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P. 15
Electric Power Systems
Plan Details
Schedule of Dislocations
Hip $4,000
Knee (except patella) or ankle $1,600
joint, bone or bones of the foot
(except toes)
Wrist joint $1,400
Elbow joint $1,200
Shoulder joint $800
Bone or bones of the hand (except $600
ingers) or collarbone
Two or more ingers or toes $250
One inger or toe $120
Additional Beneits
Blood and plasma $600
Brain injury diagnosis $300
Burns <15% of body: $200
>15% of body: $1,000
Skin grafts 50% of burn beneit
Coma $20,000
Eye surgery $200
General anesthesia $200
Lacerations $100
Lodging $200 per day
Open abdominal or thoracic $2,000
surgery
Prosthesis One device: $1,000
Two or more devices: $2,000
Ruptured disc (with repair) $1,000
Tendon, ligament, or rotator cuff Injury: $300
Injury with repair: $1,000
Transportation Up to $800 per trip
Bi-Weekly Premium
Employee $5.78
Employee + Spouse $8.47
Employee + Child(ren) $11.66
Family $14.58
15
Plan Details
Schedule of Dislocations
Hip $4,000
Knee (except patella) or ankle $1,600
joint, bone or bones of the foot
(except toes)
Wrist joint $1,400
Elbow joint $1,200
Shoulder joint $800
Bone or bones of the hand (except $600
ingers) or collarbone
Two or more ingers or toes $250
One inger or toe $120
Additional Beneits
Blood and plasma $600
Brain injury diagnosis $300
Burns <15% of body: $200
>15% of body: $1,000
Skin grafts 50% of burn beneit
Coma $20,000
Eye surgery $200
General anesthesia $200
Lacerations $100
Lodging $200 per day
Open abdominal or thoracic $2,000
surgery
Prosthesis One device: $1,000
Two or more devices: $2,000
Ruptured disc (with repair) $1,000
Tendon, ligament, or rotator cuff Injury: $300
Injury with repair: $1,000
Transportation Up to $800 per trip
Bi-Weekly Premium
Employee $5.78
Employee + Spouse $8.47
Employee + Child(ren) $11.66
Family $14.58
15
