Accident

Hip

$4,000

$2,000

Knee, ankle, or bones of the foot

$2,000

$1,000

Elbow, wrist or Lower jaw

$800

$400

Shoulder

$1,000

$500

Collarbone or bones of the hand

$1,600

$800

Finger(s) or toe(s)

$200

$100

Fractures

Hip or thigh

$4,000

$2,000

Skull-depressed

$6,000

$3,000

Skull-simple

$3,000

$1,500

Vertebral processes, Bones of the face or Nose

$700

$350

Leg

$2,000

$1,000

Vertebrae, Sternum or Pelvis

$1,600

$800

Upper jaw or upper arm

$750

$375

Lower jaw, Collarbone, Shoulder, Forearm, Hand, Wrist, Foot, Ankle,
Kneecap, Elbow or Heel

$650

$325

Rib, Finger, Toe or Coccyx

$350

$175

Multiple ribs

$1,000

$500

Eye Injury - surgical repair

$250

Eye Injury - object remove

$250

Gunshot wound

$500

Paralysis—paraplegia

$25,000

Paralysis—quadriplegia

$50,000

Coma

$10,000

Concussion

$100

21-40 square centimeters

$400

$1,000

41-65 square centimeters

$800

$2,000

66-160 square centimeters

$1,200

$6,000

161-225 square centimeters

$1,600

$14,000

More than 225 square centimeters

$2,000

$20,000

Skin graft

50% of the applicable Burn Benefit

50% of the applicable Burn Benefit

No sutures and treated by doctor

$35

Single laceration under 5 cm with sutures

$65

5-15 cm with sutures (total of all lacerations)

$250

Greater than 15 cm with sutures (total of all lacerations)

$500

Medical Services

Diagnostic Exam - Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI (1 time per benefit year)

$200

Diagnostic Exam - X-ray (1 time per covered accident)

$50

Accident Emergency Treatment, non-emergency room (once per covered accident)

$150

Physician's Follow-up Treatment office visit (per visit, up to 6 times per covered accident)

$25

Physical Therapy (per visit up to 10 visits per covered accident)

$25

Medical Devices

$125

Epidural Pain Management (up to 2 times per covered accident)

$50

Prescription drug

$25

Prosthesis (one)

$500

Prosthesis (two)

$1,000

Blood, Plasma, or Platelet Transfusion

$200

Hospital

Hospital Admission (once per benefit year)

$1,000

Hospital Confinement (per day up to 365 days per covered accident)

$250

Intensive Care Unit Admission (once per Benefit Year; payable instead of Hospital Admission benefit if
Confined immediately to ICU)

$1,500

Intensive Care Unit Confinement
(per day up to 15 days, payable in addition to any Hospital Confinement benefit)

$500

Ambulance (Ground)

$200

Ambulance (Air)

$1,500

Emergency Room Admission

$150

Family Lodging (per day up to 30 days per benefit year)

$100

Transportation (100 or more miles up to 3 times per covered accident)

$500

Rehabilitation Unit (per day up to 30 days per covered accident)

$100

Surgery

Miscellaneous Surgery requiring general anesthesia (not covered by any other benefit)

$300

Open Surgery

$1,250

Exploratory Surgery or Debridement

$250

Tendon/Ligament/Rotator Cuff Tear

$625

Torn Knee Cartilage

$625

Ruptured/Herniated Disc

$625

Emergency Dental

Emergency Dental extraction

$65

Emergency Dental crown

$200

Wellness

Wellness Screening Benefit (once per benefit year)

$50

Employee

$8.63

Employee + Spouse

$11.63

Employee + Child(ren)

$12.83

Family

$15.83