Page 31 - Looks Salon Colonial Benefits Brochure Book

Group Hospital Confinement Indemnity Insurance
Hospit
inement Indemnity Insur
ance
al Conf
Plan 3 (2 Options)
Plan 2 — Optional Benefits

Our Individual Medical Bridge insurance can help with medical costs that your
SM
health insurance may not cover. These benefits are available for you, your spouse
and eligible dependent children.

Option 1 / Option 2
Hospital confinement ..................................................................... $1500 / $2,500
_____________ __
Maximum of one benefit per covered person per calendar year
Observation room .................................................................................. $100 per visit
Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement .................................................................$100 per day
Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium
Available after 30 continuous days of a covered hospital confinement of the named insured
Health screening ........................................................................... $__________________
100*
Maximum of one health screening test per covered person per calendar year *

„ Blood test for triglycerides „ Flexible sigmoidoscopy
„ Bone marrow testing „ Hemoccult stool analysis
„ Breast ultrasound „ Mammography
„ CA 15-3 (blood test for breast cancer) „ Pap smear
„ CA 125 (blood test for ovarian cancer) „ PSA (blood test for prostate cancer)
„ Carotid Doppler „ Serum cholesterol test for HDL and LDL levels
„ CEA (blood test for colon cancer) „ Serum protein electrophoresis (blood test for myeloma)
„ Chest X-ray „ Skin cancer biopsy
„ Colonoscopy „ Stress test on a bicycle or treadmill
„ Echocardiogram (ECHO) „ Thermography
„ Electrocardiogram (EKG, ECG) „ ThinPrep pap test
„ Fasting blood glucose test „ Virtual colonoscopy

Second medical opinion .................................................................. $50 per confinement
Maximum of one benefit per covered person per confinement
Diagnostic procedure
„ Tier 1................................................................................................................ $250
„ Tier 2................................................................................................................ $500
ColonialLife.com Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined
Outpatient surgical procedure Option 1 / Option 2
„ Tier 1................................................................................................ $_______________
750 / $1,500
„ Tier 2................................................................................................. $_______________
1,500 / $3,000
Maximum of per covered person per calendar year for all
$2,500 (Option 1) / $4,500 (Option 2)
covered outpatient surgical procedures combined

IMB7000 – PLAN 3