Page 15 - 2016 Enrollment
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Zydus Pharmaceuticals (USA) Inc.
Voluntary Accident Benefit Summary
Emergency, Hospital and Treatment Care Package
Detail (Per covered person) Option 1 Option 2
Treatment/Service
Ambulance—air Once/accident within 72 hours $600 $1,200
Ambulance—ground Once/accident within 90 days $200 $400
Chiropractic care Up to 10 visits/accident within 365 $25 $50
days
Daily hospital coninement Up to 365 days/lifetime (total daily $100 $300
and ICU)
Daily ICU coninement Up to 30 days/accident (subject to $300 $600
365 days/lifetime)
Diagnostic exam Once/accident within 90 days $100 $300
Emergency room Once /accident within 72 hours $100 $200
Hospital admission Once/accident within 90 days $500 $1,500
Initial physician ofice visit Once/accident within 90 days $50 $100
Lodging Up to 30 days/lifetime $100 $150
Medical appliance Once/accident within 90 days $50 $150
Physical therapy Up to 10 visits/accident within 90 $25 $50
days
Rehabilitation facility Up to 15 days/lifetime within 90 $50 $150
days
Transportation Up to 3 trips/accident $200 $500
Urgent care Once /accident within 72 hours $50 $100
X-ray Once/accident within 90 days $50 $75
Injury/Treatment/Service
Accidental death—employee Within 90 days $20,000 $50,000
Accidental death—spouse 50% of employee beneit
Accidental death—child(ren) 25% of employee beneit
Common carrier death Within 90 days 3 times death beneit
Coma (≥168 continuous hours) Once/accident within 90 days $5,000 $15,000
Paralysis—quadriplegia Highest beneit once/accident $5,000 $15,000
Paralysis—paraplegia within 90 days $2,500 $7,500
Prosthesis—single Highest beneit once/accident $500 $1,000
Prosthesis—two or more within 365 days $1,000 $2,000
Injury
Ankle, foot bones (except toes) Once/joint/lifetime (open or closed) $500 $2,000
Collarbone—acromio/separation $250 $1,000
Collarbone—sternoclavicular $500 $2,000
Elbow $500 $1,500
Finger, toe $100 $400
Hip $2,000 $8,000
Knee $1,000 $3,200
Lower jaw $500 $1,500
Shoulder (glenohumeral ) $500 $1,500
Wrist, hand bones (except ingers) $500 $1,500
Closed (non-surgical) 50% of open beneit
Incomplete/without anesthesia 25% of closed beneit
Multiple dislocations/fractures ≤ 200% of highest beneit
* This is not a complete beneit listing. Please see HR for more detail beneit summaries.
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Voluntary Accident Benefit Summary
Emergency, Hospital and Treatment Care Package
Detail (Per covered person) Option 1 Option 2
Treatment/Service
Ambulance—air Once/accident within 72 hours $600 $1,200
Ambulance—ground Once/accident within 90 days $200 $400
Chiropractic care Up to 10 visits/accident within 365 $25 $50
days
Daily hospital coninement Up to 365 days/lifetime (total daily $100 $300
and ICU)
Daily ICU coninement Up to 30 days/accident (subject to $300 $600
365 days/lifetime)
Diagnostic exam Once/accident within 90 days $100 $300
Emergency room Once /accident within 72 hours $100 $200
Hospital admission Once/accident within 90 days $500 $1,500
Initial physician ofice visit Once/accident within 90 days $50 $100
Lodging Up to 30 days/lifetime $100 $150
Medical appliance Once/accident within 90 days $50 $150
Physical therapy Up to 10 visits/accident within 90 $25 $50
days
Rehabilitation facility Up to 15 days/lifetime within 90 $50 $150
days
Transportation Up to 3 trips/accident $200 $500
Urgent care Once /accident within 72 hours $50 $100
X-ray Once/accident within 90 days $50 $75
Injury/Treatment/Service
Accidental death—employee Within 90 days $20,000 $50,000
Accidental death—spouse 50% of employee beneit
Accidental death—child(ren) 25% of employee beneit
Common carrier death Within 90 days 3 times death beneit
Coma (≥168 continuous hours) Once/accident within 90 days $5,000 $15,000
Paralysis—quadriplegia Highest beneit once/accident $5,000 $15,000
Paralysis—paraplegia within 90 days $2,500 $7,500
Prosthesis—single Highest beneit once/accident $500 $1,000
Prosthesis—two or more within 365 days $1,000 $2,000
Injury
Ankle, foot bones (except toes) Once/joint/lifetime (open or closed) $500 $2,000
Collarbone—acromio/separation $250 $1,000
Collarbone—sternoclavicular $500 $2,000
Elbow $500 $1,500
Finger, toe $100 $400
Hip $2,000 $8,000
Knee $1,000 $3,200
Lower jaw $500 $1,500
Shoulder (glenohumeral ) $500 $1,500
Wrist, hand bones (except ingers) $500 $1,500
Closed (non-surgical) 50% of open beneit
Incomplete/without anesthesia 25% of closed beneit
Multiple dislocations/fractures ≤ 200% of highest beneit
* This is not a complete beneit listing. Please see HR for more detail beneit summaries.
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