HI2
G
group Hospital indemnity
Supplemental Hospital Indemnity Policy Series CA8500-MP This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions.
PLAN BENEFITS
PLAN 2
$200
Hospital confinement per day (up to 180 days per confinement) This benefit is paid when a Covered Person is confined to a hospital as a resident bed patient because of a Covered Sickness or as the result of Injuries received in a Covered Accident. To receive this benefit for Injuries received in a Covered Accident, the Covered Person must be confined to a hospital within six months of the date of the Covered Accident. Hospital admission per admission The benefit is paid when a Covered Person is admitted to a hospital and confined as a resident bed patient because of Injuries received in a Covered Accident or because of a Covered Sickness. In order to receive this benefit for Injuries received in a Covered Accident, the Covered Person must be admitted to a hospital within six months of the date of the Covered Accident. Hospital intensive care per day This benefit is paid when a Covered Person is confined in a hospital intensive care unit because of a Covered Sickness or due to an Injury received from a Covered Accident. To receive this benefit for Injuries received in a Covered Accident, the Covered Person must be admitted to a hospital intensive care unit within six months of the date of the Covered Accident. surgical benefit up to the amount shown If an insured has surgery performed by a physician due to an Injury received in a Covered Accident or because of a Covered Sickness, we will pay the appropriate surgical benefit amount shown in the Schedule of Opera- tions. The surgical benefit paid will never exceed the maximum surgical benefit designated in the plan. The surgery can be performed in a hospital (on an inpatient or outpatient basis), in an ambulatory surgical center, or in a Physician’s office. anestHesia benefit up to the amount shown When an insured receives benefits for a surgical procedure covered under the Surgical Benefit, we will pay the appropriate benefit amount shown in the Schedule of Operations for anesthesia administered by a Physi- cian. However, the anesthesia benefit paid will not exceed 25 percent of the amount paid under the Surgical Benefit. Hospital emergency room/pHysician benefit (medical fees) maximum per visit If an insured is injured in a Covered Accident or has treatment as the result of a Covered Sickness, we will pay the following benefit: physician (per visit) – $50 laboratory fees (per visit) – $25 X-ray (per visit) – $50
$300
$200
$2,000
$500
$50
injections/medications (per visit) – $25 maximum $250/insured per calendar year maximum $1,000/family per calendar year maximum $50/per visit
$25
Well baby care benefit per visit We will pay the Well Baby Care Benefit amount associated with each benefit plan option when an insured baby receives well baby care (four visits per calendar year per insured baby). For this plan, a baby is a Dependent Child 12 months of age or younger. This benefit is payable only if coverage is issued with the Dependent Children Rider. out-of-Hospital prescription drug benefit five-prescription maximum per year We will pay an indemnity benefit, based on the plan definitions, for each prescription filled for a Covered Person. Prescription drugs must meet three criteria: (1) be ordered by a Doctor; (2) be dispensed by a li- censed pharmacist; and (3) be medically necessary for the care and treatment of the patient. This benefit is subject to the Out-of-Hospital Prescription Drug Benefit Maximum.
$10
14 YATES LLC 2022 BENEFIT GUIDE
CAI85802 4/11
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