Page 17 - Dentons 2021 Benefits Guide Hawaii
P. 17
2021
Dentons Benefits Guide
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 $1,500
an accident, such as copays, coinsurance, and in Addition to Hospital
other medical expenses. You may elect the Admission Benefit)
following Group Accident Insurance for yourself Hospital Daily Benefit $200 up to 365 days
$400, up to 15 days
ICU Daily Benefit
or you and your dependents. Diagnostic Exams/Medical $200
Be Well—Wellness Credit Imaging $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/
Exploratory
Covered Injuries Benefit Amount Hernia Repair $150
Fractures Physician Follow-Up $150
Open Reduction— $150 to $7,500
Dependent on Location Chiropractor $25
of Injury Therapy Occupational/ $25 (up to 10 per
Closed Reduction— $75 to $3,750 Speech/Physical accident)
Dependent on Location Prosthetic Device or Artificial $750/$1,500
of Injury Limb (1/2+)
25% of the closed Appliance Benefit $100
Chip Fracture Blood/Plasma/Platelets $400
benefit amount
Schedule of Dislocations Travel Due to Accident (50+ $0.40 per mile
Open Reduction— $300 to $6,000 Miles from Residence, 3 Trips
Dependent on Location Per Accident, 1,200 Miles
of Injury Maximum)
Closed Reduction— $150 to $3,000 Lodging (Per Night) $150
Dependent on Location Rehabilitation Unit Daily $100, up to 15 days
of Injury Benefit per term, 30 days
Burns and Skin Grafts up to $10,000 per year
Burns up to $10,000 Accidental Death and Other Covered Losses
Skin Grafts 50% of burn benefit Employee $50,000
Skin Grafts for Any Other up to $500 Spouse $20,000
Accidental Traumatic Each Child $10,000
Loss of Skin Accidental Dismemberment— Up to $15,000
Concussion $150 One Benefit Per Accident, Not
Coma $10,000 Payable with Initial Accidental
Ruptured Disc (with Surgical $800 Loss
Repair) Paralysis (Paraplegia/ $15,000
Knee Cartilage (Torn/ $750/$150 Quadriplegia)
Exploratory)
Lacerations up to $600 Monthly Group Accident Rates
Tendon/Ligament/ $800/$1,200/$150
Rotator Cuff Repair (1/2+/ Monthly Premium
Exploratory) Employee $13.15
Emergency Dental Work $100/$300 Employee + Spouse $21.88
(Extraction/Crown) Employee + Child(ren) $25.65
Eye Injury $300 Family $34.38
Emergency and Hospitalization Benefits Coverage begins on the enrolled date.
Ambulance (Ground) $400
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. 17
Dentons Benefits Guide
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 $1,500
an accident, such as copays, coinsurance, and in Addition to Hospital
other medical expenses. You may elect the Admission Benefit)
following Group Accident Insurance for yourself Hospital Daily Benefit $200 up to 365 days
$400, up to 15 days
ICU Daily Benefit
or you and your dependents. Diagnostic Exams/Medical $200
Be Well—Wellness Credit Imaging $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/
Exploratory
Covered Injuries Benefit Amount Hernia Repair $150
Fractures Physician Follow-Up $150
Open Reduction— $150 to $7,500
Dependent on Location Chiropractor $25
of Injury Therapy Occupational/ $25 (up to 10 per
Closed Reduction— $75 to $3,750 Speech/Physical accident)
Dependent on Location Prosthetic Device or Artificial $750/$1,500
of Injury Limb (1/2+)
25% of the closed Appliance Benefit $100
Chip Fracture Blood/Plasma/Platelets $400
benefit amount
Schedule of Dislocations Travel Due to Accident (50+ $0.40 per mile
Open Reduction— $300 to $6,000 Miles from Residence, 3 Trips
Dependent on Location Per Accident, 1,200 Miles
of Injury Maximum)
Closed Reduction— $150 to $3,000 Lodging (Per Night) $150
Dependent on Location Rehabilitation Unit Daily $100, up to 15 days
of Injury Benefit per term, 30 days
Burns and Skin Grafts up to $10,000 per year
Burns up to $10,000 Accidental Death and Other Covered Losses
Skin Grafts 50% of burn benefit Employee $50,000
Skin Grafts for Any Other up to $500 Spouse $20,000
Accidental Traumatic Each Child $10,000
Loss of Skin Accidental Dismemberment— Up to $15,000
Concussion $150 One Benefit Per Accident, Not
Coma $10,000 Payable with Initial Accidental
Ruptured Disc (with Surgical $800 Loss
Repair) Paralysis (Paraplegia/ $15,000
Knee Cartilage (Torn/ $750/$150 Quadriplegia)
Exploratory)
Lacerations up to $600 Monthly Group Accident Rates
Tendon/Ligament/ $800/$1,200/$150
Rotator Cuff Repair (1/2+/ Monthly Premium
Exploratory) Employee $13.15
Emergency Dental Work $100/$300 Employee + Spouse $21.88
(Extraction/Crown) Employee + Child(ren) $25.65
Eye Injury $300 Family $34.38
Emergency and Hospitalization Benefits Coverage begins on the enrolled date.
Ambulance (Ground) $400
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. 17
