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| Maximum Benefit: | Plan “Basic” | Plan “A” | Plan “B” | Plan “C” | |
|---|---|---|---|---|---|
| School-Time Option | $25,000.00 | $25,000.00 | $25,000.00 | $25,000.00 | |
| 24-Hour Option | $25,000.00 | $25,000.00 | $25,000.00 | $25,000.00 | |
| Football Option | $25,000.00 | $25,000.00 | $25,000.00 | $25,000.00 | |
| Injuries Involving Motor Vehicles | $25,000.00 | $25,000.00 | $25,000.00 | $25,000.00 | |
| Benefit/Single Dismemberment Death | $10,000.00 | $10,000.00 | $10,000.00 | $10,000.00 | |
| Double Dismemberment | $20,000.00 | $20,000.00 | $20,000.00 | $20,000.00 | |
| Loss Period for Medical Benefits | Treatment must begin within 90 days from the date of Injury | ||||
| Benefit Period for Medical and AD&D/Loss of Sight Benefits | 1 YEAR | 1 YEAR | 1 YEAR | 1 YEAR | |
| Excess Coverage Applicability | Full Excess | Full Excess | Full Excess | Full Excess | |
| Hospital/Facility Services – Inpatient | |||||
| Hospital Room and Board (Semi-Private Room Rate) | 100% RE* / $750 Max | 100% RE* / $1,500 Max. | 100% RE* / $3,000 Max. | 100% RE* / $4,500 Max | |
| Hospital Intensive Care | 100% RE* / $750 Max | 100% RE* / $1,500 Max. | 100% RE* / $3,000 Max. | 100% RE* / $4,500 Max | |
| Inpatient Hospital Miscellaneous | 100% RE* / $750 Max | 100% RE* / $1,500 Max. | 100% RE* / $3,000 Max. | 100% RE* / $4,500 Max | |
| Hospital/Facility Services – Outpatient | |||||
| Outpatient Hospital Miscellaneous (Except physician services and x-rays paid as below) | 100% RE* / $750 Max | 100% RE* / $1,500 Max | 100% RE* / $3,000 Max | 100% RE* / $4,500 Max. | |
| (Except physician services and x-rays paid as below) | |||||
| Emergency Room Hospital | 100% RE* / $100 Max. | 100% RE* / $200 Max. | 100% RE* / $400 Max. | 100% RE* / $600 Max. | |
| Free-standing Ambulatory Surgical Facility | 100% RE* / $750 Max | 100% RE* / $1,500 Max | 100% RE* / $3,000 Max | 100% RE* / $4,500 Max. | |
| Day Surgery Miscellaneous | 100% RE* / $750 Max | 100% RE* / $1,500 Max | 100% RE* / $3,000 Max | 100% RE* / $4,500 Max. | |
| (Except physician services and x-rays paid as below) | |||||
| Physician’s Services | |||||
| Surgical | 100% RE* / $750 Max. | 100% RE* / $1500 Max. | 100% RE* / $3000 Max. | 100% RE* / $4500 Max. | |
| Assistant Surgeon | 25% of Surgical Benefits | 25% of Surgical Benefits | 25% of Surgical Benefits | 25% of Surgical Benefits | |
| Anesthesiologist | 25% of Surgical Benefits | 25% of Surgical Benefits | 25% of Surgical Benefits | 25% of Surgical Benefits | |
| Physician’s Non-surgical Treatment (Except as below) | 100% RE* / $35 per day | 100% RE* / $50 per day | 100% RE* / $100 per day | 100% RE* / $150 per day | |
| Physician’s Outpatient Treatment in connection with Physical Therapy and/or Spinal Manipulation | $35/Visit / 10 Visits Max | $50/Visit / 10 Visits Max | $100/Visit / 10 Visits Max | $150/Visit / 10 Visits Max | |
| Other Services | |||||
| Registered Nurses’ Services | 100% RE* | 100% RE* | 100% RE* | 100% RE* | |
| Prescriptions – outpatient | 100% RE* | 100% RE* | 100% RE* | 100% RE* | |
| X-rays, includes interpretation – outpatient | 100% RE* / $200 Max. | 100% RE* / $250 Max. | 100% RE* / $400 Max. | 100% RE* / $600 Max. | |
| Outpatient Diagnostic Imaging (MRI, CAT Scan, etc) includes interpretation | 100% RE* / $400 Max. | 100% RE* / $500 Max. | 100% RE* / $800 Max. | 100% RE* / $1200 Max. | |
| Ground Ambulance | 100% RE* / $350 Max. | 100% RE* / $500 Max. | 100% RE* / $1000 Max. | 100% RE* / $1500 Max. | |
| Air Ambulance | 100% RE* / $350 Max. | 100% RE* / $500 Max. | 100% RE* / $1000 Max. | 100% RE* / $1500 Max. | |
| Durable Medical Equipment (includes Orthopedic Braces & Appliances) | Max100% RE* / $200. | 100% RE* / $250 Max | 100% RE* / $400 Max. | 100% RE* / $600 Max. | |
| Dental Treatment to sound, natural teeth due to covered injury. | Max100% RE* / $200. | 100% RE* / $250 Max | 100% RE* / $400 Max. | 100% RE* / $600 Max. | |
| (When the dentist certifies that treatment will continue beyond the 52 week benefit Period the Company will continue to cover the incurred expenses at 100% RE*; provided such expenses are incurred within 2 years from the date of the first treatment for Injury) | |||||
| Replacement of eyeglasses, hearing aids, contact lenses,if medical treatment is also received for the covered injury. | 100% RE* / $200 Max | 100% RE* / $250 Max | 100% RE* / $400 Max | 100% RE* / $600 Max | |
| Heart or Circulatory Malfunction | 100% RE* / $10,000 Max. | 100% RE* / $10,000 Max. | 100% RE* / $10,000 Max. | 100% RE* / $10,000 Max. | |
| *RE means Reasonable Expense | GER_0314EFTB(0152 | ||||
