Schedule of Benefits

Click Here for Coverage Information

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 $10035/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