PAID BENEFITS
BENEFIT DESCRIPTION
ONE-UNIT
TWO-UNITS
Accidental Death Within 90 days** of covered accident and caused by resulting injury/injuries. (in UT, 180 days; in WA, 365 days) Accidental Death (Via Common Carrier) Death must occur within 90 days** of covered accident while fare-paying passenger on a common carrier (plane, bus, train) (in AK, or ferry). (in UT, 180 days; in WA, 365 days) Accidental Dismemberment We will pay the applicable lump sum benefit indicated in the policy for dismemberment. A Covered Accident must occur within 90 days of the accident (in UT, 180). Benefits will be paid only once per Covered Person, per Covered Accident. Air Ambulance Air transportation within 48 hours. Once per Covered Accident. (in PA, 30 days) Ambulance Ground transportation within 90 days. Once per Covered Accident. Ambulatory Surgical Center Facility and/or Outpatient Hospital Facility Max 1 per Accident. Appliances Payable when a Covered Person receives a medical appliance, prescribed by a physician, as an aid in personal locomotion for on or Off-the-Job Injuries sustained in a Covered Accident. Benefits are payable for the following types of appliances: a wheelchair, a leg brace, a back brace, a walker, and/or a pair of crutches. Blood, Plasma, and Platelets Transfusion, administration, cross-matching, typing and processing required within 90 days of a Covered Accident. Once per Covered Accident. Burn Treated within 72 hours of a Covered Accident. Once per Covered Accident. *Spouse and Child (in PA, 30 days; in WA, 365 days)
$25,000 Employee $10,000 Spouse* $5,000 Child
$50,000 Employee $20,000 Spouse* $10,000 Child
Accidental Benefit will be doubled
Accidental Benefit will be doubled
$625 - $40,000
$625 - $40,000
$1,000
$2,000
$100
$200
$100
$200
$125 per Covered Accident, per Covered Person.
$125 per Covered Accident, per Covered Person.
$300 primary insured $200 Spouse*/dep child
$300 primary insured $200 Spouse*/dep child
Size & Degree up to $10,000
Size & Degree up to $20,000
Chiropractor Visit Max 5 visits per Covered Accident
$35 per day
$70 per day
Concussion We will pay if any Insured Person is diagnosed by a Physician with a concussion as a result of a Covered Accident. Payable once per Covered Accident. Coma We will pay if any Insured Person is comatose in a Hospital setting for a duration of at least seven days as a result of a Covered Accident. Payable once per Covered Accident. (in WA, within 365 days from the time of the Covered Accident) Dislocations Diagnosed within 90 days, correction with anesthesia by Physician and corrected by Open (surgical) or Closed (non-surgical) reduction. Emergency Dental Work Once per Covered Accident regardless of teeth involved. (in WA, if the dental work is performed within 365 days from the time of the Covered Accident) Emergency Room Treatment Treatment sought within 72 hours*** of Covered Accident. (in PA, 30 days; in WA, 365 days)
$100
$200
$5,000
$10,000
$50 - $2,000 (policy contains complete schedule)
$100 - $4,000 (policy contains complete schedule)
$150 repairs with crown $50 for extraction
$300 repairs with crown $100 for extraction
$200
$200
* In CA and NV, Spouse or Domestic Partner, In HI, Spouse or Reciprocal Beneficiary; ** in PA, 90 days does not apply; ***in TX, 72 hour limit does not apply
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