SCHEDULE
of BENEFITS
Policy year maximum $20,000. Lifetime maximum $250,000.
|
T250 |
T500 |
T1000 |
T2000 |
Daily Hospital*
You will be paid the amount in the benefit schedule
when you are admitted to a Hospital and for each additional
day you are confined to a Hospital for a maximum of
up to an additional 30 days if you are confined to
a Hospital for a covered Injury or Sickness. Sickness
is subject to a 30-day waiting period. You must be
admitted to the hospital and confinement for Injury
must occur within 6 months of the date of the covered
Accident.
|
First
Day
$250
There after
$200
|
First
Day
$500
There after
$400
|
First
Day
$1000
There after
$1000
|
First
Day
$2000
There after
$1000
|
Intensive Care / Cardiac Care
Unit*
If you are confined in a Hospital ICU due to a covered
Injury received in a covered Accident or Sickness,
you will be paid the daily benefit amount in the benefit
schedule for a maximum of up to 30 days following
the 1st day admission. You must be admitted to a Hospital
ICU within 6 months of the date of the covered Accident.
|
$250 |
$500 |
$1,000 |
$1,000 |
Doctor Office Visit
If you are injured in a covered Accident or have treatment
as a result of a covered Sickness, you will be paid
the benefit amount shown for each visit. This benefit
is limited to 5 visits per person per Policy year.
|
$50 |
$50 |
$75 |
$75 |
Emergency Room
If you are injured in a covered Accident or have treatment
as a result of a covered Sickness, you will be paid
up to the benefit amount shown for a visit to the
Emergency Room. This benefit is limited to 1 visit
per person per Policy year.
|
$50 |
$50 |
$75 |
$75 |
Diagnostic/Lab/X-Ray
If you are injured in a covered Accident or have treatment
as a result of a covered Sickness, you will be paid
the benefit amount shown for each visit. This benefit
is limited to 5 sittings or draws per person per Policy
year.
|
$50 |
$50 |
$75 |
$75 |
Additional Accident Injury
Benefit
If you are injured in a covered Accident and receive
treatment from a Doctor within one year after the
accident, you will be paid the benefit amount shown
for X-rays, Doctor Services, Emergency Room Services,
Supplies, and Appliances. This benefit is payable
if you receive initial treatment within 60 days after
the Accident. This Additional Accident Injury Benefit
is paid prior to the application of other scheduled
benefits.
|
$200 |
$300 |
$400 |
$400 |
Surgical Benefit
If you receive surgery due to a covered Accident or
a covered Sickness you will be paid the amount for
the surgery shown in the benefits schedule. The surgery
can be performed in a Hospital or in an Ambulatory
Surgical Center. Limit to one surgery per year.
|
$0 |
Max
$500 |
Max
$1,000 |
Max
$1,000 |
Anesthesia
When a covered surgical procedure is performed you
will be paid 25% of the amount paid under the surgical
benefit when administered by a Doctor in connection
with the procedure.
|
$0 |
Max
$125 |
Max
$250 |
Max
$250 |
Wellness Benefit
We will pay the amount shown in the benefits schedule
per calendar year when you visit a Doctor for well
check-ups. Limit to one visit per policy year.
|
$50 |
$50 |
$75 |
$75 |
Accidental Death
& Dismemberment Benefit
The plan will provide your designated beneficiary
with the insurance benefit in the event of death or
dismemberment.
|
Primary
$5,000
Spouse
$2,500
Children
$1,250
|
Primary
$5,000
Spouse
$2,500
Children
$1,250
|
Primary
$5,000
Spouse
$2,500
Children
$1,250
|
Primary
$5,000
Spouse
$2,500
Children
$1,250
|
National PPO Network
|
Yes |
Yes |
Yes |
Yes |
Prescription Drug Card
|
Yes |
Yes |
Yes |
Yes |
Discount Lab Benefits
|
Yes |
Yes |
Yes |
Yes |
Durable Medical Equipment
|
Yes |
Yes |
Yes |
Yes |
Dental Care Discount
|
Yes |
Yes |
Yes |
Yes |
Vision Care Discount
|
Yes |
Yes |
Yes |
Yes |
Monthly Price
Coverage is Guaranteed with a 12 month
wait on Pre-existing Conditions
|
| Single |
$97.00 |
$123.00 |
$184.00 |
$198.10 |
| Single Plus 1 |
$166.50 |
$218.00 |
$341.00 |
$370.40 |
| Family |
$215.00 |
$287.00 |
$463.00
|
$503.60 |
