598.00 343.00
Family rate 2,219.00 1,721.00 1,515.00 1,163.00 826.00 454.00
50 or older
Single rate 1,115.00 899.00 777.00 610.00 449.00 271.00
Two-party rate 1,783.00 1,402.00 1,227.00 944.00 676.00 380.00
Family rate 2,451.00 1,904.00 1,670.00 1,281.00 905.00 493.00
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BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
HOW IS THE PREMIUM PAID
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
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
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
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
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BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
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BUPA CRITICAL CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 2013
7001 S.W. 97th Avenue
Miami, Florida 33173
Tel. +1 (305) 398 7400
Fax +1 (305) 275 8484
www.bupalatinamerica.com
bupa@bupalatinamerica.com
PR-CRI 2013 ENG
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