Mark III Employee Benefits - Robeson County Government, NC

¹ National Safety Council, Report on Injuries in America, 2003. Use of statistics does not imply endorsement.

Schedule of Benefits	Plan I	Plan II
Accident Specific Sum Injuries Benefit Pays for dislocations, burns, ruptured discs and torn knee cartilage, eye injuries, lacerations, internal injuries, fractures, and blood and plasma. See Rider for specific amounts payable, definitions, and limitations for each specific accident. (Benefits will not be paid for services rendered by a member of the immediate family of a Covered Person.)	$30 – $2,000	$60 – $4,000
The following is an example of the Policy Schedule Benefits.
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
Family Lodging Benefit 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
Wellness Benefit 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
Accidental Death Benefit Death must occur as a result of a Covered Accident and must occur within 90 days of a Covered Accident.

PLAN I
	Insured	Spouse		Child
Common-Carrier Accidents Motorized-Vehicle or Pedestrian Accidents Other Accidents	$35,000 25,000 15,000	$17,500 $12,500 $7,500		$3,500 $2,500 $1,500
PLAN II
Common-Carrier Accidents Motorized-Vehicle or Pedestrian Accidents Other Accidents	$70,000 50,000 30,000	$35,000 25,000 15,000		$7,000 $5,000 $3,000
Accidental Dismemberment Pays a percentage of the Accidental Death Benefit selected.			PLAN I		PLAN II
Both arms and both legs Two arms or two legs Two eyes, hands, or feet One eye, hand, foot, arm, or leg One or more fingers and/or one or more toes			100% 50% 50% 20% 5%		100% 50% 50% 20% 5%

Renewability
You are guaranteed the right to renew this policy for your lifetime by the payment of premiums in effect at the beginning of each term. You can never be singled out for a rate increase. Rates can be changed only if the rate is changed for all policies of this class. While this policy is in force, no change will be made because of your age or physical condition.

Effective Date
The Effective Date of the policy and riders will be the date shown on the Policy Schedule or endorsement, not the date the application is signed.

Issue Aages
AccidentSelect is available to individuals 18 - 64. Coverage is available for your eligible dependent children under age 19, if living with the Insured (through age 24 if the child is a full-time student). This may vary by state.

Family Coverage
Spouse and dependent children coverage is available. Family Coverage includes the insured, his or her spouse, and or dependent children under age 19, if living with the insured (through 24 if the child is a full-time student. This may vary by state. Newborn children are automatically covered under the terms of the policy from the moment of birth. Single-Parent Coverage includes the insured and all of his or her dependent children who are unmarried and under 25.

Time Limit on Certain Defenses
(1) Misstatements in the Application: After two years from the issue date only fraudulent misstatements in the application may be used to void the policy or deny any claim for loss incurred or disability that starts after the two-year period.

(2) Pre-Existing Conditions: Benefits for a loss that occurs more than two years after the date the policy is issued will not be reduced or denied because the condition causing the loss existed before the effective date, unless the condition is specifically excluded from coverage.

Fraudulent Misstatement
If a fraudulent misstatement is made in the application for this policy, the insurer may reduce or deny any claim or void the policy at any time.

additional limitations and exclusions
The Insurer will not pay benefits for a Covered Accident that is caused by or occurs as a result of:

a) Driving any taxi or intrastate or interstate long-distance vehicle for wage, compensation or profit. (Does not apply in Iowa.)

e) Participating in any sport or activity for wage, compensation or profit; or racing any type vehicle in an organized event. (Does not apply in Iowa.)

f) Travel in, or descent from any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a commercial airline (other than a chartered airline) on a regularly scheduled passenger trip.

h) Participating in any activity or event, including the operation of a vehicle, while under the influence of a controlled substance (unless administered by a physician or taken according to the physician’s instructions), or committing an illegal act while intoxicated (intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred).

i) Participating in, or an attempt to participate in, an illegal activity that is defined as a felony, whether charged or not. (A felony is defined by the law of the jurisdiction in which the activity takes place.) (Does not apply in Iowa.)

j) Intentionally self-inflicted bodily injury or attempting suicide, while sane or insane (while sane in Missouri).

k) Any loss incurred while on active duty status in the armed forces. (If the Insurer is notified of such active duty, a refund will be provided for any premiums paid for any period for which no coverage is provided as a result of the exception.)

Premiums Rates - Plan I Class B
Individual	Single Parent Family	Two-Adult Family	Family
$12.06	$17.85	$17.37	$23.16


Premiums Rates - Plan II Class B
Individual	Single Parent Family	Two-Adult Family	Family
$20.33	$31.55	$30.46	$41.68