Benefit
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Covered
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Basic Plan
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Premier Plan
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Medical Expenses-We pay up to amount shown for doctor fees, xrays, emergency services and repair to sound natural teeth, if diagnosed by a licensed dentist to be a result of the accident.*
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Insured
Spouse
Children
|
up to $250
up to $250
up to $250
|
up to $500
up to $500
up to $500
|
Ambulance (needed as a result of accidental injury)-We pay the amount shown for transfer to or from a hospital by regular ambulance. We pay the amount shown for transfer to or from a hospital by air ambulance.
|
Insured
Spouse
Children
|
$100
$200
|
$200
$400
|
Hospital Confinement-We pay the amount shown for each day a covered person is admitted to and confined as an inpatient in a hospital up to a maximum of 90 days for each period of continuous hospital confinement.*
|
Insured
Spouse
Children
|
$100/day
$100/day
$100/day
|
$200/day
$200/day
$200/day
|
Dislocation or Fracture-We pay up to maximum amount shown. Amount paidbased on injury (see Injury Benefit Amounts listed in brrochure AWD9079 or in the policy). No benefit will be paid for any dislocation or fracture that is not listed in the Injury Benefit Amounts chart.
|
Insured
Spouse
Children
|
up to $2000
up to $1000
up to $500
|
up to $4000
up to $2000
up to $1000
|
Loss of Life or Limbs-We pay maximum amount shown for death. Losses of limb benefit amounts are based on injury (see Injury Benefit Amounts in accident brochure AWD9079 or in the policy)> If an accident occurs while a covered person is a fare-paying passenger on a scheduled common carrier, we pay a benefit equal to 3 times the amount shown.
|
Insured
Spouse
Children
|
up to $20,000
up to $10,000
up to $5,000
|
up to $40,000
up to $20,000
up to $10,000
|
Disability (Primary Insured only)-We pay the amount shown when the primary insured is totally disabled for 3 full days; payable for only one disability at a time; maximum benefit period 6 months. For any period of disability less than one full month, 1/30th of the monthly disability amount is paid for each day of total disability. The primary insured is totally disabled when, due to an accidental injury as defined in the policy, is under the care of a physician, unless the physician states that no further treatment is needed; and is not able to do any and every important duty o his or her regular job (if the primary insured is retired, he or she must be unable to engage in the normal and necessary activities of a retired person of like age and good health); and is not working at any job for pay or profit.
|
Insured
Spouse
Children
|
$600/month
n/a
n/a
|
$1200/month
n/a
n/a
|
Outpatient Physician's Treatment Benefit Rider (APOPTR1)-We pay the amount shown when a covered person is treated by a physician outside of a hospital. This benefit is limited to 2 visits per calendar year, per covered person; and a maximum of 4 visits per calendar year if the policy is in force as family coverage. Treatment can be for sickness, annual wellness exams, or other visits to a physician outside of a hospital.
|
Insured
Spouse
Children
|
$50/visit
$50/visit
$50/visit
|
$100/visit
$100/visit
$100/visit
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BASIC PLAN PREMIUMS
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PREMIER PLAN PREMIUMS
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||
Monthly Bankdraft
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Annual
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Monthly Bankdraft
|
Annual
|
Individual $29.56
|
Individual $340.88
|
Individual $57.03
|
Individual $656.76
|
Family $53.96
|
Family $622.39
|
Family $105.83
|
Family $1,220.78
|