| BENEFIT | BENEFIT AMOUNT | DESCRIPTION OF COVERAGE |
| Accidental Death | $20,000 for Primary Insured,
$10,000 for Spouse &
$5,000 for a Child | We will pay the applicable lump sum benefit indicated for Accidental Death of a Covered Person to the beneficiary as Provided under the Payment of Benefits provision of this Policy. Accidental Death must occur within 90 days of a covered accident. |
| Accidental Dismemberment | $20,000 for both: arms, legs,
eyes, hands, or feet.
$10,000 for one: arm, leg, eye,
hand or foot.
$1,000 for one or more fingers
or toes. | We will pay the applicable lump sum benefit indicated when dismemberment occurs as a result of accidental injury within 90 days of a covered accident. Loss of use does not constitute dismemberment except for eye injury resulting in loss of the eye or permanent loss of vision such that central vision acuity cannot be corrected to better than 20/200. Only the highest single benefit per Covered Person will be paid for dismemberment. Benefits will be paid only once per covered Person, per covered accident. |
| Accident Follow-up Treatment | $25 per day for treatment, up to a maximum of three treatments | Payable when additional treatment is required over and above emergency accident treatment within the first 72 hours following the accident. The first additional treatment must occur within 30 days of the covered accident in a physician’s office or hospital emergency room. This treatment is not payable on the same day as payment is made for physical therapy. |
| Ambulance | $300 per covered accident for ground or air ambulance per Covered Person | Payable when a Covered Person requires ambulance transportation to a hospital for injuries sustained in a covered accident. The service must be provided by a licensed or professional ambulance company. |
| Concussion Benefit | $100 per covered accident, per Covered Person | Payable when a concussion is diagnosed by any type of imaging within 72 hours of the covered accident. |
| Disability | Not to exceed $1,000 per month up to 3 months | Payable when Primary Insured is totally disabled due to injuries resulting from an accident. Up to $1,000 per month benefit paid after a 7 day elimination period, prorated daily with a $3,000 benefit maximum. |
| Durable Equipment | Up to $40 per covered accident, per Covered Person | Provides for medical equipment prescribed by a physician to aid in the recovery from a covered accident. This benefit includes but is not limited to: a wheelchair, crutches, leg brace/support, knee immobilizer, neck collar, splints, slings, a back brace, or a walker. |
| Emergency Accident Treatment | $200 once per covered accident, per Covered Person | Payable when a Covered Person receives treatment within 72 hours resulting from a covered accident. This benefit is payable for treatment by a physician or treatment received in an emergency room or ambulatory surgical center. |
| Emergency Dental Work | $75 per covered accident, per Covered Person | Payable once for emergency dental treatment per Covered Person per covered accident. Emergency dental work does not include false teeth such as dentures, bridges, veneers, partials, crowns, or implants. |
| Hospital Confinement
due to Accident | $200 per day up to 365 days per covered accident, per Covered Person | Payable when a Covered Person is admitted for a hospital confinement of at least 18 hours within 30 days of the covered accident. Not paid for days for which the Intensive Care Benefit is paid. |
| Intensive Care Confinement | $500 per day up to 15 days | Payable when a Covered Person is confined for up to 15 days in a Hospital Intensive Care Unit as the result of the covered accident. Not paid in addition to the Hospital Confinement benefit. |
| Initial Hospital Admission | $300 per covered accident, per Covered Person | Payable when a Covered Person is admitted for a Hospital confinement of at least 18 hours resulting from a covered accident. Hospital confinement must begin within 30 days of the covered accident. This benefit does not apply to an emergency room visit. |
| MRI, CT, CAT, X-ray, or PET Scan | $75 per covered accident, per Covered Person | Payable when a Covered Person receives one of these procedures for injuries sustained in a covered accident. |
| Paralysis | $2,500 per Lifetime, per Covered Person | Payable for Paraplegia, Hemiplegia or Quadriplegia. |
| Physical Therapy | $25 per treatment per day, up to a maximum of 10 treatments per covered accident, per Covered Person | Payable when physical therapy is received for injuries sustained in a covered accident for which the initial treatment was received within 72 hours. Therapy must begin within 30 days of the covered accident and received within 6 months after the accident. This benefit is not payable for the same date that the Accident Follow-Up Treatment Benefit is paid. |
| Prosthesis | $750 per covered accident, per Covered Person | Payable when a Covered Person receives a prosthetic device as a result of injuries sustained in a covered accident. This benefit is not payable for repair or replacement of prosthetic devices, hearing aids, wigs, or dental aids, including false teeth. |
| Hospital Confinement Rider
due to Sickness (Not available in TN) | $200 per day for each day of inpatient hospital confinement due to sickness | • We will pay the daily benefit amount for each day that a covered person is confined for at least 18 hours as an inpatient in a licensed hospital due to sickness. The Daily Benefit for sickness which is medically necessary while this policy is in force is limited to 365 days for any one sickness.
• The Daily Benefit is reduced by 50% while confined due to mental or nervous disorders. The most we will pay is 30 days each confinement. You must be out of the hospital at least 90 days for a new confinement to be considered.
• This Rider does not pay for confinement in a U.S. government hospital. |