LIMITED MEDICAL 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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