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Accidental injury coverage Beneit Amount
provides a beneit according to the Initial and Emergency Care
schedule below when a covered Ground Ambulance/Air Ambulance $400/$1,200
person suffers covered injuries or Emergency Care Treatment $400
undergoes a broad range of medical Diagnostic Exam (x-ray or lab) $50
treatments or care resulting from a Physician Oice Visit $200
covered accident. Hospitalization Beneits
Hospital Admission $2,000
Who Can Elect Coverage Hospital Stay (per day) $400
All active, full-time employees of Intensive Care Unit Stay (per day) $800
the employer who are United States Fractures and Dislocations
citizens or permanent resident aliens Per Covered Surgically-Repaired Fracture $300-$10,000
regularly working a minimum of 24 Per Covered Non-Surgically-Repaired Fracture $150-$5,000
hours per week in the United States. Chip Fracture (percent of fracture beneit) 25%
Per Covered Surgically-Repaired Dislocation $300-$6,000
You will be eligible for coverage Per Covered Non-Surgically-Repaired Dislocation $150-$3,000
after 60 days of active service. Follow-Up Care
Follow-Up Visit To The Doctor $200
X Your spouse/domestic Follow-Up Physical Therapy Visits $75
partner: Up to age 70, as Enhanced Accident Beneits
long as you apply for and are Examples
approved for coverage yourself Small Lacerations (less than or equal to 6 inches long and $150
X Your child(ren): Birth to 26; requires 2 or more sutures)
26+ if disabled, as long as you Large Lacerations (more than 6 inches long and requires 2 or $800
more sutures)
apply for and are approved for Coma (lasting 7 days with no response) $40,000
coverage yourself Concussion $200
This accidental injury plan provides Plus up to 22 additional beneits. See certiicate for details, including limitations
and exclusions.
24-hour coverage. The beneit
amounts shown in this summary Beneit
will be paid regardless of the actual Wellness, Health Screening Test, or Preventive Care Beneit Amount
expenses incurred. Beneits are only Examples include (but are not limited to) routine gynecological $100 per year
payable when all policy terms and exams, general health exams, mammography, and certain blood
tests. A 30-day beneit waiting period applies during which
conditions are met. Please read all beneits will not be paid.
the information in this summary to
understand terms, conditions, state
variations, exclusions and limitations
applicable to these beneits. See
your certiicate of insurance for
more information.
22 2020 Benefits Guide
provides a beneit according to the Initial and Emergency Care
schedule below when a covered Ground Ambulance/Air Ambulance $400/$1,200
person suffers covered injuries or Emergency Care Treatment $400
undergoes a broad range of medical Diagnostic Exam (x-ray or lab) $50
treatments or care resulting from a Physician Oice Visit $200
covered accident. Hospitalization Beneits
Hospital Admission $2,000
Who Can Elect Coverage Hospital Stay (per day) $400
All active, full-time employees of Intensive Care Unit Stay (per day) $800
the employer who are United States Fractures and Dislocations
citizens or permanent resident aliens Per Covered Surgically-Repaired Fracture $300-$10,000
regularly working a minimum of 24 Per Covered Non-Surgically-Repaired Fracture $150-$5,000
hours per week in the United States. Chip Fracture (percent of fracture beneit) 25%
Per Covered Surgically-Repaired Dislocation $300-$6,000
You will be eligible for coverage Per Covered Non-Surgically-Repaired Dislocation $150-$3,000
after 60 days of active service. Follow-Up Care
Follow-Up Visit To The Doctor $200
X Your spouse/domestic Follow-Up Physical Therapy Visits $75
partner: Up to age 70, as Enhanced Accident Beneits
long as you apply for and are Examples
approved for coverage yourself Small Lacerations (less than or equal to 6 inches long and $150
X Your child(ren): Birth to 26; requires 2 or more sutures)
26+ if disabled, as long as you Large Lacerations (more than 6 inches long and requires 2 or $800
more sutures)
apply for and are approved for Coma (lasting 7 days with no response) $40,000
coverage yourself Concussion $200
This accidental injury plan provides Plus up to 22 additional beneits. See certiicate for details, including limitations
and exclusions.
24-hour coverage. The beneit
amounts shown in this summary Beneit
will be paid regardless of the actual Wellness, Health Screening Test, or Preventive Care Beneit Amount
expenses incurred. Beneits are only Examples include (but are not limited to) routine gynecological $100 per year
payable when all policy terms and exams, general health exams, mammography, and certain blood
tests. A 30-day beneit waiting period applies during which
conditions are met. Please read all beneits will not be paid.
the information in this summary to
understand terms, conditions, state
variations, exclusions and limitations
applicable to these beneits. See
your certiicate of insurance for
more information.
22 2020 Benefits Guide
