Page 20 - 2019 Sertek Enrollment Guide
P. 20
2019 BENEFITS ENROLLMENT
Bi-Weekly Post Tax Accident Benefit Amount
Premium* Schedule of Dislocations
Hip Joint $2,000
Premium Knee Joint $1,000
Employee $5.46 Bones of Foot $1,000
Employee + Spouse $9.14 Ankle $1,000
Employee + $11.30 Wrist $800
Child(ren) Elbow $600
Family $14.98 Shoulder $400
* Employees residing in the state of Hand $400
Washington are not eligible for this Collarbone $400
coverage Lower Jaw $400
Finger or Toe $100
Example Open Reduction (requires 2 × non-surgical benefit (above)
Broken Ankle $ Paid to surgery)
You Follow-Up Care
Emergency Room $200 Follow-Up Physician Office Visit $100 (10 × per accident)
X-Ray $25 Follow-Up Physical Therapy $50 (10 × per accident)
Broken Ankle, Closed $800 Additional Benefits
Reduction (no Burns (small/large) $300/$900
surgery) Skin Grafts 50% of burn benefit
$100/$200
Lacerations (small/large)
Ankle Brace $150 General Anesthesia $200
Crutches $150 Abdominal or Thoracic Surgery $1,500
Physical Therapy (10 $500 Tendon, Ligament, Rotator $400/$200
sessions) Cuff, or Knee Surgery (repair/
Physician Follow-Up $100 exploratory)
Total Payable to $1,925 Ruptured Disc Surgery $750
Employee Eye Injury (surgery/removal of $400/$200
foreign object)
Emergency Dental (extraction/ $150/$75
broken tooth)
Concussion $150
Coma $10,000
Diagnostic Advanced $75
Appliance $150
Prosthesis $500
Paralysis (paraplegia/ $3,000/$6,000
quadriplegia)
Blood, Plasma, Platelets $200
Transportation $200
Family Lodging $75 per day
Wellness (payable once per year per covered person)
Each Covered Member $75
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Bi-Weekly Post Tax Accident Benefit Amount
Premium* Schedule of Dislocations
Hip Joint $2,000
Premium Knee Joint $1,000
Employee $5.46 Bones of Foot $1,000
Employee + Spouse $9.14 Ankle $1,000
Employee + $11.30 Wrist $800
Child(ren) Elbow $600
Family $14.98 Shoulder $400
* Employees residing in the state of Hand $400
Washington are not eligible for this Collarbone $400
coverage Lower Jaw $400
Finger or Toe $100
Example Open Reduction (requires 2 × non-surgical benefit (above)
Broken Ankle $ Paid to surgery)
You Follow-Up Care
Emergency Room $200 Follow-Up Physician Office Visit $100 (10 × per accident)
X-Ray $25 Follow-Up Physical Therapy $50 (10 × per accident)
Broken Ankle, Closed $800 Additional Benefits
Reduction (no Burns (small/large) $300/$900
surgery) Skin Grafts 50% of burn benefit
$100/$200
Lacerations (small/large)
Ankle Brace $150 General Anesthesia $200
Crutches $150 Abdominal or Thoracic Surgery $1,500
Physical Therapy (10 $500 Tendon, Ligament, Rotator $400/$200
sessions) Cuff, or Knee Surgery (repair/
Physician Follow-Up $100 exploratory)
Total Payable to $1,925 Ruptured Disc Surgery $750
Employee Eye Injury (surgery/removal of $400/$200
foreign object)
Emergency Dental (extraction/ $150/$75
broken tooth)
Concussion $150
Coma $10,000
Diagnostic Advanced $75
Appliance $150
Prosthesis $500
Paralysis (paraplegia/ $3,000/$6,000
quadriplegia)
Blood, Plasma, Platelets $200
Transportation $200
Family Lodging $75 per day
Wellness (payable once per year per covered person)
Each Covered Member $75
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