Page 18 - AONNH19
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Voluntary Accident Insurance
Accidental injury coverage provides a Benefit Amount
beneit according to the schedule below Initial and Emergency Care
when a covered person suffers covered Ground Ambulance/Air Ambulance $400/$1,200
injuries or undergoes a broad range of Emergency Care Treatment $400
medical treatments or care resulting from Diagnostic Exam (x-ray or lab) $50
a covered accident. Physician Office Visit $200
Hospitalization Benefits
Who Can Elect Coverage Hospital Admission $2,000
All active, full-time employees of the Hospital Stay (per day) $400
employer who are United States citizens Intensive Care Unit Stay (per day) $800
or permanent resident aliens regularly Fractures and Dislocations
working a minimum of 20 hours per Per Covered Surgically-Repaired Fracture $300-$10,000
week in the United States. Per Covered Non-Surgically-Repaired Fracture $150-$5,000
Chip Fracture (percent of fracture benefit) 25%
You will be eligible for coverage after 60 Per Covered Surgically-Repaired Dislocation $300-$6,000
days of active service. Per Covered Non-Surgically-Repaired Dislocation $150-$3,000
X Your spouse/domestic partner: Follow-Up Care
Up to age 70, as long as you apply Follow-Up Visit To The Doctor $200
for and are approved for coverage Follow-Up Physical Therapy Visits $75
yourself. Enhanced Accident Benefits
X Your child(ren): Birth to 26; 26+ if Examples
disabled, as long as you apply for and Small Lacerations (less than or equal to 6 inches $150
long and requires 2 or more sutures)
are approved for coverage yourself. Large Lacerations (more than 6 inches long and $800
requires 2 or more sutures)
This accidental injury plan provides 24 Coma (lasting 7 days with no response) $40,000
hour coverage. The beneit amounts Concussion $200
shown in this summary will be paid Plus up to 22 additional benefits . See certificate for details, including
regardless of the actual expenses limitations and exclusions .
incurred. Beneits are only payable
when all policy terms and conditions Wellness, Health Screening Test, Benefit
are met. Please read all the information or Preventive Care Benefit Amount
in this summary to understand terms, Examples include (but are not limited to) routine $100 per
gynecological exams, general health exams,
year
conditions, state variations, exclusions mammography, and certain blood tests . A 30-day
and limitations applicable to these benefit waiting period applies during which benefits
will not be paid .
beneits. See your certiicate of insurance
for more information.
18 2019 Benefits Enrollment
Accidental injury coverage provides a Benefit Amount
beneit according to the schedule below Initial and Emergency Care
when a covered person suffers covered Ground Ambulance/Air Ambulance $400/$1,200
injuries or undergoes a broad range of Emergency Care Treatment $400
medical treatments or care resulting from Diagnostic Exam (x-ray or lab) $50
a covered accident. Physician Office Visit $200
Hospitalization Benefits
Who Can Elect Coverage Hospital Admission $2,000
All active, full-time employees of the Hospital Stay (per day) $400
employer who are United States citizens Intensive Care Unit Stay (per day) $800
or permanent resident aliens regularly Fractures and Dislocations
working a minimum of 20 hours per Per Covered Surgically-Repaired Fracture $300-$10,000
week in the United States. Per Covered Non-Surgically-Repaired Fracture $150-$5,000
Chip Fracture (percent of fracture benefit) 25%
You will be eligible for coverage after 60 Per Covered Surgically-Repaired Dislocation $300-$6,000
days of active service. Per Covered Non-Surgically-Repaired Dislocation $150-$3,000
X Your spouse/domestic partner: Follow-Up Care
Up to age 70, as long as you apply Follow-Up Visit To The Doctor $200
for and are approved for coverage Follow-Up Physical Therapy Visits $75
yourself. Enhanced Accident Benefits
X Your child(ren): Birth to 26; 26+ if Examples
disabled, as long as you apply for and Small Lacerations (less than or equal to 6 inches $150
long and requires 2 or more sutures)
are approved for coverage yourself. Large Lacerations (more than 6 inches long and $800
requires 2 or more sutures)
This accidental injury plan provides 24 Coma (lasting 7 days with no response) $40,000
hour coverage. The beneit amounts Concussion $200
shown in this summary will be paid Plus up to 22 additional benefits . See certificate for details, including
regardless of the actual expenses limitations and exclusions .
incurred. Beneits are only payable
when all policy terms and conditions Wellness, Health Screening Test, Benefit
are met. Please read all the information or Preventive Care Benefit Amount
in this summary to understand terms, Examples include (but are not limited to) routine $100 per
gynecological exams, general health exams,
year
conditions, state variations, exclusions mammography, and certain blood tests . A 30-day
and limitations applicable to these benefit waiting period applies during which benefits
will not be paid .
beneits. See your certiicate of insurance
for more information.
18 2019 Benefits Enrollment
