A. Dislocations (reduced under general anesthesia)

Hip

Open reduction
Closed reduction
 

$2,000
$665

$4,000
$1,330

Knee or shoulder

Open reduction
Closed reduction
 

$665
$265

$1,330
$530

Collar bone

Open reduction
Closed reduction
 

$1,065
$200

$2,130
$400

Ankle or foot (excluding toes)

Open reduction
Closed reduction
 

$665
$200

$1,330
$400

Lower jaw

Open reduction
Closed reduction
 

$665
$330

$1,330
$665

Wrist or elbow

Open reduction
Closed reduction
 

$530
$265

$1,065
$530

Toe or finger

Open reduction
Closed reduction

$130
$65

$265
$130
 

B. Tendons and Ligaments

Tendons and ligaments must be torn, ruptured or severed and must be treated by a physician within 72 hours after the Covered Accident and repaired through surgery within six months after the Covered Accident. If a Covered Person receives a fracture and/or a dislocation and also tears, ruptures, or severs a tendon/ ligament in a Covered Accident, the Insurer will pay only one benefit. The Insurer will pay the largest of this benefit, the Fractures Benefit or the Dislocation Benefit.

Repair of one
Repair of all if more than one
 

$330
$665

$665
$1,330

C. Burns
(Treated by a physician within 72 hours after the accident)

1. Second-degree burns of at least 25% - 35% of body surface

2. Second-degree burns of more than 35% of body surface

3. Third-degree burns covering 6 through 9 square inches of body surface

4. Third-degree burns covering 10 through 25 square inches of body surface

5. Third degree burns covering more than 25 square inches of body surface
 

$265

$665

$530

$1,330

$2,665

$530

$1,330

$1,065

$2,665

$5,330

D. Ruptured Disc or Torn Knee Cartilage

Must be treated by a physician within 72 hours after the accident and repaired through surgery within one year after the Covered Accident.

Accident during first year of coverage
Thereafter
 

$130
$400

$265
$800

E. Eye Injury

With surgical repair
 

$130

$265

Accident Follow-up Treatment Benefit

Pays for additional treatment of injuries sustained in a Covered Accident over and above emergency treatment administered within 72 hours following the accident. This benefit is payable for up to a maximum of three treatments per Covered Person per Covered Accident. Such treatment must begin within 30 days of the Covered Accident or discharge from the hospital or extended care facility, and be within the six-month period following the Covered Accident or discharge. Treatments must be furnished by a physician in a physician’s office or in a hospital on an outpatient basis. (Benefits will not be paid for services rendered by a member of the immediate family of a Covered Person.)
 

$25/visit

$25/visit

Accident Emergency Treatment Benefit

Pays for emergency treatment for a Covered Accident, we will pay the amount shown in the Policy Schedule for treatment received. This benefit is payable for treatment by a physician, x-rays or treatment received in a hospital emergency room. Treatment must be received within 72 hours of such accident for benefits to be payable. This benefit is payable once per Covered Accident. (Benefits will not be paid for services rendered by a member of the immediate family of a Covered Person.)

Insured & Spouse
Children
 

$100
$70

$150
$105

Initial Hospitalization For Injury Benefit

When a Covered Person is hospital confined for 24 hours or more for a covered accidental bodily injury, the Insurer will pay the benefit amount shown in the Policy Schedule. This benefit is payable only once per Hospital Confinement and only once for each Covered Person per calendar year.
 

$500

$1,500

Accident Hospital Income Benefit

Pays for hospital confinement for treatment of a Covered Accident, the Insurer will pay the daily amount shown in the Policy Schedule for each day of such confinement. Such confinement must start within 30 days of the accident. The Insurer will pay this benefit for up to 365 days per Covered Accident.
 

 $100/day

 $200/day

Additional Intensive Care Unit Benefit

Pays an additional benefit equal to three times the Accidental Hospital Income Benefit for each day the Covered Person is confined in an Intensive Care Unit (ICU). This ICU benefit is payable for up to 15 days per Covered Accident.
 

$300/day

 $600/day

Ambulance Benefit

Pays for ambulance transportation to a hospital or emergency center for injuries sustained in a Covered Accident. Ambulance transportation must be within 72 hours of the accident. Pays four times the Ambulance Benefit for transportation provided by an air ambulance. The hospital or emergency center must be within 100 miles of the site of the accident or residence of the Covered Person. A licensed professional ambulance company must provide the ambulance service. Benefit is limited to one trip per Covered Accident per Covered Person.

Ground Ambulance
Air Ambulance
 

$150
$600

$150
$600

Appliances Benefit

Pays if a physician advises a Covered Person to use a medical appliance as an aid in personal mobility as a result of injuries sustained in a Covered Accident. Benefits include and are payable for:  crutches, leg braces, wheelchairs, and walkers. This benefit is not payable for prosthetic devices. Benefit is payable once per Covered Accident per Covered Person.
 

 $100

 $150

Physical Therapy Benefit

Pays if a physician advises a Covered Person to seek treatment from a physical therapist. Physical therapy must be for injuries sustained in a Covered Accident and must start within 30 days of such accident or discharge from the hospital. Pays for one treatment per day for up to six treatments per Covered Accident. The six treatments must take place within six months after the accident.
 

$50/day

$75/day

Prosthesis Benefit

Pays if a Covered Person requires use of a prosthetic device as a result of a Covered Accident. This benefit is payable once per Covered Accident per Covered Person. Benefit is not payable for hearing aids or any dental aids (including false teeth).
 

$500

$750

Transportation Benefit

Pays for transportation to a hospital for special treatment and confinement for injuries sustained in a Covered Accident. This benefit is payable for the trip to the hospital. The local attending physician must prescribe the treatment, and the treatment must not be available locally. This benefit is not payable for transportation to any hospital located within a 100-mile radius of the site of the accident or residence of the Covered Person. This benefit is payable for up to three trips per calendar year per Covered Person.
 

$300

$300

Pays for one motel or hotel room for a member (or members) of the immediate family to accompany the Covered Person for hospital confinement for the treatment of injuries sustained in a Covered Accident. This benefit is payable only during the same period of time the injured Covered Person is confined to the hospital. Benefit is not payable for the trip to the hospital. The hospital and the motel or hotel must be more than 100 miles from the residence of the Covered Person. The local attending physician must prescribe the treatment. This benefit is payable for up to 30 days per Covered Accident.

$100/day

$100/day

After 12 months of paid premium for this benefit, the Insurer will pay for an Insured to undergo routine examinations or other preventive testing. Benefits include and are payable for: annual physical exams; mammograms, pap smears, immunizations, flexible sigmoidoscopy, Prostatic Specific Antigen, and blood screenings. This benefit will become available following each anniversary of this Rider ’s Effective Date, and is payable only once each 12-month period. Family members include an insured employee’s spouse and dependent children. Services must be under the supervision of, or recommended by a physician, and a charge must be incurred.
 

$60/year

$60/year

Transportation Benefit

Pays for transportation to a hospital for special treatment and confinement for injuries sustained in a Covered Accident. This benefit is payable for the trip to the hospital. The local attending physician must prescribe the treatment, and the treatment must not be available locally. This benefit is not payable for transportation to any hospital located within a 100-mile radius of the site of the accident or residence of the Covered Person. This benefit is payable for up to three trips per calendar year per Covered Person.
 

$300

$300