PAID BENEFITS
BENEFIT DESCRIPTION
ONE-UNIT
TWO-UNITS
Air Ambulance Air transportation within 48 hours. Once per Covered Accident. Ambulance Ground transportation within 90 days. Once per Covered Accident.
$500
$500
$100
$100
$25,000 Employee $10,000 Spouse $5,000 Child
$50,000 Employee $20,000 Spouse $10,000 Child
Accidental Death Within 90 days of Covered Accident.
Accidental Death (Via Common Carrier) Fare-paying passenger on a common carrier. (plane, bus, train)
Accidental Benefit will be doubled
Accidental Benefit will be doubled
Emergency Room Treatment Treatment sought within 72 hours of Covered Accident. Hospital Admission Confined within 180 days. Once per Covered Accident. (minimum 20 hours) Hospital Confinement Confined within 180 days. Maximum of 90 days.
$200
$200
$500
$1,000
$100 per day
$200 per day
Hospital Intensive Care Unit Within 30 days of Covered Accident. Maximum of 15 days. Major Diagnostic Exams Angiogram, CT and CTA scan; MRI, MRA or EEG as result of a Covered Accident. Physicians Office/Urgent Care Within 60 days of Covered Accident. Once per Covered Accident. Blood, Plasma and Platelets Transfusion, administration, cross-matching, typing and processing required within 90 days of a Covered Accident. Once per Covered Accident.
$200 per day
$400 per day
$100 per calendar year
$200 per calendar year
$50
$50
$300 primary insured $200 Spouse/ dep child
$300 primary insured $200 Spouse/ dep child
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