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Plan Description

Member Eligibility Definition

Active Members under the age of 65.

Minimum Hours Requirement

Does not apply

Definition of Dependents

Spouse/Domestic Partner under the age of 65.

Children from Live Birth to Age 26.

Dependent Eligibility Rules

  • Member Coverage is required for Dependent Coverage.

  • A person may not be covered as both a Member and a Dependent.

  • A person may only be covered as a Dependent by one participating Member.

  • Dependent Nonconfinement rules apply

Eligibility may be subject to state laws and regulations

Benefit Waiting Period

None

Coverage Type

24 Hour

Accident Day Limit

90 days

Guaranteed Issue

All Amounts

Age Reduction Schedule

Does not apply

Accidental Death Benefit

Loss of Life

For Members

$25,000

For Member’s Spouse or Domestic Partner

$12,500

For Member’s Child

$6,250

   

Common Carrier Benefit

Common Carrier

For Members

$75,000

For Member’s Spouse or Domestic Partner

$37,500

For Member’s Child

$18,750

   

Accidental Dismemberment Benefit

Dismemberment

Dismemberment, loss of all toes on one foot

$ 2,500

Dismemberment, loss of big toe

$ 2,500

Dismemberment, loss of both hands

$10,000

Dismemberment, loss of both feet

$10,000

Dismemberment, loss of four fingers of the same hand

$ 2,500

Dismemberment, loss of one arm

$ 5,000

Dismemberment, loss of one-foot

$ 5,000

Dismemberment, loss of one hand

$ 5,000

Dismemberment, loss of one hand and one-foot

$10,000

Dismemberment, loss of one leg

$ 5,000

Dismemberment, loss of thumb and index finger of the same hand

$ 2,500

Catastrophic Loss Benefit

Catastrophic

Loss of hearing in both ears

$25,000

Loss of hearing in one ear

$15,000

Loss of sight in both eyes

$25,000

Loss of sight in one eye

$15,000

Loss of speech

$25,000

Loss of speech & hearing in both ears

$50,000

Fracture Benefit

Fracture

Skull (non-depressed)

$1,000 Closed / $2,000 Open

Skull (depressed)

$1,500 Closed / $3,000 Open

Facial bone (including nose, except upper jaw)

$500 Closed / $1,000 Open

Upper jaw

$500 Closed / $1,000 Open

Lower jaw

$250 Closed / $500 Open

Vertebral processes

$250 Closed / $500 Open

Vertebral body (except vertebral processes)

$1,000 Closed / $2,000 Open

Collar bone

$250 Closed / $500 Open

Shoulder blade

$250 Closed / $500 Open

Sternum (breast bone)

$250 Closed / $500 Open

Rib

$250 Closed / $500 Open

Pelvis (except coccyx)

$1,000 Closed / $2,000 Open

Coccyx (tailbone)

$250 Closed / $500 Open

Upper arm

$500 Closed / $1,000 Open

Forearm

$250 Closed / $500 Open

Wrist

$250 Closed / $500 Open

Hand (except fingers)

$250 Closed / $500 Open

Finger

$50 Closed / $100 Open

Hip/Thigh

$1,500 Closed / $3,000 Open

Kneecap

$250 Closed / $500 Open

Leg (except thigh)

$500 Closed / $1,000 Open

Ankle

$250 Closed / $500 Open

Foot (except toes)

$250 Closed / $500 Open

Toe

$50 Closed / $100 Open

Chip Fracture

50.00% of Fracture Benefit

Dislocation Benefit

Dislocation

Lower jaw

$300 Closed / $600 Open

Spine

$600 Closed / $1,200 Open

Collarbone

$250 Closed / $500 Open

Shoulder

$250 Closed / $500 Open

Rib

$250 Closed / $500 Open

Elbow

$250 Closed / $500 Open

Wrist

$250 Closed / $500 Open

Hand (except fingers)

$250 Closed / $500 Open

Finger

$50 Closed / $100 Open

Hip

$1,500 Closed / $3,000 Open

Knee

$1,000 Closed / $2,000 Open

Ankle

$500 Closed / $1,000 Open

Foot (except toes)

$500 Closed / $1,000 Open

Toe

$50 Closed / $100 Open

Partial Dislocation

50.00% of Dislocation Benefit

Burn Benefit

Burn

2nd Degree:

Less than 10%

$50

At least 10% but less than 25%

$100

At least 25% but less than 35%

$250

35% or more

$500

Skin graft

50.00% of Burn Benefit

3rd Degree:

Less than 10%

$500

At least 10% but less than 25%

$1,000

At least 25% but less than 35%

$2,500

35% or more

$5,000

Skin graft

50.00% of Burn Benefit

Eye Injury Benefit

Eye Injury

Surgery

$150

Removal of foreign object

$75

Laceration Benefit

Laceration

Repaired without stitches

$25

Repaired with stitches:

Less than 2 inches (5.08 cm)

$50

2 - 6 inches (5.08 - 15.24 cm)

$100

Over 6 inches (over 15.24 cm)

$200

Torn Knee Cartilage Benefit

Torn Knee Cartlidge

With surgical repair

$500

Torn, Ruptured or Severed Tendon/Ligament/Rotator Cuff Benefit

Torn, ruptured or severed tendon/ligament/rotator cuff

Surgical repair: rotator cuff

$500

Surgical repair: two rotator cuffs

$750

Surgical repair: one tendon/ligament

$500

Surgical repair: two or more tendons/ligaments

$750

Broken Tooth Benefit

Broken Tooth

Crown

$150

Extraction

$75

Filling

$50

Additional Injuries Benefit

Additional Injuries

Concussion

$200

Coma

$5,000

Ruptured disc with surgical repair

$500

Puncture wound

$50

Ambulance Benefit

Ambulance

Air ambulance

$750

Ground/Water ambulance

$200

Emergency Care Benefit

Emergency Care

Emergency room

$100

Physician's office

$50

Urgent care

$50

Non-emergency initial care benefit

$25

Medical Testing Benefit

Medical Testing

X-ray

$50

Advanced diagnostic test

$100

Physician follow-up benefit

$50

Therapy Services Benefit

Therapy Services

Cognitive behavioral therapy

$25

Occupational therapy

$25

Physical therapy

$25

Respiratory therapy

$25

Speech therapy

$25

Vocational therapy

$25

Pain Management Benefit

Pain Management

Epidural

$100

General anesthesia

$100

Medical Appliance Benefit

Medical Appliance

Brace

$50

Cane

$50

Crutches

$50

Walker- expected use < 1 yr

$100

Walker - expected use ≥ 1 yr

$250

Walking boot

$50

Wheel chair/motorized scooter - expected use < 1 yr

$100

Wheel chair/motorized scooter - expected use ≥ 1 yr

$500

Other device used for mobility

$50

Prosthetic Device Benefit

Prosthetic Device

One device only

$500

More than one device

$1,000

Modification benefit

$500

Blood/plasma/platelets benefit

$250

Inpatient Surgery Benefit

Inpatient Surgery

Cranial surgery

$1,000

Abdominal pelvic cavity surgery

$1,000

Thoracic cavity surgery

$1,000

Hernia repair

$100

Outpatient ambulatory surgery benefit

$150

Exploratory surgery without repair

$100

Hospital Benefit

Hospital

Non-ICU hospital admission

$750

ICU hospital admission

$750

Non-ICU hospital confinement

$100

ICU confinement

$200

Inpatient rehabilitation benefit

$100

Transportation benefit

$200

Lodging benefit

$100

Paralysis Benefit

Paralysis

Four limbs

$10,000

Three limbs

$7,500

Two limbs

$5,000

One limb

$2,500

Transportation Benefit

Pays a benefit per Round trip, if the hospital/facility is more than 50 miles from primary residence. Limit to 3 per year.

Lodging Benefit

Pays a benefit per day if a Covered Person is confined in a Hospital for treatment of an accidental injury, and a companion who accompanies the Covered Person while the Covered Person is Confined, stays in a Lodging for which a charge is made. The lodging facility must be more than 50 miles one way from the primary residence and proof must be submitted that the companion incurred an expense for staying at the Lodging for each day of the Stay. This benefit is limited to 30 days per calendar year.

Limits for Specific Accidental Losses

(1) Coma Limit: A benefit is not payable for a medically induced Coma.

(2) Accident Day Limit: A person must seek treatment within 90 days of the accident.

(3) Dislocation Limits:

(a) A benefit is payable only once for the Dislocation of a joint after the coverage effective date. No benefit is payable for subsequent Dislocations of the same joint after the coverage effective date.

(b) If the person suffers more than one Dislocation as a result of the same Accident, the total benefit payable for all such Dislocations is limited to two times the benefit amount payable for the joint involved which has the highest benefit amount.

(4) Fracture Limits:

(a) If the person suffers more than one Fracture to the same bone as a result of the same Accident, only one Fracture benefit is payable.

(b) If the person suffers more than one Fracture as a result of the same Accident, the total benefit payable for all such Fractures is limited to two times the benefit amount payable for the Fracture involved which has the highest benefit amount.

(5) Lodging: Limited to 30 days per calendar year.

(6) Inpatient Rehabilitation Benefit: Limited to 15 days per accident, max of 30 days per year.

(7) Non-ICU Hospital Confinement: 365 per accident, max 3 per year.

(8) ICU Confinement: 30 per accident, max 3 per year.

(9) Therapy Services: Limited to 10 per accident and to 10 per calendar year.


This product may not be available in all states. 




An Accidental Loss is not covered if it results from any of these:

(1) Suicide or attempted suicide, while sane or insane.

(2) Intentionally self-inflicted Injuries, or any attempt to inflict such Injuries.

(3) Sickness, whether the claim results directly or indirectly from the Sickness.

(4) Medical or surgical treatment, whether the claim results directly or indirectly from the treatment.

(5) Taking part in any riot or insurrection.

(6) War, or any act of war. War means declared or undeclared war and includes resistance to armed

aggression. Terrorism is not considered an act of war. Terrorism means the deliberate use of violence or the threat of violence against civilians to create an emotional response through the suffering of victims or to achieve military, political, religious or social objectives.

(7) An Accident that occurs while the person is serving on full-time active duty for more than 90 days in any armed forces. But this does not include Reserve or National Guard active duty for training.

(8) Travel or flight in any vehicle used for aerial navigation, if:

(a) the person is riding as a passenger in any aircraft not intended or licensed for the transportation of passengers;

(b) the person is performing as a pilot or a crew member of any aircraft; or

(c) the person is riding as a passenger in an aircraft owned, operated, controlled or leased by or on behalf of the Contract Holder or any of its subsidiaries or affiliates. This includes getting in, out, on or off any such vehicle.

(9) Commission of or attempt to commit an assault or a felony.

(10) Being under the influence of alcohol or alcohol intoxication, including but not limited to having a blood alcohol level above the limit for permissible operation of a motor vehicle in the jurisdiction where the Accident occurred, regardless of whether the person:

(a) was operating a motor vehicle; and

(b) was convicted of an alcohol related offense.

(11) Being under the influence of or taking any non-prescription drug, medication, narcotic, stimulant, hallucinogen, barbiturate, amphetamine, gas, fumes or inhalants, poison or any other controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended, unless prescribed by and administered in accordance with the advice of the person’s Doctor.

(12) Participation in these hazardous sports: scuba diving; bungee jumping; base jumping; skydiving; ziplining; parachuting; hang gliding; paragliding; paramotoring; parascending; or ballooning.






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Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 100,000 members.
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