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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 |