Page 20 - Dentons 2021 Benefits Guide Mainland
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Group Accident Covered Injuries Benefit Amount
$150
The Group Accident insurance plan helps offset Urgent Care $1,000
Hospital Admission Benefit
your out-of-pocket expenses in the event of ICU Admission Benefit (Pays in $1,500
an accident, such as copays, coinsurance, and Addition to Hospital Admission
other medical expenses. You may elect the Benefit) $200 up to 365
Hospital Daily Benefit
following Group Accident Insurance for yourself days
or you and your dependents. ICU Daily Benefit $400, up to 15
days
Be Well—Wellness Credit Diagnostic Exams/Medical Imaging $200
$300
Outpatient Surgery Facility
Each family member who has Accident Services
coverage can receive a $50 wellness credit for Pain Management (Epidural) $100
getting a health screening test. Treatment and other Services $1,500/$150
Open Abdominal Surgery/
Covered Injuries Benefit Amount Exploratory
Fractures Hernia Repair $150
Open Reduction—Dependent $150 to $7,500 Physician Follow-Up $150
on Location of Injury Chiropractor $25
Closed Reduction— $75 to $3,750 Therapy Occupational/Speech/ $25 (up to 10
Dependent on Location of Physical per accident)
Injury Prosthetic Device or Artificial Limb $750/$1,500
Chip Fracture 25% of the (1/2+)
closed benefit Appliance Benefit $100
amount Blood/Plasma/Platelets $400
Schedule of Dislocations Travel Due to Accident (50+ $0.40 per mile
Open Reduction—Dependent $300 to $6,000 Miles from Residence, 3 Trips Per
on Location of Injury Accident, 1,200 Miles Maximum)
Closed Reduction— $150 to $3,000 Lodging (Per Night) $150
Dependent on Location of Rehabilitation Unit Daily Benefit $100, up to 15
Injury days per term,
Burns and Skin Grafts up to $10,000 30 days per
Burns up to $10,000 year
Skin Grafts 50% of burn Accidental Death and Other Covered Losses
benefit Employee $50,000
Skin Grafts for Any Other up to $500 Spouse $20,000
Accidental Traumatic Loss of Each Child $10,000
Skin Accidental Dismemberment—One Up to $15,000
Concussion $150 Benefit Per Accident, Not Payable
Coma $10,000 with Initial Accidental Loss
Ruptured Disc (with Surgical $800 Paralysis (Paraplegia/Quadriplegia) $15,000
Repair)
Knee Cartilage (Torn/Exploratory) $750/$150 Monthly Group Accident Rates
Lacerations Up to $600
Tendon/Ligament/Rotator Cuff $800/$1,200/ Monthly Premium
Repair (1/2+/Exploratory) $150 Employee $13.15
Emergency Dental Work $100/$300 Employee + Spouse $21.88
(Extraction/Crown) Employee + Child(ren) $25.65
Eye Injury $300
Emergency and Hospitalization Benefits Family $34.38
Ambulance (Ground) $400 Coverage begins on the enrolled date.
Ambulance (Air) $1,500 See additional Unum benefit information on the Dentons
Emergency Room $150 Portal.
Primary Care Physician or $150 Please refer to the policy for complete definitions of
Specialist covered conditions, exclusions and limitations.
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$150
The Group Accident insurance plan helps offset Urgent Care $1,000
Hospital Admission Benefit
your out-of-pocket expenses in the event of ICU Admission Benefit (Pays in $1,500
an accident, such as copays, coinsurance, and Addition to Hospital Admission
other medical expenses. You may elect the Benefit) $200 up to 365
Hospital Daily Benefit
following Group Accident Insurance for yourself days
or you and your dependents. ICU Daily Benefit $400, up to 15
days
Be Well—Wellness Credit Diagnostic Exams/Medical Imaging $200
$300
Outpatient Surgery Facility
Each family member who has Accident Services
coverage can receive a $50 wellness credit for Pain Management (Epidural) $100
getting a health screening test. Treatment and other Services $1,500/$150
Open Abdominal Surgery/
Covered Injuries Benefit Amount Exploratory
Fractures Hernia Repair $150
Open Reduction—Dependent $150 to $7,500 Physician Follow-Up $150
on Location of Injury Chiropractor $25
Closed Reduction— $75 to $3,750 Therapy Occupational/Speech/ $25 (up to 10
Dependent on Location of Physical per accident)
Injury Prosthetic Device or Artificial Limb $750/$1,500
Chip Fracture 25% of the (1/2+)
closed benefit Appliance Benefit $100
amount Blood/Plasma/Platelets $400
Schedule of Dislocations Travel Due to Accident (50+ $0.40 per mile
Open Reduction—Dependent $300 to $6,000 Miles from Residence, 3 Trips Per
on Location of Injury Accident, 1,200 Miles Maximum)
Closed Reduction— $150 to $3,000 Lodging (Per Night) $150
Dependent on Location of Rehabilitation Unit Daily Benefit $100, up to 15
Injury days per term,
Burns and Skin Grafts up to $10,000 30 days per
Burns up to $10,000 year
Skin Grafts 50% of burn Accidental Death and Other Covered Losses
benefit Employee $50,000
Skin Grafts for Any Other up to $500 Spouse $20,000
Accidental Traumatic Loss of Each Child $10,000
Skin Accidental Dismemberment—One Up to $15,000
Concussion $150 Benefit Per Accident, Not Payable
Coma $10,000 with Initial Accidental Loss
Ruptured Disc (with Surgical $800 Paralysis (Paraplegia/Quadriplegia) $15,000
Repair)
Knee Cartilage (Torn/Exploratory) $750/$150 Monthly Group Accident Rates
Lacerations Up to $600
Tendon/Ligament/Rotator Cuff $800/$1,200/ Monthly Premium
Repair (1/2+/Exploratory) $150 Employee $13.15
Emergency Dental Work $100/$300 Employee + Spouse $21.88
(Extraction/Crown) Employee + Child(ren) $25.65
Eye Injury $300
Emergency and Hospitalization Benefits Family $34.38
Ambulance (Ground) $400 Coverage begins on the enrolled date.
Ambulance (Air) $1,500 See additional Unum benefit information on the Dentons
Emergency Room $150 Portal.
Primary Care Physician or $150 Please refer to the policy for complete definitions of
Specialist covered conditions, exclusions and limitations.
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