Benefit Conditions and Limitations: This document provides only the highlights. All claims for a covered loss must meet specific Benefit Conditions and Limitations and are otherwise subject to all other terms set forth in the group policy. Common Exclusions:* In addition to any benefit specific exclusions, no payments will be made for losses which directly or indirectly, is caused by or results from: • intentionally self-inflicted injury, including suicide or any attempted suicide; • committing an assault or felony; • bungee jumping; parachuting; skydiving; parasailing; hang-gliding; • declared or undeclared war or act of war; • aircraft or air travel, except as a commercial passenger or Aircraft used by the Air Mobility Command (unless owned, leased or controlled by Subscriber); • sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment, except bacterial infection from an accidental external cut or wound or accidental ingestion of contaminated food; • activities of active military duty, except Reserve or National Guard active duty training lasting 31 days or less; • operating any vehicle under the influence of alcohol or any drug, narcotic or other intoxicant; • voluntary use of drugs, unless taken as prescribed and under direction of a physician; • services or treatment rendered by a physician, nurse or any other person who is: employed by the subscriber, living with or immediate family of the Covered Person, or providing alternative medical treatments. Actual policy terms may vary depending on your plan design and location. Specific Benefit Exclusions and Limitations:* Emergency Care Treatment: Treatment must occur within 30 days of the Covered Accident. Limits: payable once per Covered Accident, per Covered Person. Excludes: treatment provided by an immediate family member, clinic, or doctor’s office. Physician Office Visit: Must be diagnosed and treated by a physician within 120 days of the Covered Accident. Limits: payable once per Covered Accident, per Covered Person; not payable if a Covered Person is eligible to receive a benefit under Emergency Treatment. Excludes: routine health examinations or immunizations for Covered Persons Age 60 and older, and visits for mental or nervous disorders. Diagnostic Exam: payable once per Covered Accident, per Covered Person. Treatment must occur within 120 days of the Covered Accident. Ground or Water Ambulance/Air Ambulance: Services must be provided from the scene of the Covered Accident or within 120 days of Covered Accident. Limits: payable once per Covered Accident, per Covered Person; only one benefit will be paid ground or water/air, whichever is greater. Hospital Admission: Inpatient admission must occur within 90 days of the Covered Accident due to such accident. Limits: payable once per Covered Accident. Excludes: treatment in an emergency room, provided on an outpatient basis, or for re-admission for the same Covered Accident. Hospital Stay per day: Must be admitted for at least 23 hours or admitted inpatient and confined within 90 days of the Covered Accident. Limits: 365 days per Covered Accident; 1 stay per accident; not payable for hospital re-admission for same Covered Accident; This benefit will pay in addition to the ICU Stay Benefit. Stays within 90 days for the same or a related Covered Accident are considered one Stay. Intensive Care Unit (ICU) Admission Benefit: Must be admitted as an Inpatient and confined in an ICU of a Hospital, within 90 days due to a Covered Accident. The ICU Admission will be payable on Day 1 and is limited to 10 admissions within a 12 month period during the life of the Policy. Excludes: treatment in an emergency room, provided on an outpatient basis, or for ICU re-admission for the same Covered Accident. Intensive Care Unit Stay per day: Must be admitted for at least 23 hours or admitted inpatient and confined within 90 days of the Covered Accident. Limits: 365 days per Covered Accident. Not payable for hospital re-admission for same Covered Accident; This benefit will pay in addition to the Hospital Stay Benefit. Stays within 90 days for the same or a related Covered Accident are considered one Stay. Fracture/Dislocation: If more than one fracture, only one benefit will be paid, whichever is the greater amount. Chip fracture not paid in addition to closed fracture. Limits: Both fractures and dislocations are limited to 1 per accident. Must be diagnosed and treated by a physician within 120 days of the Covered Accident. Follow-up Physician Office Visit: Limits: 10 follow up visit(s) for each Covered Person, per Covered Accident for follow up physician office visits. Must be examined, treated or prescribed by physician. First examination or treatment must be provided within 120 days of the Covered Accident. Subsequent follow up treatment must be completed within 365 days of the Covered Accident. Follow Up Office Visit can include treatment by providers that are appropriately licensed professionals practicing chiropractic care, speech therapy, occupational therapy, vocational therapy, respiratory therapy, and mental health treatment associated with traumatic Covered Accidents. Follow-up Physical Therapy Visit: Limits: 10 follow up visit(s) for each Covered Person, per Covered Accident for follow up physical therapy visits. Must be examined, treated or prescribed by physician. First examination or treatment must be provided within 180 days of the Covered Accident. Subsequent follow up treatment must be completed within 365 days of the Covered Accident. Large Lacerations: Treatment by Physician must be received within 90 days of the Covered Accident. Limits: payable 1 time per Covered Person, Per Covered Accident; Multiple lacerations pay a maximum of 2 times the benefit. Concussion: Must be diagnosed by a physician within 90 days of the Covered Accident. Limits: payable 1 time per Covered Accident. Coma: Limits: payable 1 time per Covered Accident. Must be unconscious for 7 days or more with no response to external stimuli and requiring artificial respiratory or life support. Excludes: medically induced coma. Wellness Treatment, Health Screening Test and Preventive Care Benefit: Limit: 1 per year per Covered Person. Sports Accident Benefit: This coverage is payable if a Covered Person sustains a Covered Injury resulting directly and independently of all other causes from a covered Organized Sports Activity or covered Personal Sports Activity. Organized Sports Activity: A scholastic or amateur athletic competition or supervised organized practice for competition that takes place on a regularly occurring and scheduled basis. The competition must be overseen by a legal entity, including but not limited to, a public and private school system, sports conference, municipality, or religious or charitable organization and requires formal registration to participate. The term Organized Sports Activity does not include: play such as pick-up games and spontaneous play; coaching or officiating for pay; personal or trained workouts; participation in any sport or sporting activity for wage, compensation or profit; and racing any type of vehicle in an organized event. Personal Sports Activity: Any sport or physical activity with the goal to improve physical fitness and wellness, not meant for competition. Personal Sports Activity does not include: coaching or officiating for pay, participation in any sport or sporting activity for wage, compensation or profit; and racing any type of vehicle in an organized event. *State Variations For purposes of this brochure, wherever the term Spouse appears, it shall also include Domestic Partner registered under any state which legally recognizes Domestic Partnerships or Civil Unions. Additional information is available from your Benefit Services Representative. Specific Benefit Exclusions and Limitations: The timeframe to obtain services following a covered
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