Routine Annual Physical Examination Benefit Rider 3 • One benefit per year for a Routine Annual Physical Examination, subject to a 12-month Waiting Period.
Benefit $150
Accidental Death $10,000
Accidental Death & Dismemberment Benefit Rider 3 • Benefits for accidental death or an accidental bodily injury resulting in the loss of finger, toe, hand, arm, foot, leg or sight. To be covered, death or dismemberment must occur within 90 days of the covered accident and while this policy and rider are in force. • Lifetime maximum is $10,000.
Max. Dismemberment Benefit
Sight, both eyes Sight, one eye
$5,000 $2,500
Hand/arm/foot/leg (multi) $5,000 Hand/arm/foot/leg (single) $2,500 Finger or toe (multiple) $500 Finger or toe (single) $250
Benefit $100 per piece
Home Medical Equipment Benefit Rider 3 • Benefits paid when you need Home Medical Equipment prescribed by your Physician while receiving Home Health Care Enhanced Services and/or Home Health Care Aide benefits. • Lifetime maximum is $500.
Home Medical Equipment Limited to Mobility assistance Transfer aids Bathroom safety Home accommodations Personal medical equipment
Ambulance Benefit Rider 3 • Benefits paid for transportation in an Ambulance for Emergency Care, including transportation from one medical facility to another when health care services are provided during the trip. • Lifetime maximum is $2,500.
Benefit $200 per trip Per each one-way trip 4 trips per year
Max Amount per Accident Option 1 Option 2 $1,250 $2,500
Accident Expense Benefit Rider 3 • Benefits for dislocations, fractures or knee ligament tears when treated by a health care practitioner in a Hospital Emergency Room, Urgent Care Facility or Physician’s office within 48 hours of the Covered Accident. • Lifetime maximum is $10,000.
Max. Accident Benefit
Option 1 Option 2 $1,250 $2,500 $1,000 $2,000
Fracture, hip or skull
Dislocation Hip
Tear, knee ligament or meniscus Dislocation Knee Fracture, all other
$500 $1,000
$500 $1,000 $250 $500
3 See the Rider and/or Outline of Coverage for state-specific details.
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