Accident Insurance
BENEFITS AMOUNTS Initial Care & Emergency 1 – Most treatment / service required within 72 hours of accident; Once per accident per insured person Emergency Room $200 Urgent Care Center $125 Initial Physician Office Visit $100 Ambulance Up to $1,500 Specified Injuries 1,2 Fractures (Surgical / Non-surgical) Up to $8,000/Up to $4,000 Dislocations (Surgical / Non-surgical) Up to $10,000/Up to $5,000 Lacerations Up to $1,000 Burns Up to $20,000 Dental Up to $400 Hospital, Surgical & Diagnostic 1,3 Admission $1,500 Daily Confinement (Up to 365 days per accident) $300 per day ICU Confinement (Up to 15 days per accident) $600 per day Rehab. Facility Confinement (Up to 30 days per accident) $150 per day Surgical Up to $2,000 Diagnostic Up to $300 Follow-Up Care 1 – Treatment / service required within 365 days of accident; Medical device is once per accident per insured person Physician Follow-Up Office Visit $75; Up to 6 per accident Therapy Services $25; Up to 6 per accident Medical Device $100 Prosthetic Device(s) $750; Up to 2 per accident Additional Benefits 1 – Benefits are payable within 365 days of accident Transportation (Up to 3 trips per accident) $300 per trip Lodging (Up to 30 nights per accident) $125 per night Childcare (Up to 30 days per accident) $20 per day Catastrophic Benefits 1 ,4 – Benefits are payable within 365 days of accident; Once per accident per insured person Principal Sum (PS) You: $25,000
Spouse: $10,000 Child(ren): $5,000
Common Carrier Accidental Death Transportation of Remains Dismemberment & Paralysis Reasonable Modifications
300% of PS Up to $5,000
Up to 100% of PS Up to 10% of PS
Coma
50% of PS
SERVICES Hearing Discount Program
The Hearing Discount program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more.
1 Additional limitations apply as described in the certificate. 2 Fractures and dislocations require treatment within 90 days of accident, burns and lacerations within 72 hours of an accident, and dental care within 30 days. If an insured person sustains both a fracture and dislocation as the result of the same accident, the maximum amount payable is up to 200% of the amount payable for the injury with the highest applicable benefit amount. 3 Daily confinement must begin with 90 days of accident and ICU confinement within 30 days. Surgical treatment timeframes vary. If applicable, diagnostic services must be received within 90 days of accident. Except for confinement benefits, most benefits are payable once per accident per insured person. If any surgery occurs concurrently with an open reduction for a fracture or dislocation of the same bone or joint as a result of the same accident, only the highest applicable benefit is payable. 4 The principal sum for you and your spouse reduces by 50% when you reach the age of 70.
10 INFRATECH CORPORATION 2023 BENEFITS GUIDE
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