What's Covered

The plan will pay an accident benefit if you receive any of the services or meet any of the conditions described below as the result of injuries received in a covered accident. The injury must occur, and the services must be received, while you are covered under the plan. No benefit is payable if you are not covered under the plan at the time services are received or these conditions are met. The amount of benefit varies on the type of service received as described in Accident Insurance Benefits.

Accident Hospital Care Benefits

Blood, Plasma, Platelets: Transfusion, administration, cross matching, typing and processing of blood, plasma, platelets administered within 90 days after a covered accident. This benefit is payable once per covered accident.

Coma: You have been in a coma for at least 14 days. This benefit is payable once per covered accident.

Hospital Admission: Admission to a hospital as a result of a covered accident. The admission must begin within six months after a covered accident. This benefit is payable once per covered accident. No benefit is payable for any of the following:

Emergency room treatment
Outpatient surgery
A stay of less than 20 hours in an observation unit

Hospital Confinement: Confinement in a hospital for at least 20 consecutive hours on an inpatient basis as the result of a covered accident. The hospital confinement must begin within six months after a covered accident. Benefits are payable daily for up to 365 days for a covered accident. Benefits are payable for only one hospital confinement at a time even if the confinement is caused by more than one covered accident. Only one type of confinement benefit is payable for each period of eligible confinement.

If you are discharged from the hospital and then re-confined within 30 days due to the same covered accident or due to a related condition, the re-confinement will be considered part of the previous hospital confinement(s).

Critical Care Unit Confinement: Confinement in Critical Care Unit for at least 20 consecutive hours on an inpatient basis as the result of a covered accident. The confinement must begin within 30 days after a covered accident. Benefits are payable daily for up to 15 days for a covered accident. Benefits are payable for only one Critical Care Unit confinement at a time even if the confinement is caused by more than one covered accident. Only one type of confinement benefit is payable for each period of eligible confinement.

If you are discharged from the Critical Care Unit and then re-confined within 30 days due to the same covered accident or due to a related condition, the re-confinement will be considered part of the previous Critical Care Unit confinement(s).

Rehabilitation Facility Confinement: Confinement in a Rehabilitation Facility for 20 consecutive hours on an inpatient basis as the result of a covered accident. Benefits are payable daily for each subsequent and continuous day (or portion thereof) of inpatient Rehabilitation Facility Confinement, for up to 90 days per covered accident. Benefits are payable for only one Rehabilitation Facility Confinement at a time even if the Confinement is caused by more than one covered accident. Only one type of Confinement benefit is payable for each period of eligible Confinement.

If you are released and readmitted to a Rehabilitation Facility within 30 days due to the same Covered Accident or due to a related condition, the re-Confinement will be considered part of the previous Rehabilitation Facility Confinement(s).

Lodging: Hotel/motel stay by your companion while you are confined in a hospital. The hospital must be more than 100 miles from your home. This benefit is payable for up to 30 days per covered accident.

Surgery: The surgery must take place within 30 days after a covered accident. The benefit amount varies based on the type of services received. This benefit is payable once per covered accident. No benefit is payable for hernia repair.

Transportation: Transportation for you for special treatment and confinement in a hospital. The special treatment must be prescribed by a doctor and not available locally. The transportation must be more than 100 miles one-way. This benefit is payable once per covered accident. No benefit is payable for transportation by ground ambulance or air ambulance.

Accident Care Benefits

Ambulance, Air: Transport by a licensed professional air ambulance company to or from a hospital or between medical facilities, for treatment of injuries received as the result of a covered accident. The transport must be within 48 hours after the covered accident. This benefit is payable once per covered accident.

Ambulance, Ground: Transport by a licensed professional ambulance company to or from a hospital or between medical facilities, for treatment of Injuries received as the result of a covered accident. The transport must be within 90 days after the covered accident. This benefit is payable once per covered accident.

Emergency Room Treatment: Examination and treatment by a doctor in an emergency room within 7 days after a covered accident. This benefit is payable once per covered accident. Exception: If you are also eligible for an initial doctor visit benefit, the initial doctor visit benefit amount will be subtracted from the emergency room treatment benefit.

Initial Doctor Visit: Examination and treatment by a doctor within 14 days after a covered accident. This benefit is payable once per covered accident. Exception: If you are also eligible for an emergency room treatment benefit or the urgent care facility treatment benefit, the initial doctor visit benefit will be subtracted from those treatment benefits.

Follow-Up Doctor Treatment: Follow-up treatment by a doctor within 180 days after a covered accident and be completed within 12 months after the covered accident. This benefit is only available if you are eligible for the initial doctor visit benefit or the emergency room treatment benefit. This benefit is payable once per covered accident.

Major Diagnostic Exams: A major diagnostic exam must be prescribed by a doctor and must occur within 6 months after the covered accident. This benefit is payable once per covered accident.

Medical Equipment: The medical equipment must be prescribed by a doctor and use must begin within 90 days after the covered accident. This benefit is payable once per covered accident. The types of eligible equipment are:

Crutches
Wheelchair
Back brace
Leg brace
Walker

Outpatient Surgery: Miscellaneous surgery that is not covered by any other specific sum injury benefit. The surgery must take place within 30 Days after a covered accident. Only one surgery benefit is payable per 24-hour period even though more than one surgical procedure may be performed. Only one surgery benefit is payable per covered accident. No benefit is payable for hernia repair.

Physical or Occupational Therapy: Therapy must be prescribed by a doctor and provided by a physical therapist or by an occupational therapist in an office or Hospital or a Rehabilitation Facility on an inpatient or outpatient basis. The therapy must begin within 180 days after a covered accident and be completed within 12 months after the covered accident. This benefit is payable up to 6 times per covered accident.

Prosthetic Device: You receive a prosthetic device prescribed by a doctor for use following the loss of use of a hand, a foot or the sight of an eye. The prosthetic device must be received within one year of a covered accident. The benefit amount varies based on the number of prosthetic devices received. This benefit is payable once per covered accident. Prosthetic devices do not include any of the following:

Hearing aids
Dental aids including false teeth
Eye-glasses
Artificial joints
Cosmetic prostheses such as hair wigs

Speech Therapy: Speech therapy must be prescribed by a doctor and provided by a speech therapist in an office or a Rehabilitation Facility on an inpatient or outpatient basis. The therapy must begin within 180 days after a covered accident and be completed within 12 months after the covered accident. This benefit is payable 6 times per covered accident.

Urgent Care Facility Treatment: Examination and treatment by a doctor in an Urgent Care Facility within 7 days after a covered accident. This benefit is payable once per covered accident. Exception: If you are also eligible for an Initial Doctor Visit benefit, the Initial Doctor Visit benefit amount will be subtracted from the Urgent Care Facility treatment benefit. If you are also eligible for an Emergency Room treatment benefit, the Urgent Care Facility treatment benefit will be subtracted from the Emergency Room treatment benefit.

X-ray: An x-ray must be prescribed by a Doctor. This benefit is payable within 90 days of a covered accident and is payable once per covered accident.

Common Injuries Benefits

Burns: The burn must be treated by a doctor within 72 hours after a covered accident. The benefit amount varies based on the burn classification. If Your burns meet more than one of the burn classifications, the higher amount will be payable. This benefit is payable once per covered accident.

Concussion: The concussion must be diagnosed by a doctor within 72 hours after a covered accident. The diagnosis must be confirmed by the use of some type of medical imaging procedure; i.e. x-ray, CAT scan, or MRI.

Dislocations: The dislocation must be diagnosed by a doctor within 90 days after a covered accident. The dislocation must require open or closed reduction by a doctor. The benefit amount will vary based on the type of services received.

If the reduction is done without anesthesia, the benefit will be reduced to 25% of what would have been paid for a closed reduction of the same joint.
If the dislocation is incomplete, the benefit will be reduced to 25% of what would have been paid for a closed reduction of the same joint.

If you receive more than one dislocation in the same covered accident, a benefit is payable for all dislocations. However, the benefit will be no more than two times the benefit amount for the joint involved which pays the highest benefit amount.

If you receive a dislocation and a fracture in the same covered accident, a benefit is payable for both. However, the benefit will be no more than two times the amount for the bone or joint involved which pays the highest benefit amount.

If you receive a dislocation or a fracture and you tear, rupture, or sever a tendon/ligament/rotator cuff in the same covered accident, only one benefit is payable. The benefit payable will be the largest of the dislocation, the fracture, or the tendon/ligament/rotator cuff benefit.

This benefit is payable once per covered accident. Exception: Subsequent dislocations of the same joint in a different covered accident are not covered.

Emergency Dental Work While Hospital Confined: Natural teeth must be damaged due to a covered accident and either extracted or repaired by the placement of a crown. The benefit amount varies based on the type of services received. This benefit is payable once per covered accident regardless of the number of teeth involved.

Eye Injury: The eye injury must be treated by a doctor within 90 days after a covered accident. The injury must require surgery or the removal of a foreign object by a doctor. The benefit amount varies based on the type of services received. This benefit is payable once per covered accident. No benefit is payable for examination with anesthesia or for an injury to the eyelid.

Fractures: The fracture must be diagnosed by a doctor within 90 days after a covered accident. The fracture must require open or closed reduction by a doctor. If the doctor diagnoses the fracture as a chip fracture, the benefit will be reduced to 25% of what would have been paid for a closed reduction of the same bone. The benefit amount varies based on the type of services received.

If you receive more than one fracture in a covered accident, a benefit is payable for all fractures. However, the benefit will be no more than two times the benefit amount listed for the bone which pays the highest benefit amount.

If you receive a fracture and a dislocation in the same covered accident, a benefit is payable for both. However, the benefit will be no more than two times the amount for the bone or joint involved which pays the highest benefit amount.

If you receive a fracture or a dislocation and you tear, rupture, or sever a tendon/ligament/rotator cuff in the same covered accident, only one benefit is payable. The benefit payable will be the largest of the fracture, the dislocation, or the tendon/ligament/rotator cuff benefit.

Laceration: The laceration must be treated by a doctor within 72 hours after a covered accident. The benefit amount will be based on the total length of all lacerations requiring repair that are received in any one covered accident. If the laceration is severe enough to require stitches but the doctor chooses to repair it another way, the benefit will be determined as if the laceration was stitched. This benefit is payable once per covered accident.

Paralysis: Paralysis must be confirmed by a doctor and based on documented evidence of the injury that caused the paralysis. The duration of the paralysis must be at least 30 days and expected to be permanent. The benefit amount varies based on the degree of paralysis. This benefit is payable once per covered accident.

Ruptured Disk: You must receive surgical repair of a ruptured disk. The ruptured disk must be treated by a doctor within 90 days after a covered accident. Surgical repair by a doctor is required within one year after the covered accident. This benefit is payable once per covered accident.

Skin Graft: The skin graft is for a burn for which a benefit was paid under the burn benefit in this section. This benefit is payable once per covered accident.

Tendon/Ligament/Rotator Cuff: The tendon, ligament, or rotator cuff must be torn, ruptured, or severed and repaired through surgery within 90 days after a covered accident. The benefit amount varies based on the number of repairs required and the services received. This benefit is payable once per covered accident.

If You receive a dislocation or a fracture and you tear, rupture, or sever a tendon/ligament/rotator cuff in the same covered accident, only one benefit is payable. The benefit payable will be the largest of the dislocation, the fracture, or the tendon/ligament/rotator cuff benefit.

Torn Knee Cartilage: You must receive surgical repair of torn knee cartilage. The injury must be treated by a doctor within 60 days after a covered accident. Surgical repair of the tear must occur within six months after the covered accident. The benefit amount varies based on the type of service received. This benefit is payable once per covered accident.

Additional Benefits

Sports Accident Benefit: An additional percentage of the Accident Hospital Care, Accident Care or Common Injuries
benefit amount is payable if the covered accident is the result of an Organized Sporting Activity. This benefit does not apply to any additional benefits provided under a separate rider.