Page 159 - Aflac Flipbook 2023

American Family Life Assurance Company of Columbus (herein referred to as Aflac)
V ISION

INSUR A NCE

COV ER AGE

POLICY SERIES VSN100

Worldwide Headquarters • 1932 Wynnton Road • Columbus, Georgia 31999
Toll-Free 1.800.99.AFLAC (1.800.992.3522)
I. Read the Policy Carefully. This document provides a very brief Option 3 VISION CORRECTION BENEFIT: After a 24-month
description of the important features of the policy. This is not the waiting period, Aflac will pay $270 when a charge is incurred for
insurance contract and only the actual policy provisions will control. prescribed Vision Correction Materials or $480 when a charge
The policy itself sets forth, in detail, the rights and obligations of is incurred for Refractive Error Correction Surgery for a covered
both you and Aflac. It is, therefore, important that you READ THE person. This benefit is payable once per covered person during each
POLICY CAREFULLY. successive 36-month period following the end of the waiting period,
and applies only for charges incurred during that period. NOTE:
II. Benefits. Subject to the waiting period, listed in the Benefit section
(Part 5) of the policy, for the Vision Correction Benefit and the If a covered person receives a benefit for Vision Correction
provisions in the Limitations and Exclusions section, we will pay Materials and later receives Refractive Error Correction
the following benefits when a charge is incurred for covered vision Surgery during the same 36-month period, we will pay $210 for
treatment that occurs while coverage is in force. See the policy for Refractive Error Correction Surgery.
the specific waiting period for the Vision Correction Benefit. C. SPECIFIC EYE DISEASES/DISORDERS BENEFIT: Aflac will pay
A. EYE EXAMINATION BENEFIT: Aflac will pay $45 when a charge is $1,000 when a covered person is first diagnosed after the Effective
incurred for an eye examination for a covered person. This benefit Date as having any of the eye diseases or disorders listed below.
is limited to one examination per covered person, per Policy Year. The eye disease or disorder must be diagnosed by an
The eye examination must be performed by an Optometrist or Ophthalmologist or a Physician.
Ophthalmologist. No lifetime maximum. Glaucoma (excluding preglaucoma and/or borderline glaucoma)
While the policy is in force, the following benefits will be paid, Proliferative diabetic retinopathy Retinal detachment
subject to Part 2, Limitations and Exclusions of the policy, Retinitis pigmentosa Macular degeneration
and all other policy provisions. Please see section (III) of this
document. This benefit is payable only once per covered disease or disorder,
per covered person, and will be paid in addition to any other benefit
B. VISION CORRECTION BENEFIT: The option you have chosen in the policy.
on your application is indicated below by a check mark in
the appropriate option box. PLEASE NOTE: Only one Vision D. EYE SURGERY BENEFIT: When a surgical operation is performed
Correction Benefit option can be in effect at any given time. on a covered person for a diagnosed eye disease or disorder, Aflac
will pay the indemnity amount listed in the Schedule of Operations
Option 1 VISION CORRECTION BENEFIT: Aflac will pay $80 in the policy for the specific procedure when a charge is incurred.
when a charge is incurred for prescribed Vision Correction Materials Surgeries must be performed by an Ophthalmologist or a Physician.
or $130 when a charge is incurred for Refractive Error Correction
Surgery for a covered person. This benefit is payable once per If any operation for a diagnosed eye disease or disorder is performed
covered person, per Policy Year. NOTE: If a covered person other than those listed, Aflac will pay an amount comparable to the
receives a benefit for Vision Correction Materials and later amount shown in the Schedule of Operations for the operation most
receives Refractive Error Correction Surgery in the same Policy nearly similar in severity and gravity.
Year, we will pay $50 for Refractive Error Correction Surgery. NOTE: Surgical benefits for Refractive Error Correction Surgery
Option 2 VISION CORRECTION BENEFIT: After a 12-month are payable only under the Vision Correction Benefit.
waiting period, Aflac will pay $175 when a charge is incurred for Surgical benefits are limited to surgeries of the eye, eye socket,
prescribed Vision Correction Materials or $295 when a charge eyelid, and tear ducts. Only one benefit is payable per 24-hour
is incurred for Refractive Error Correction Surgery for a covered period for surgery even though more than one surgical procedure
person. This benefit is payable once per covered person during each may be performed. We will pay the highest eligible benefit. No
successive 24-month period following the end of the waiting period, lifetime maximum.
and applies only for charges incurred during that period. NOTE:
If a covered person receives a benefit for Vision Correction
Materials and later receives Refractive Error Correction
Surgery during the same 24-month period, we will pay $120 for
Refractive Error Correction Surgery.

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