LIMITED MEDICAL INDEMNITY PLANS

Daily Hospital Confinement Benefit
Pays daily benefit, due to a covered injury or sickness, for an inpatient hospital Confinement at the direction of a physician. We will pay up to a maximum of 180 days per confinement, unless confinement is due to a mental or emotional disorder. We will pay up to a maximum of 30 days per confinement for a mental or emotional disorder.

Plan 1: $100 per day
Plan 2: $200 per day
Plan 3: $400 per day
Plan 4: $700 per day
Plan 5: $1,000 per day

Intensive Care/Coronary Care Benefit Rider
Pays a daily benefit for confinement in a Hospital Intensive Care Unit or Hospital Coronary Unit due to an injury or sickness, up to a maximum of 20 days per confinement. Each period of confinement must be separated by a period of at least 30 days. This benefit is in lieu of the Daily Hospital Confinement Benefit.

Plan 1: $100 per day
Plan 2: $200 per day
Plan 3: $400 per day
Plan 4: $700 per day
Plan 5: $1,000 per day

Emergency Accident Rider
Pays incurred expenses, not to exceed the maximum benefit selected, for treatment of an injury requiring immediate attention by a Physician in the Physician’s Office, Clinic, Urgent Care Facility or Hospital Emergency Room. This benefit is subject to a maximum of 2 visits per calendar year per Covered Adult, except for Covered Dependent Children. The maximum number of visits for all Dependent Children combined is 2 visits per calendar year.

Plan 1: $300 per accident
Plan 2: $300 per accident
Plan 3: $300 per accident
Plan 4: $300 per accident
Plan 5: $300 per accident

Annual First Occurrence Hospital Confinement Rider
Pays a lump sum benefit the first time each calendar year an Insured is confined to a hospital as an inpatient. The confinement must be due to an injury or sickness and at the direction of a physician.

Plan 1: N/A
Plan 2: N/A
Plan 3: $300 per year
Plan 4: $500 per year
Plan 5: $1,000 per accident

Surgical & Anesthesia Benefit Rider
Pays actual charges, not to exceed the scheduled amount for Surgery performed, due to a covered injury or sickness by a physician. Scheduled amounts are based on the selected benefit amount multiplied by the maximum percentage of surgical benefit shown in the rider. We will only pay for one surgical procedure regardless of the number of procedures performed at the same time. We will pay actual charges the for anesthesia administered by a physician in connection with the surgery, up to 25% of the amount paid for the surgical procedure.

Plan 1: N/A
Plan 2: N/A
Plan 3: $2,000 max
Plan 4: $2,000 max
Plan 5: $3,000 max

Outpatient Sickness Rider
Pays the selected benefit for treatment of a covered sickness by a Physician in a Physician’s Office, Clinic, Urgent Care Facility or Emergency Room. This benefit is subject to a maximum number of visits per calendar year for Covered Adults and Covered Dependent Children. The maximum number of visits is 5 per adult, 5 for all dependent children and 10 for all persons combined.

Plan 1: $50 per visit
Plan 2: $50 per visit
Plan 3: $50 per visit
Plan 4: $50 per visit
Plan 5: $75 per visit

Wellness Benefit
Pays $75 for covered routine examinations or other preventative testing. Benefit is payable once per person per calendar year up to two times per family per calendar year. The following examinations and tests are covered by this benefit: Mammography, Pap Smear, Flexible Sigmoidoscopy, Colonoscopy, Cholesterol and Diabetes Screening, PSA, EKG, and Chest X-ray.

Plan 1: $75 per year
Plan 2: $75 per year
Plan 3: $75 per year
Plan 4: $75 per year
Plan 5: $75 per year

Diagnostic Testing Benefit
Pays actual charges, up to $250 per calendar year, for diagnostic tests not covered under the Wellness Benefit. Benefit is payable once per person per calendar year and two times per family per calendar year. This benefit will be reduced by any payment received under the Wellness Benefit for the same test in the same calendar year. The maximum benefit per covered person is $250 per calendar year not to exceed $500 per family per calendar year.

Plan 1: $75 per year
Plan 2: $75 per year
Plan 3: $75 per year
Plan 4: $75 per year
Plan 5: $75 per year

Term Life
Employee: $10,000
Spouse: $5,000
Child: $1,000

Back