BENEFIT DESCRIPTION
ONE-UNIT
TWO-UNITS
Epidural Pain Management Payable when a Covered Person is prescribed, receives and incurs a charge for an epidural administered for pain management in a hospital or a physician’s office for injuries sustained in a Covered Accident. (in WA, within 365 days from the time of the Covered Accident) Eye Injury Treated by a physician within 90 days of Covered Accident. Must require surgery or removal of a foreign object. (in WA, 365 days) Fractures Fractures requiring Surgical or Non-Surgical reduction within 90 days of Covered Accident. (In IN, 6 months) Gunshot Wounds* Unintentional wound requiring confinement within 24 hours and surgery within 72 hours after the injury. Primary insured only. (in WA, 365 days) Hospital/Intensive Care Unit Admission Confined within 180 days. (in WA, 365 days) Once per Covered Accident. (minimum of 20 hours) Hospital Confinement Confined within 180 days. (in WA, 365 days) Maximum of 365 days. Hospital Intensive Care Unit Confinement Within 30 days of Covered Accident. (in WA, 365 days) Maximum of 15 days. ICU paid in addition to Hospital Confinement Knee Cartilage - Torn Treated by a physician within 60 days of Covered Accident. Must be repaired within 180 days. (in IN, 6 months of Covered Accident and within185 days for repair; in WA, 365 days from time of Covered Accident and within 365 days for repair) Laceration Lacerations requiring repair by a physician within 72 hours of a Covered Accident. (in WA, 365 days) Lodging Companion Lodging when Insured is confined to a hospital more than 100 miles from home. Maximum of 30 days. (in PA, 75 miles) Major Diagnostic Exams Angiogram, CT and CTA scan; MRI, MRA, or EEG as result of a Covered Accident. (in WA, receives within 365 days from time of Covered Accident) Paraplegia We will pay if any Insured Person’s lower portion of their body and both legs become completely paralyzed and cannot be recovered as the result of a Covered Accident. (in WA, within 365 days from time of Covered Accident) Physicians Follow-up Office Visits First follow-up must occur within 30 days of initial Physician Office Visit. (in WA, 365 days) Physical Therapy Payable when a Covered Person receives emergency treatment for injuries sustained in a Covered Accident and later advised to seek treatment from a licensed physical therapist. Physical therapy must start within 30 days** of the Covered Accident (in WA, 365 days) or discharge from hospital and take place within six months after the accident. Prosthesis Payable when a Covered Person requires use of a prosthetic device as a result of on or Off-the-Job Injuries sustained in a Covered Accident. (in WA, within 365 days from time of Covered Accident) This benefit is not payable for repair or replacement of prosthetic devices, hearing aids, wigs, or dental aids, to include false teeth. Physicians Office Visit Within 60 days of Covered Accident. Once per Covered Accident. (in IN, 6 months; in WA, 365 days)
$100 paid no more than twice per Covered Accident, per Covered Person.
$100 paid no more than twice per Covered Accident, per Covered Person.
$200
$200
$25 - $2,500 (any Insured) (policy contains complete schedule)
$50 - $5,000 (any Insured) (policy contains complete schedule)
$500
$500
$1,000 If admitted directly to ICU, add $500
$2,000 If admitted directly to ICU, add $1,000
$150 per day
$300 per day
$300 per day
$600 per day
$1,000 (less any benefit paid for arthroscopic surgery previously performed) $200 for exploratory surgery $100 - $800 (based on length of lacerations, see policy)
$500 (less any benefit paid for arthroscopic surgery previously performed) $100 for exploratory surgery $50 - $400 (based on length of lacerations, see policy)
$100 per night
$100 per night
$100 per calendar year
$200 per calendar year
$2,500
$5,000
$75
$150
$25 / Max 6
$50 / Max 8
$70 per treatment per day, to a maximum of ten treatments per Covered Accident, per Covered Person.
$35 per treatment per day, to a maximum of ten treatments per Covered Accident, per Covered Person.
$1,500 once per Covered Accident, per Covered Person.
$750 once per Covered Accident, per Covered Person.
*Benefit not approved in PA; **In IN, Physical Therapy must begin within 6 months.
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