Routine Annual Physical Examination Benefit Rider 3 (Not available in Colorado and Virginia) • One benefit per year for a Routine Annual Physical Examination, subject to a 12-month Waiting Period. 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. Home Medical Equipment Benefit Rider 3 • Benefits paid when you need Home Medical Equipment prescribed by your Physician while receiving Home Health Care Select Services and/or Home Health Care Aide benefits. • Lifetime maximum is $500.
Benefit $150
Accidental Death $10,000
Max. Dismemberment Benefit
Sight, both eyes Sight, one eye
$5,000 $2,500 $5,000 $2,500
Hand/arm/foot/leg (multi) Hand/arm/foot/leg (single)
Finger or toe (multiple) Finger or toe (single)
$500 $250
Benefit $100 per piece
Home Medical Equipment Limited to Mobility assistance Transfer aids Bathroom safety Home accommodations Personal medical equipment
Ambulance Benefit Rider 3 (Not available in Colorado)
Benefit $200 per trip Per each one-way trip 4 trips per year
• 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. 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.
Max Amount per Accident Option 1 Option 2 $1,250 $2,500
Max. Accident Benefit
Option 1 Option 2 Fracture, hip or skull $1,250 $2,500 Dislocation Hip $1,000 $2,000 Tear, knee ligament or meniscus $500 $1,000 Dislocation Knee $500 $1,000 Fracture, all other $250 $500
3 See the Rider and/or Outline of Coverage for state-specific details.
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