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 90 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, visits for mental or nervous disorders, and visits by a surgeon while confined to a Hospital. Diagnostic Exam: payable once per Covered Accident, per Covered Person; Treatment must occur within 90 days of the Covered Accident. Ground or Water Ambulance/Air Ambulance: Services must be provided from the scene of the Covered Accident or within 90 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; if eligible for Hospital Stay Benefit and Initial Intensive Care Unit Benefit, only 1 benefit will be paid for the same Covered Accident, whichever is greater; Stays within 90 days for the same or a related Covered Accident are considered one Stay. 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; if eligible for Hospital Stay Benefit and Initial Intensive Care Unit Benefit, only 1 benefit will be paid for the same Covered Accident, whichever is greater; 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 90 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 90 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 120 days of the Covered Accident. Subsequent follow up treatment must be completed within 365 days of the Covered Accident. Wellness Treatment, Health Screening Test and Preventive Care Benefit: Limit: 1 per year per Covered Person. 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 times per Covered Accident. Coma: Limits: payable 1 times 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. *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 accident is extended in NM, VT and WA, the exclusion for Physician Office Visit does not apply to residents of ID. For residents of TX Emergency Care exclusion is limited to treatment provided by an Immediate Family Member and does not apply to a licensed dentist. Hospital/ICU Stay requires a 31-day minimum for Idaho residents. See your Certificate for detail. For residents of NH Hospital/ICU stays within 180 days for the same or a related Covered Accident are considered one Stay. Common Exclusions may vary for residents of AK, ID, LA, MN, NC, NM, SC, SD, VT and WA. Wellness Treatment, Health Screening Test and Preventive Care Benefit is not available to residents of ID. For residents of WA it is titled Health Screening Test or Preventive Care. The coverage effective date will not be deferred for residents of TX if receiving chemotherapy or radiation treatment and deferring due to disability or ADLS only applies to the Spouse. For residents of ID the effective date won’t be deferred due to ability to perform ADLs. Ground or Water Ambulance/Air Ambulance benefits may differ for residents of CT. Portability in TX and VT is referred to as Continuation due to loss of eligibility. VT residents are not subject to the age limit to continue coverage. Portability conditions may differ for residents of AK, AR, CT, FL, ID, LA, ME, MD, MS, NH, NC, ND, SC, TX, VT, WA, and WI. Covid- 19 benefits are not available to residents of ID, OR and WA. Physician Office Visit will always be available to residents of AK, VT, and WA. Emergency Care Treatment, Diagnostic Exam, and Ambulance benefit[s] will always be available to residents of VT and WA. Hospital Stay/Intensive Care Unit Stay benefit[s] will always be available to residents of VT. Hospital Stay/Intensive Care Unit Stay additional benefits may be available to resident of ID and NH. Covered Accident definition differs for residents of AR, ID, NM, VT and WA. Benefits may not be available or may be limited to residents of NM. Covered Injury definition differs for residents of NM. Covered Loss definition differs for residents of NM, VT. Hospital definition differs for residents of NH and VT.
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