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.
Prescription Drug Benefit 1 30-day prescription benefit of $10/Generic or $25/ Brand. 90-day prescription benefit of $30/Generic or $75/ Brand.
Home Health Care Enhanced Benefits 1
Daily maximum benefit of $150 - $450 with a maximum benefit period of 365 days 2 for the following services in your home from an Approved Home Health Care Practitioner, subject to the eligibility conditions:
Maximum Benefit per Policy Year
Classic
Premier
Deluxe
Classic Premier Deluxe $150 $300 $450 $75 $150 $200 $75 $150 $200 $75 $150 $200
$300
$600
$900
Accidental Death $10,000 Max. Dismemberment Benefit
Nursing Care
Routine Annual Physical Examination Benefit Rider 3 One benefit per year for a routine annual physical examination, subject to a 12-month waiting period.
Physical Therapy Speech Pathology
Sight, both eyes Sight, one eye
$5,000 $2,500 $5,000 $2,500
Occupational Therapy
$75 $150 $200
Benefit $150
Hand/arm/foot/leg (multi) Hand/arm/foot/leg (single)
Chemotherapy Specialist Services
$60 $120 $200
Enterostomal Therapy
Finger or toe (multiple) Finger or toe (single)
$500 $250
$50 $100 $200
Home Medical Equipment Benefit Rider 3 Benefits paid when you need home medical equipment prescribed by your physician while receiving Home Health Care Services. Lifetime maximum is $500.
Medical Social Worker Services $100 $200 $300 Respiratory Therapy $50 $100 $200 Home Health Care Aide Services 1 $50 $100 $150 Homemaker Services Benefit 1 Daily maximum care benefit for care received at home from an unlicensed family member, neighbor or friend.
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 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
Benefit $100 per piece Home Medical Equipment Limited to
Mobility assistance
Bathroom safety
Classic
Premier
Deluxe
Transfer aids
Home accommodations
$25
$50
$75
Personal medical equipment
Policy Maximum
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
$4,000
$5,000
$6,000
1 See the Policy and/or Outline of Coverage for state-specific details. 2 Maximum benefit period may vary by state. Restoration of Benefits 1 The Maximum Benefit Period and/or Policy Maximum will be restored if benefits have not been paid or required for 180 consecutive days.
are provided during the trip. Lifetime maximum is $2,500.
Benefit $200 per trip
3 See the Rider and/or Outline of Coverage for state-specific details.
Per each one-way trip
4 trips per year
Made with FlippingBook - professional solution for displaying marketing and sales documents online