Page 23 - 2018 Franke Enrollment
P. 23
Franke
Beneit Amount Bi-Weekly Accident 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 + Child(ren) $11.30
Wrist $800 Family $14.98
Elbow $600 * Employees residing in the state of
Shoulder $400 Washington are not eligible for this
Hand $400 coverage
Collarbone $400
Lower Jaw $400 Example
Finger or Toe $100 $ Paid to
Open Reduction (requires surgery) 2 × non-surgical beneit (above) Broken Ankle You
Follow-Up Care Emergency Room $200
Follow-Up Physician Ofice Visit $100 (10 × per accident)
Follow-Up Physical Therapy $50 (10 × per accident) X-Ray $25
Additional Beneits Broken Ankle, Closed $800
Burns (small/large) $300/$900 Reduction (no surgery)
Skin Grafts 50% of burn beneit Ankle Brace $150
Lacerations (small/large) $100/$200 Crutches $150
General Anesthesia $200 Physical Therapy (10 $500
Abdominal or Thoracic Surgery $1,500 sessions)
Tendon, Ligament, Rotator Cuff, or $400/$200 Physician Follow-Up $100
Knee Surgery (repair/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/quadriplegia) $3,000/$6,000
Blood, Plasma, Platelets $200
Transportation $200
Family Lodging $75 per day
Wellness (payable once per year per covered person)
Each Covered Member $75
23
Beneit Amount Bi-Weekly Accident 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 + Child(ren) $11.30
Wrist $800 Family $14.98
Elbow $600 * Employees residing in the state of
Shoulder $400 Washington are not eligible for this
Hand $400 coverage
Collarbone $400
Lower Jaw $400 Example
Finger or Toe $100 $ Paid to
Open Reduction (requires surgery) 2 × non-surgical beneit (above) Broken Ankle You
Follow-Up Care Emergency Room $200
Follow-Up Physician Ofice Visit $100 (10 × per accident)
Follow-Up Physical Therapy $50 (10 × per accident) X-Ray $25
Additional Beneits Broken Ankle, Closed $800
Burns (small/large) $300/$900 Reduction (no surgery)
Skin Grafts 50% of burn beneit Ankle Brace $150
Lacerations (small/large) $100/$200 Crutches $150
General Anesthesia $200 Physical Therapy (10 $500
Abdominal or Thoracic Surgery $1,500 sessions)
Tendon, Ligament, Rotator Cuff, or $400/$200 Physician Follow-Up $100
Knee Surgery (repair/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/quadriplegia) $3,000/$6,000
Blood, Plasma, Platelets $200
Transportation $200
Family Lodging $75 per day
Wellness (payable once per year per covered person)
Each Covered Member $75
23
