CO-PAY PLANS

Maximum Medical Expense Accident & Sickness
Benefits will be paid for covered Medical Expenses that are incurred while the Covered Person's coverage is in force. The Covered Person must be under a Doctor's care, and the treatment must be medically necessary, for covered Injury or Sickness

Plan 1: $1,500
Plan 2: $2,500
Plan 3: $3,500
Plan 4: $5,000

Deductible
This is the amount of eligible Medical Expenses which must be satisfied for each covered loss before benefits are payable under the policy.

Plan 1: $200
Plan 2: $200
Plan 3: $150
Plan 4: $150

Coinsurance:
The portion of eligible medical expenses that the company will pay (after the deductible has been satisfied).

Plan 1: 50%
Plan 2: 60%
Plan 3: 70%
Plan 4: 80%

Office Visit Co-pay / Max Payment
This benefit applies to the physician charge only. Benefits payable under this benefit are applied to the per occurrence maximum

Plan 1: $20 co-pay / $40 per visit
Plan 2: $20 co-pay / $50 per visit
Plan 3: $15 co-pay / $60 per visit
Plan 4: $15 co-pay / $60 per visit

Additional In Patient Hospital Benefit. This benefit is payable after the basic benefit is exhausted.

Plan 1: $300 per day
Plan 2: $400 per day
Plan 3: $500 per day
Plan 4: $500 per day

In/Out Patient Surgery:
Plan 1: $1,500 per occurrence
Plan 2: $2,500 per occurrence
Plan 3: $3,500 per occurrence
Plan 4: $5,000 per occurrence

Diagnostic Lab & X-Ray
This maximum applies to all x-rays and lab test performed on an out-patient basis for one occurrence. Benefits paid under this benefit are applied to the per occurrence maximum.

Plan 1: $500
Plan 2: $750
Plan 3: $1,000
Plan 4: $1,000

Emergency Room Visit Deductible
This Deductible does not apply to visits do to an accidental bodily injury or if the Emergency Room Visit which results in admission to a Hospital. This Deductible only applies to charges billed by the Hospital.

Plan 1: $250
Plan 2: $250
Plan 3: $250
Plan 4: $250

Accidental Death:
If bodily Injuries result in the loss of the Covered Person's life within the Loss Period stated on the Schedule of Benefits, we will pay the Principal Sum shown on the Schedule of Benefits.

Plan 1: $5,000
Plan 2: $10,000
Plan 3: $10,000
Plan 4: $10,000

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