Emergency Care Category

Benefits are paid when an insured person receives services described below for an injury sustained in a covered accident. The injury must be diagnosed by a physician with services received within the timeframe stated.

Initial Accident Treatment

Pays for treatment in one of the facilities listed below.

Physician’s Office

60 days

One physician’s office, urgent care or ER visit per accident

$75

$100

$150

$200

$250

Urgent Care Facility

60 days

$75

$100

$150

$200

$250

Emergency Room

30 days

$150

$200

$300

$400

$500

Telemedicine Treatment

Pays for treatment via telemedicine services.

60 days

One per accident

$30

$40

$60

$80

$40

Ambulance

Pays for transportation by a licensed professional ambulance company to or from a hospital.

Ground

60 days

One ground or air transport per accident

$150

$200

$300

$400

$500

Air

60 days

$450

$600

$900

$1,200

$1,500

X-Ray

Pays for an x-ray prescribed by a physician for diagnosis of an injury, for which the Initial Accident Treatment was paid.

60 days

One per accident

$150

$200

$300

$400

$300

Diagnostic Exams

Pays for a CT, CAT, MRI or EEG prescribed by a physician for diagnosis of an injury, for which the Initial Accident Treatment was paid.

60 days

One per accident but no more than one per calendar year

$75

$100

$150

$200

$150

Blood, Plasma or Platelets

Pays for transfusion, administration, cross-matching, typing and processing for treatment of an injury, for which the Initial Accident Treatment was paid.

60 days

One per accident

$450

$600

$900

$1,200

-

ER Observation Unit

Pays for a stay in an ER observation unit, based on number of hours held.

Held 4 to 20 hours

30 days

One per accident

$37.50

$50

$75

$100

-

Held longer than 20 hours

30 days

$75

$100

$150

$200

-

Supportive Care Category

Benefits are paid when an insured person receives services described below for an injury sustained in a covered accident, for which the Initial Accident Treatment benefit was paid, unless otherwise stated. Services must be received within the timeframe stated.

Follow-Up Treatment

Pays for follow-up treatment prescribed and provided by a physician in their office or as an outpatient in a hospital for an injury, for which either the Initial Accident Treatment or Telemedicine Treatment benefit was paid.

Within 180 days up to 365 days

Two per accident

$75

$100

$150

$200

$200

Physical, Occupational or Speech Therapy

Pays for therapy prescribed by a physician for an injury. Benefits will not be paid for therapy in a hospital or nursing home.

Within 180 days up to 365 days

Six per accident

$45

$60

$90

$120

-

Chiropractic or Acupuncture Treatment

Pays for chiropractic or acupuncture treatment for an injury.

Within 180 days up to 365 days

Six per accident

$45

$60

$90

$120

-

Epidural Pain Management

Pays for an epidural injection in the spine prescribed by a physician for pain management of an injury, for which either the Initial Accident Treatment or Telemedicine Treatment benefit was paid.

180 days

One per accident

$75

$100

$150

$200

-

Prescription Medication

Pays for medication prescribed by a physician for an injury, for which either the Initial Accident Treatment or Telemedicine Treatment benefit was paid. Benefits will not be paid for medication used or administered in a hospital or nursing home.

180 days

Two per accident but no more than six per calendar year

$7.50

$10

$15

$20

-

Medical Supplies

Pays for over-the-counter medical supplies for an injury, for which either the Initial Accident Treatment or Telemedicine Treatment benefit was paid. Medical supplies do not include prescription medication, appliances or prosthetic devices. Examples include medical bandages, gauze or dressings.

180 days

One per accident but no more than three per calendar year

$7.50

$10

$15

$20

-

Appliances

Pays for appliances purchased or rented for aid in personal locomotion or mobility prescribed by a physician for an injury, for which either the Initial Accident Treatment or Telemedicine Treatment benefit was paid. Examples include crutches, braces, walkers and wheelchairs.

180 days

One per accident

$187.50

$250

$375

$500

$125

Prosthetic Devices

Pays for prosthetic devices prescribed by a physician to replace a hand, foot or eye lost due to an accident, for which the Initial Accident Treatment benefit was paid. Hearing aids; dental aids, including false teeth; eyeglasses; cosmetic prostheses such as wigs or joint replacements such as an artificial hip or knee are not covered.

One Device

Multiple Devices

365 days

365 days

One per accident

One per accident

$750

$1,500

$1,000

$2,000

$1,500

$3,000

$2,000

$4,000

-

-

Residence/Vehicle Modification

Pays if an insured person incurs charges making permanent structural modifications to their primary residence or vehicle certified by a physician as necessary to enable use due to an injury.

365 days

One per accident

$750

$1,000

$1,500

$2,000

-

Transportation

Pays for either ground or air transportation if any insured person is required to travel more than 50 miles from their residence for treatment prescribed by a physician and locally unavailable. Transportation by ambulance is not covered.

Ground

Air

180 days

180 days

Three round trips (collectively for ground and air, not individually) per accident

$150

$375

$200

$500

$300

$750

$400

$1,000

-

-

Lodging

Pays for a companion's lodging if accompanying an insured person confined to a hospital more than 100 miles away from the insured person's residence for treatment.

180 days

30 nights per accident

$150

$200

$300

$400

-

Specific Injury Care

Benefits are paid when an insured person receives services described below for an injury sustained in a covered accident, for which the Initial Accident Treatment benefit was paid, unless otherwise stated. The injury must be diagnosed by a physician, unless otherwise stated, with services received within the timeframe stated.

Burns

Pays the benefit amount multiplied by the appropriate factor from the schedule below for burns.

Benefit Example: For the Tier 3 plan and a 3rd degree burn covering 20% of the body, would pay $750 calculated as $1,500 x 0.50 (3rd degree burns covering 15% to 34% of the body).

30 days

One per accident

$750

$1,000

$1,500

$2,000

-

Burns Schedule

3rd degree burns covering 35% or more of body

1.00

2nd degree burns covering 35% or more of body

0.10

3rd degree burns covering 15% to 34% of body

0.50

2nd degree burns covering 15% to 34% of body

0.05

3rd degree burns covering less than 15% of body

0.10

2nd degree burns covering less than 15% of body

0.01

Burns – Skin Graft

Pays Burns benefit amount paid multiplied by the percentage below for a skin graft.

Benefit Example: From the example above where a skin graft is necessary, would pay $375.

365 days

One per accident

50%

50%

50%

50%

-

Child Organized Sports

Pays the percentage below multiplied by all benefit amounts paid for services received by an insured child or dependent grandchild for treatment of an injury sustained while participating in an organized sport, as defined in the policy. The maximum amount payable is $1,000.

Benefit Example: For a fracture paying $1,800 through other benefits, would pay an additional $180.

60 days

One per accident

10%

10%

10%

10%

-

Coma

Pays for a coma requiring respiratory assistance lasting more than 14 days. Comas that are medically induced or the result of drug or alcohol use are not covered.

60 days

One per accident

$15,000

$20,000

$30,000

$40,000

-

Concussion

Pays for a concussion. This benefit will not be paid if the Traumatic Brain Injury benefit is paid.

30 days

One per accident

$37.50

$50

$75

$100

-

Dental Emergency

Pays for dental work on a natural tooth requiring a crown or extraction. Diagnosis by a physician and payment of the Initial Accident Treatment benefit are not required.

Crown

Extraction

60 days

60 days

One per accident

One per accident

$150

$45

$200

$60

$300

$90

$400

$120

-

-

Dislocation

Pays the benefit amount multiplied by the appropriate factor from the schedule below for an open reduction (surgical) or closed reduction (non-surgical) treatment for a dislocation. If the dislocation requires closed reduction treatment without anesthesia or is diagnosed as an incomplete dislocation (not completely separated), the amount payable is 25% of what is calculated for closed reduction. The benefit will only be paid for the first dislocation.

Benefit Example: For the Tier 3 plan and an incomplete dislocation of the shoulder joint, would pay $150 calculated as $3,000 (closed reduction) x 0.20 (shoulder joint) x 25% (incomplete dislocation).

Open Reduction

Closed Reduction

60 days

60 days

All dislocations per one accident limited to two times the dislocation with the highest benefit amount

$3,000

$1,500

$4,000

$2,000

$6,000

$3,000

$8,000

$4,000

-

-

Dislocation Schedule

Lower Jaw

0.25

Two or More Fingers or Toes

0.07

Shoulder Joint

0.20

One Finger or Toe

0.03

Collar Bone (Sternoclavicular)

0.25

Hip Joint

1.00

Collar Bone (Acromioclavicular)

0.05

Knee Joint (except Patella)

0.40

Elbow Joint

0.30

Ankle Joint

0.40

Wrist Joint

0.35

Bone(s) of Foot (except Toes)

0.40

Bone(s) of Hand (except Fingers)

0.15

Ear Injury

Pays for an ear Injury resulting in hearing loss greater than 60%.

60 days

One per lifetime

$150

$200

$300

$400

-

Eye Injury

Pays for an eye injury provided by a Physician requiring surgery or removal of a foreign object.

60 days

One per accident

$150

$200

$300

$400

-

Fracture

Pays the benefit amount multiplied by the appropriate factor from the schedule below for an open reduction (surgical) or closed reduction (non-surgical) treatment for a fracture. If the fracture is a chip fracture (a piece of the bone is broken off near a joint at a place where a ligament is usually attached), the amount payable is 25% of what is calculated.

Benefit Example: For the Tier 3 plan and a closed reduction chip fracture of an elbow, would pay $300 calculated as $3,000 (closed reduction) x 0.40 (elbow) x 25% (chip fracture).

Open Reduction

Closed Reduction

60 days

60 days

All fractures per one accident limited to two times the fracture with the highest benefit amount

$3,000

$1,500

$4,000

$2,000

$6,000

$3,000

$8,000

$4,000

-

-

Fracture Schedule

Skull (Depressed)

1.00

Vertebral Process

0.15

Skull (Non-Depressed)

0.40

Sacrum

0.07

Bones of Face or Nose

0.15

Coccyx

0.07

Upper Jaw

0.15

Hip, Thigh (Femur), Acetabulum

0.90

Lower Jaw (Mandible except for Alveolar Process)

0.20

Lower Leg (Tibia, Fibula)

0.55

Shoulder Blade (Scapula)

0.55

Kneecap (Patella)

0.40

Collar Bone (Clavicle)

0.40

Ankle

0.40

Sternum

0.40

Hand (except Fingers) or Wrist

0.35

Upper Arm (Humerus)

0.55

Foot (except Toes)

0.35

Elbow

0.40

Two or More Ribs

0.20

Forearm (Radius, Ulna)

0.40

Rib

0.10

Pelvis (except Coccyx)

0.90

Two or More Fingers or Toes

0.15

Vertebrae (except Vertebral Process)

0.30

One Finger or Toe

0.07

Gunshot Wound

Pays for treatment for a gunshot wound from a conventional firearm that is not intentionally self‐inflicted.

24 hours for treatment; 72 hours for surgery

One per accident, regardless of number of wounds

$750

$1,000

$1,500

$2,000

-

Laceration

Pays the benefit amount multiplied by the appropriate factor from the schedule below for lacerations.

Benefit Example: For the Tier 3 plan and a laceration 10 centimeters long, would pay $75 calculated as $150 x 0.50 (5 to 15 centimeters).

30 days

One per accident

$75

$100

$150

$200

-

Laceration Schedule

More than 15 centimeters

1.00

Less than 5 centimeters

0.25

5 to 15 centimeters

0.50

Not requiring stitches or glue

0.125

Occupational HIV

Pays for the primary insured’s treatment of occupational HIV – infection with the Human Immunodeficiency Virus (HIV), through contaminated blood or bodily fluids during the course of the duties of their normal occupation.

60 days

One per lifetime

$450

$600

$900

$1,200

-

Paralysis

Pays complete paraplegia or quadriplegia paralysis lasting at least 90 consecutive days and diagnosed by a physician to be permanent.

Quadriplegia

Paraplegia

60 days

60 days

One quadriplegia or paraplegia benefit per lifetime

$22,500

$11,250

$30,000

$15,000

$45,000

$22,500

$60,000

$30,000

-

-

Poisoning

Pays for an adverse reaction from ingesting or being exposed to a substance. Substances covered by this benefit include, but are not limited to, household items, food, prescription medication, allergens, toxic plants and envenomations. Substances not covered by this benefit include alcohol and illegal narcotics.

30 days

One per accident but no more than one per calendar year

$37.50

$50

$75

$100

-

Post-Traumatic Stress Disorder (PTSD)

Pays for treatment provided by a Psychiatrist or Ph.D.-level Psychologist for Post-Traumatic Stress Disorder (PTSD). Diagnosis must be based on criteria established in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV-TR).

60 days

One per accident but no more than one per caleandar year

$300

$400

$600

$800

-

Traumatic Brain Injury

Pays for a traumatic brain injury diagnosed by CT, CAT, MRI, EEG, PET or x-ray. This benefit will not be paid if the Concussion benefit is paid.

60 days

One per accident

$450

$600

$900

$1,200

-

Hospital Care Category

Benefits are paid when an insured person receives services described below for an injury sustained in a covered accident, for which the Initial Accident Treatment benefit was paid. The injury must be diagnosed by a physician with services received within the timeframe stated.

Benefits will not be paid for Hospital Confinement, Rehabilitation Unit, Sub-Acute Intensive Care Unit or Intensive Care Unit for the same day. Benefits will be paid for one period of confinement at a time, even if caused by more than one accident. If an insured person is confined in a hospital, and later becomes confined again within 90 days for the same condition, this will be treated as a continuation of the prior confinement. If more than 90 days pass between periods of confinement, this will be treated as a new confinement.

Hospital Admission

Pays one benefit for confinement in a hospital – assignment to a bed as a resident inpatient as prescribed by a physician in a hospital for a period of at least 20 continuous hours.

180 days

One per accident but only one per calendar year

$750

$1,000

$1,500

$2,000

$3,000

Hospital Confinement

Pay a daily benefit for confinement in a hospital – assignment to a bed as a resident inpatient as prescribed by a physician in a hospital for a period of at least 20 continuous hours.

180 days

365 days per accident

$150

$200

$300

$400

$400

Intensive Care Unit

Pays a daily benefit for confinement in an intensive care unit. If confined after 30 days, pays the Hospital Confinement benefit.

180 days

30 days per accident

$300

$400

$600

$800

$800

Sub-Acute Intensive Care Unit

Pays a daily benefit for confinement in a sub-acute intensive care unit. If confined after 30 days, pays the Hospital Confinement benefit.

180 days

30 days per accident

$225

$300

$450

$600

-

Rehabilitation Unit

Pays a daily benefit for confinement in a rehabilitation unit immediately following a period of hospital confinement.

180 days

30 days per accident but no more than 60 days per calendar year

$150

$200

$300

$400

-

Child Care

Pays for child care for insured children and dependent grandchildren while an insured person is confined to a hospital. The child care provider must be licensed in the jurisdiction in which services are provided. One benefit will be paid daily for all insured children and dependent grandchildren and not for each child.

180 days

30 days per accident while the insured person is confined

$30

$40

$60

$80

-

Surgical Care Category

Benefits are paid when an insured person receives services described below for an injury sustained in a covered accident. The injury must be diagnosed by a physician with services received within the timeframe stated. Two or more surgical procedures provided through the same incision or entry point are considered one surgery, and only the higher benefit amount will be paid.

Open Abdominal, Thoracic or Cranial Surgery

Pays for abdominal, thoracic or cranial surgery to repair an internal injury. For hernia repair, this benefit will not be paid and the Hernia Surgery will be paid. If exploratory surgery is performed with no repair, this benefit will not be paid and the Exploratory Surgery benefit will be paid.

180 days

One per accident

$1,500

$2,000

$3,000

$4,000

-

Tendon, Ligament, Rotator Cuff or Knee Cartilage Surgery

Pays for surgery to repair a tendon, ligament, rotator cuff or knee cartilage that is torn, severed or ruptured. If exploratory surgery is performed with no repair or knee cartilage is shaved (debridement), this benefit will not be paid and the Exploratory Surgery benefit will be paid.

180 days

One per accident

$750

$1,000

$1,500

$2,000

-

Ruptured Disc Surgery

Pays for surgery to repair a ruptured disc in the spine.

180 days

One per accident

$750

$1,000

$1,500

$2,000

-

Hernia Surgery

Pays for surgery to repair a hernia.

180 days

One per accident

$375

$500

$750

$1,000

-

Exploratory Surgery

Pays for arthroscopic or laparoscopic surgery for diagnostic purposes only. This benefit will not be paid if any other Surgical Care benefit, except the Anesthesia benefit, is paid.

180 days

One per accident

$375

$500

$750

$1,000

-

Miscellaneous Outpatient Surgery

Pays for surgery requiring anesthesia as an outpatient. This benefit will not be paid if the Dislocation benefit, Eye Injury benefit, Fracture benefit or any other Surgical Care benefit,

except the Anesthesia benefit, is paid.

180 days

One per accident

$150

$200

$300

$400

-

Anesthesia

Pays for general anesthesia administered by a nurse anesthetist or physician for a surgery for which a Surgical Care benefit was paid.

180 days

One per accident

$150

$200

$300

$400

-

Preventive Care Category

Wellness Benefits

Pays for blood screening for triglycerides, cholesterol, HDL or LDL; fasting blood glucose test (blood test for diabetes); annual physical exams; routine eye exams; or immunizations.

Not Applicable

One per day up to two days per insured person but no more than four days for all insured persons combined in a calendar year

$50

$50

$50

$50

-

Accidental Death and Dismemberment Rider

Benefits are paid when an insured person incurs any of the losses or receives any of the services described below for an injury sustained in a covered accident. Death or injury must be certified or diagnosed by a physician with services for an injury received within the timeframe stated. The maximum amount payable for all losses from the same covered accident is equal to the amount paid for the loss with the highest benefit amount – this is not applicable to the Accidental Death – Automobile with Seatbelt or Children Education benefits.

Accidental Death

Pays for accidental death. This benefit will not be paid if the Accidental Death – Common Carrier benefit is paid.

Primary Insured (100%)

Spouse (50%)

Child (25%)

180 days

Not Applicable

$30,000

$15,000

$7,500

$40,000

$20,000

$10,000

$60,000

$30,000

$15,000

$80,000

$40,000

$20,000

-

-

-

Accidental Death – Automobile with Seatbelt

Pays an additional amount for accidental death from an injury sustained while driving or riding in an automobile while wearing and properly utilizing a seatbelt as certified by the police accident report. The automobile must be a four-wheeled passenger motor vehicle for use on public highways and not being used to transport passengers for hire.

Primary Insured (100%)

Spouse (50%)

Child (25%)

180 days

Not Applicable

$7,500

$3,750

$1,875

$10,000

$5,000

$2,500

$15,000

$7,500

$3,750

$20,000

$10,000

$5,000

-

-

-

Accidental Death – Common Carrier

Pays for accidental death while riding as a fare-paying passenger on a scheduled common

carrier. Common carrier means commercial airplanes, trains, buses, trolleys, subways, ferries and boats that operate on a regularly scheduled basis between predetermined points or cities. Taxis and privately chartered vehicles are not common carriers.

Primary Insured (100%)

Spouse (50%)

Child (25%)

180 days

Not Applicable

$75,000

$37,500

$18,750

$100,000

$50,000

$25,000

$150,000

$75,000

$37,500

$200,000

$100,000

$50,000

-

-

-

Accidental Dismemberment

Pays the benefit amount multiplied by the appropriate factor from the schedule below for accidental dismemberment.

Benefit Example: For the Tier 3 plan with a spouse losing one hand, would pay $15,000 calculated as $30,000 (spouse) x 0.5 (one hand or one arm).

Primary Insured (100%)

Spouse (50%)

Child (25%)

180 days

Not Applicable

$30,000

$15,000

$7,500

$40,000

$20,000

$10,000

$60,000

$30,000

$15,000

$80,000

$40,000

$20,000

-

-

-

Dismemberment Schedule

Both hands or both arms

1.0

Sight in one eye

0.5

Both feet both legs

1.0

One hand or one arm

0.5

Sight in both eyes

1.0

One foot or one leg

0.5

Hearing in both ears

1.0

One or more entire toes

0.1

Speech

1.0

One or more entire fingers

0.1

One hand or arm and one foot or leg

1.0

Benefits are paid when an insured person incurs any of the losses or receives any of the services described below for an injury sustained in a covered accident. Death or injury must be certified or diagnosed by a physician with services for an injury received within the timeframe stated. The maximum amount payable for all losses from the same covered accident is equal to the amount paid for the loss with the highest benefit amount – this is not applicable to the Accidental Death – Automobile with Seatbelt or Children Education benefits.

Children Education

Pays an additional amount to the beneficiary for any insured children’s and dependent grandchildren’s education costs if an insured person suffers accidental death. This benefit will be paid for any insured children and dependent grandchildren between the ages of 18 and 22 who is enrolled as a full-time student at an accredited college, university, vocational or trade school at the time of death. Proof of full-time student status will be required.

180 days

Not Applicable

$750

$1,000

$1,500

$2,000

-