Accident 1.0-Premier
Accidents happen in places where you and your family spend
the most time – at work, in the home and on the playground – and
theyre unexpected. How you care for them shouldn’t be.
In your lifetime, which of these accidental injuries have happened to you or someone you know?
l Sports-related accidental injury
l Broken bone
l Burn
l Concussion
l Laceration
l Back or knee injuries
Colonial Life’s Accident Insurance is designed to help you ll some of the gaps caused by increasing deductibles,
co-payments and out-of-pocket costs related to an accidental injury. The benet to you is that you may not need to
use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater nancial security.
l Car accidents
l Falls & spills
l Dislocation
l Accidental injuries that send you
to the Emergency Room, Urgent Care
or doctors oce
What additional features are
included?
l Worldwide coverage
l Portable
l Compliant with Healthcare Spending
Account (HSA) guidelines
Will my accident claim payment be
reduced if I have other insurance?
You’re paid regardless of any other insurance you
may have with other insurance companies, and the
benets are paid directly to you (unless you specify
otherwise).
What if I change employers?
If you change jobs or leave your employer, you can
take your coverage with you at no additional cost.
Your coverage is guaranteed renewable as long as
you pay your premiums when they are due or within
the grace period.
Can my premium change?
Colonial Life can change your premium only if we
change it on all policies of this kind in the state
where your policy was issued.
How do I le a claim?
Visit coloniallife.com or call our Customer Service
Department at 1.800.325.4368 for additional
information.
Accident Insurance
Your Colonial Life policy also provides benets for the following injuries received as a result of a covered accident.
l Burn (based on size and degree) ....................................................................................$1,000 to $12,000
l Coma .............................................................................................................................................................$12,500
l Concussion .......................................................................................................................................................$150
l Emergency Dental Work .................................... $100 Extraction, $400 Crown, Implant, or Denture
l Lacerations (based on size) ........................................................................................................... $50 to $800
Requires Surgery
l Eye Injury ...........................................................................................................................................................$300
l Tendon/Ligament/Rotator Cu .......................................................... $750 - one, $1,500 - two or more
l Ruptured Disc ..................................................................................................................................................$750
l Torn Knee Cartilage .......................................................................................................................................$750
Surgical Care
l Surgery (cranial, open abdominal or thoracic) ................................................................................$1,500
l Surgery (hernia) ..............................................................................................................................................$150
l Surgery (arthroscopic or exploratory) ....................................................................................................$300
l Blood/Plasma/Platelets ................................................................................................................................$300
Benets listed are for each covered person per covered accident unless otherwise specied.
Initial Care
l Accident Emergency Treatment........... $200 l Ambulance .......................................$600
l X-ray Benet .................................................. $60 l Air Ambulance ............................. $2,000
Common Accidental Injuries
Dislocations (Separated Joint) Non-Surgical Surgical
Hip $9,600 $19,200
Knee (except patella) $4,800 $9,600
Ankle – Bone or Bones of the Foot (other than Toes) $3,840 $7,680
Collarbone (Sternoclavicular) $2,400 $4,800
Lower Jaw, Shoulder, Elbow, Wrist $1,440 $2,880
Bone or Bones of the Hand $1,440 $2,880
Collarbone (Acromioclavicular and Separation) $480 $960
One Toe or Finger $480 $960
Fractures Non-Surgical Surgical
Depressed Skull $9,000 $18,000
Non-Depressed Skull $3,600 $7,200
Hip, Thigh $5,400 $10,800
Body of Vertebrae, Pelvis, Leg $2,700 $5,400
Bones of Face or Nose (except mandible or maxilla) $1,260 $2,520
Upper Jaw, Maxilla $1,260 $2,520
Upper Arm between Elbow and Shoulder $1,260 $2,520
Lower Jaw, Mandible, Kneecap, Ankle, Foot $1,080 $2,160
Shoulder Blade, Collarbone, Vertebral Process $1,080 $2,160
Forearm, Wrist, Hand $1,080 $2,160
Rib $900 $1,800
Coccyx $720 $1,440
Finger, Toe $360 $720
Transportation/Lodging Assistance
If injured, covered person must travel more than 50 miles from residence to receive special treatment
and connement in a hospital.
l Transportation ............................................................................. $600 per round trip up to 3 round trips
l Lodging (family member or companion) ............................................... $150 per night up to 30 days for
a hotel/motel lodging costs
Accident Hospital Care
l Hospital Admission* ........................................................................................................$2,000 per accident
l Hospital ICU Admission* ................................................................................................$4,000 per accident
* We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both.
l Hospital Connement .........................................................$300 per day up to 365 days per accident
l Hospital ICU Connement ...................................................$600 per day up to 15 days per accident
Accident Follow-Up Care
l Accident Follow-Up Doctor Visit ..........................................................$50 (up to 4 visits per accident)
l Medical Imaging Study ......................................................................................................$300 per accident
(limit 1 per covered accident and 1 per calendar year)
l Occupational or Physical Therapy ..................................................... $35 per treatment up to 10 days
l Appliances ..........................................................................................$125 (such as wheelchair, crutches)
l Prosthetic Devices/Articial Limb ....................................................$750 - one, $1,500 - more than 1
l Rehabilitation Unit .................................................$150 per day up to 15 days per covered accident,
and 30 days per calendar year.
Maximum of 30 days per calendar year
Accidental Dismemberment
l Loss of Finger/Toe ............................................................................. $1,250 – one, $2,400 – two or more
l Loss or Loss of Use of Hand/Foot/Sight of Eye .................. $12,000 – one, $24,000 – two or more
Catastrophic Accident
For severe injuries that result in the total and irrecoverable:
l Loss of one hand and one foot l Loss of the sight of both eyes
l Loss of both hands or both feet l Loss of the hearing of both ears
l Loss or loss of use of one arm and one leg or l Loss of the ability to speak
l Loss or loss of use of both arms or both legs
Named Insured ................ $25,000 Spouse ..............$25,000 Child(ren) .........$12,500
365-day elimination period. Amounts reduced for covered persons age 65 and over.
Payable once per lifetime for each covered person.
Accidental Death
Accidental Death Common Carrier
l Named Insured $50,000 $200,000
l Spouse $50,000 $200,000
l Child(ren) $10,000 $40,000
71744-NC
EXCLUSIONS
We will not pay benets for losses that are caused by or are the result of: hazardous avocations; felonies or illegal
occupations; racing; semi-professional or professional sports; sickness; suicide or self-inicted injuries; war or armed
conict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benet for injuries
that are caused by or are the result of: birth; intoxication.
For cost and complete details, see your Colonial Life benets counselor. Applicable to policy form Accident 1.0-NS-NC.
This is not an insurance contract and only the actual policy provisions will control.
My Coverage Worksheet (For use with your Colonial Life benets counselor)
Who will be covered? (check one)
Employee Only
Spouse Only
One Child Only
Employee & Spouse
One-Parent Family, with Employee
One-Parent Family, with Spouse
Two-Parent Family
When are covered accident benets available? (check one)
On and O -Job Benets
O -Job Only Benets
Accident 1.0-Premier
Colonial Life
1200 Colonial Life Boulevard
Columbia, South Carolina 29210
coloniallife.com
©2014 Colonial Life & Accident Insurance Company.
Colonial Life insurance products are underwritten by Colonial
Life & Accident Insurance Company, for which Colonial Life is
the marketing brand.
Colonial Life and Making benets count are registered service
marks of Colonial Life & Accident Insurance Company.
6-14
Accident 1.0-NS-O
1
77816
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY
1200 Colonial Life Boulevard, P.O. Box 1365, Columbia, South Carolina 29202
1.800.325.4368 www.coloniallife.com
A Stock Company
ACCIDENT ONLY INSURANCE COVERAGE
THE POLICY PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED TO COVER ALL MEDICAL EXPENSES.
OUTLINE OF COVERAGE (Applicable to Policy Form Accident 1.0-HS, and state abbreviations where used.)
THE POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health
Insurance for People with Medicare available from the Company.
Please
Read The
Policy Carefully. This outline provides a very brief description of the important features of the policy. This is
not an insurance contract and only the actual policy provisions will control. The policy sets forth in detail the rights and obligations of
both you and us. It is, therefore, important to READ THE POLICY CAREFULLY.
Renewability.
The policy is guaranteed renewable as long as premiums are paid when they are due or within the grace period.
The premium can be changed only if we change it on all policies of this kind in force in the state where the policy was issued.
Coverage Provided by
The Policy.
The policy is designed to provide to covered persons coverage for losses resulting from
injuries received from a covered accident only, subject to any limitations or exclusions. It does not provide coverage for basic
hospital, basic medical-surgical or major medical expenses.
B
E
N
E
F
I
T
S
- All benefits are payable once per covered person per covered accident unless specified otherwise.
We will
p
a
y
these benefits for any covered person who receives injuries as the result of a covered a
cc
i
d
e
n
t
:
Accident Emergency
T
r
e
a
t
m
e
n
t
-
$200
Benefit payable if, as the result of a covered accident, a covered person is injured and requires examination and treatment by a doctor
in a hospital emergency room, urgent care center, or doctor’s office (other than acupuncturist or occupational or physical therapist)
within 72 hours after covered accident. A charge must be incurred for the treatment. We will not pay the Accident Emergency
Treatment and the Accident Follow-Up Doctor Visit benefits for visits on the same day.
Accident Follow
-
U
p
Doctor Visit - $50,
Maximum
of four visits per covered person per covered a
cc
i
d
e
n
t
Benefit payable in the amount and up to the maximum number of visits for initial treatment more than 72 hours after the covered
accident or follow-up treatment (other than occupational or physical therapy) provided by a doctor in a doctor’s office, urgent care
facility or emergency room for injuries received due to a covered accident. Treatment must begin within 60 days of the covered
accident, be completed with 365 days of the covered accident, not be for routine examination or preventative testing and a
c
har
ge must
be incurred. We will not pay the Accident Emergency Treatment and the Acci
dent Follow-Up Doctor Visit benefits for visits on the
same day.
Accidental Death - Named Insured $50,000 Spouse $50,000 Children $
1
0
,
000
Benefit payable if a covered person is injured in a covered accident and the injury causes the covered person to die within 90 days after
the accident. If we pay this benefit, we will not pay the Accidental Death-Common Carrier benefit.
Accidental Death -
Common
Carrier - Named Insured $200,000 Spouse $200,000 Children $40,000
Benefit payable if, as the result of a covered accident, a covered person is injured while a fare-paying passenger on a common carrier
and the injury causes the covered person to die within 90 days after the accident. Common carrier means: commercial airplanes, trains,
buses, trolleys, subways, ferries and boats that operate on a regularly scheduled basis between predetermined points or cities. Taxis and
privately chartered vehicles are not common carriers. If we pay this benefit, we will not pay the Accidental Death benefit.
Accident 1.0-NS-O
2
77816
Accidental Dismemberment
(Loss
of
Finger,
T
o
e
,
Hand,
F
oo
t
or Sight of An
E
y
e
)
$1,200
Payable for loss of: one finger or one toe
$2,400
Payable for loss of: two or more fingers, or two or more toes or any combination of two or more fingers or toes.
$12,000
Payable for loss of: one hand, or one foot, or sight of one eye.
$24,000
Payable for loss of: both hands, or both feet, or the sight of both eyes, any combination of two or more hands, feet, or the
sight of an eye.
Benefit payable if the insured loses a finger, toe, hand, foot or sight of an eye within 90 days after the covered accident and a charge is
incurred, as the result of a covered accident. If the covered person loses a finger or toe and later loses a hand or foot on the same side
of the body as a result of the same covered accident, the amount paid for the loss of a finger or toe benefit will be subtracted from the
amount paid for the loss of a hand
or foot. Loss of a hand means that the hand is cut off through or above the wrist joint or the
use
o
f
the hand is permanently lost. Loss of a foot means that the foot is cut off through or above the ankle joint or the use of the foot is
permanently lost. Loss of a finger means that the finger is cut off at the joint proximate to the first interphalangeal joint where it is
attached to the hand. Loss of a toe means that the toe is cut off at the joint proximate to the fi
rst interphalangeal joint where it is
attached to the foot. Loss of sight of an eye means that at least 80 percent of vision is permanently lost.
Air
Ambulance
- $2,000
Benefit payable if a licensed professional air ambulance company transports by air any covered person to or from a hospital or
between medical facilities for treatment for injuries received in a covered accident and a charge is incurred. Transportation must occur
within 48 hours after the covered accident.
Ambulance
- $600
Benefit payable if a licensed professional ambulance company transports any covered person by ground transportation to or from a
hospital or between medical facilities for treatment for injuries received in a covered accident and a charge is incurred. Transportation
must occur within 90 days after the covered accident.
Appliance -
$125
Benefit payable if, as the result of a covered accident, an appliance is prescribed by a doctor to aid in personal locomotion or mobility;
use must begin within 90 days after covered accident and a charge must be incurred. For purposes of this benefit, appliance means a
back brace, cane, crutches, leg brace, walker and wheelchair.
B
l
oo
d
/
P
l
a
s
m
a
/
P
l
a
te
l
et
s
- $300
Benefit payable if, as the result of a covered accident, a covered person requires the transfusion, administration, cross matching, typing
and processing of blood/plasma/platelets, they are administered within 90 days after the covered accident, and a charge is incurred.
Burn
- Benefit payable if, as the result of a covered accident, a covered person is treated by a doctor within 72 hours after the accident
for burns as described below, and a charge must be incurred.
$1,000
- Second degree burns covering a total of at least 36% of the body
s
u
r
f
a
c
e
$2,000
-
Third
degree burns covering at least 9 square inches but less than
18
square
i
n
c
h
e
s
$4,000
-
Third
degree burns covering at least
18
square inches but less than 35 square
i
n
c
h
e
s
$12,000
-
Third
degree burns covering 35 or more square
i
n
c
h
e
s
Burn
- Skin Graft - 50% of applicable burn
b
e
n
e
f
i
t
Payable only for a skin graft for a burn for which a burn benefit was received under the policy and for which a charge is incurred.
Accident 1.0-NS-O
3
77816
Catastrophic
Accident - payable once per lifetime per covered
p
e
r
s
o
n
Accident
O
cc
u
r
s
:
Prior to the covered person’s attaining age 65
Covered
P
e
r
s
o
n
Named Insured
Benefit
A
m
o
un
t
$25,000
Spouse
$25,000
Child(ren)
$12,500
After the covered person’s attaining age 65 and
prior to the covered person’s attaining age 70
Named Insured
Spouse
Child(ren)
$12,500
$12,500
$6,250
After the covered person’s attaining age 70
Named Insured
$6,250
Spouse
$6,250
Child(ren)
$3,125
Benefit payable if any covered person sustains a catastrophic loss as the result of a covered accident and is under the appropriate care
of a doctor during the elimination period and remains alive at the end of the elimination period.
Catastrophic loss means an injury that within 365 days of the covered accident results in total and irrecoverable:
Loss of both hands or both feet; or
Loss or loss of use of both arms or both legs; or
Loss of one hand and one foot; or
Loss or loss of use of one arm and one leg; or
Loss of the sight of both eyes; or
Loss of the hearing of both ears; or
Loss of the ability to speak.
For purposes of this benefit, the following definitions apply. Loss of a hand means that the hand is cut off through or above the wrist
joint. Loss of a foot means that the foot is cut off through or above the ankle joint. Loss of an arm means the arm is cut off above the
elbow. Loss of a leg means the leg is cut off above the knee. Loss of use of an arm means the loss of function of the entire arm from
the shoulder to the hand. Loss of use of a leg means the loss of f
unction of the entire leg from the hip to the foot. Loss of sight of
both eyes means at least 80 percent of vision is permanently lost in both eyes, such that it cannot be corrected to any functional degree
by any procedure, aid or device. Loss of hearing of both ears means deafness in both ears, such that it cannot be corrected to any
functional degree by any procedure, aid or device. Loss of the ability to speak means loss of audible communication, such that it
cannot be corrected to any functional degree by any procedure, aid or device.
E
l
i
m
i
na
t
i
o
n
p
e
ri
o
d
means the period of 365 days after the date of a covered accident. The catastrophic accident benefit will be payable
once per lifetime for each covered person in this policy.
Coma -
$
1
2
,
500
Benefit payable if any covered person is diagnosed with or treated for a coma lasting for a period of at least seven consecutive days
resulting from a covered accident. The condition must require intubation for respiratory assistance, be diagnosed or treated by a doctor
within 90 days after the covered accident, and a charge must be incurred. For purposes of this benefit, coma means a continuous state
of profound unconsciousness characterized by the absence of eye opening, motor response and verbal response. The term “coma”
does not include any medically induced coma.
Concussion
- $150
Benefit payable if any covered person sustains a concussion diagnosed by a doctor within 72 hours from date of covered accident as
the result of a covered accident and a charge is incurred.
Dislocation
(Separated
J
o
i
n
t
)
Complete
Dislocation
of
J
o
i
n
t
Closed
R
e
d
u
c
t
i
o
n
(with Anesthesia
)
Open
R
e
d
u
c
t
i
o
n
(with Anesthesia
)
Hip $9,600 $19,200
Knee (except patella) $4,800 $9,600
Ankle - bone or bones of the foot (other than toes) $3,840 $7,680
Collarbone (sternoclavicular) $2,400 $4,800
Lower jaw, shoulder (glenohumeral), elbow, wrist $1,440 $2,880
Bone or bones of the hand (other than fingers) $1,440 $2,880
Collarbone (acromioclavicular and separation),
one toe or finger
$480 $960
Incomplete dislocation 25% of applicable amount for closed reduction of joint involved or
dislocation reduction without anesthesia.
Accident 1.0-NS-O
4
77816
Benefit payable if, as the result of a covered accident, any covered person has a dislocation diagnosed by a doctor within 90 days after
the accident; reduction must require correction with anesthesia by a doctor, for which a charge is incurred. Benefit payable for more
than one dislocation (requiring open or closed reduction) is no more than two times the amount for the joint involved which has the
highest benefit amount. An incomplete disloc
ation is a dislocation in which the joint is not completely separated. Benefit payable only
for the first dislocation of a joint after the policy coverage effective date. Subsequent dislocations of the same joint after the policy
coverage effective date will not be covered under this benefit.
E
m
e
rg
e
n
c
y
Dental Work -
$400
- Broken tooth repaired with a crown, dentures or implant
$100
- Broken tooth resulting in extraction
The specified dental services must be required by a covered person as the result of injuries received in an accident, must begin within
60 days of the covered accident and a charge must be incurred for the services. Each Emergency Dental Work benefit is payable only
once per covered person per covered accident, regardless of the number of teeth involved.
E
y
e
I
nju
r
y
- $300
Benefit payable if, as the result of a covered accident, a covered person requires surgery on or the removal of a foreign object from the
eye by a doctor within 90 days after the covered accident and a charge is incurred. An examination with anesthesia will not be
considered surgery.
F
r
a
c
t
u
r
e
(Broken Bone)
Closed reduction Open
r
e
d
u
c
t
i
o
n
Skull (except bones of face or nose)
depressed skull fracture
Skull (except bones of face or nose)
non-depressed skull fracture
$9,000 $18,000
$3,600 $7,200
Hip, thigh (femur) $5,400 $10,800
Vertebrae, body of (excluding vertebral
processes), pelvis (except coccyx), leg
Bones of face or nose (except mandible or
maxilla)
Upper jaw, maxilla (except alveolar process),
upper arm between elbow and shoulder
Lower jaw, mandible (except alveolar process),
kneecap, foot (except toes), ankle
Shoulder blade, collarbone, vertebral processes,
forearm, hand, wrist (except fingers)
$2,700 $5,400
$1,260 $2,520
$1,260 $2,520
$1,080 $2,160
$1,080 $2,160
Rib $900 $1,800
Coccyx $720 $1,440
Finger, Toe $360 $720
Chip Fracture 25% of the applicable amount for closed reduction for the bone involved as
listed above.
Benefit payable if, as the result of a covered accident, a covered person has a fracture diagnosed by a doctor within 90 days after the
accident. The fracture must require open (surgical) or closed (non-surgical) reduction by a doctor, and a charge is incurred for the
reduction. Benefit payable for more than one fracture (open or closed reduction) is no more than two times the amount for the bone
involved which has the highest benefit amount. If a cover
ed person has a fracture and a dislocation in a covered accident, maximum
benefit payable will be two times the amount for the bone or joint involved with the highest benefit amount. A chip fracture is a
fracture in which a piece of the bone is broken off near a joint at a place where a ligament is usually attached.
Hospital Admission
-
$2,000
Benefit payable if, as the result of a covered accident, a covered person is confined in a hospital within six months after the accident
and a charge is incurred. Payable once per covered accident. We will not pay this benefit for emergency room treatment, outpatient
treatment, or a stay of less than 20 hours in an observation unit. We will not pay the Hospital Admission benefit and the Hospital
Intensive Care Unit Admission benefit for the same covered accident.
Accident 1.0-NS-O
5
77816
Hospital Confinement
-
$300
per day up to
365
days per covered person per covered a
cc
i
d
e
n
t
Benefit payable if, as the result of a covered accident, a covered person is initially confined in a hospital or a hospital sub-acute
intensive care unit within six months after the covered accident, and a charge is incurred. We will not pay this benefit for emergency
room treatment, outpatient treatment, or confinement of less than 20 hours to an observation unit. We will not pay the Hospital
Confinement benefit and the Hospital Intensive Care Unit confinement benefit concurrently. If the covered person is confined in a
hospital intensive care unit for more than 15 days, the Hospita
l Confinement benefit will begin on the 16th day.
Hospital
I
n
te
n
s
i
v
e
Care Unit
Admission
-
$4,000
- one per covered person per covered a
cc
i
d
e
n
t
Benefit payable if, as the result of a covered accident, a covered person is admitted directly to a hospital intensive care unit within 30
days after the covered accident and a charge is incurred; payable once per covered accident. We will not pay this benefit for emergency
room treatment, outpatient treatment, or a stay of less than 20 hours in an observation unit. We will not pay the Hospital Intensive
Care Unit Admission benefit and the Hospital Admission benefit for the same covered accident.
Hospital
I
n
te
n
s
i
v
e
Care Unit
Confinement
-
$600
per day up to
15
days per covered person per covered a
cc
i
d
e
n
t
Benefit payable if, as the result of a covered accident, a covered person is confined to a hospital intensive care unit. Hospital intensive
care unit confinement must begin within 30 days after the accident, and a charge must be incurred. We will not pay the Hospital
Intensive Care Unit Confinement benefit and the Hospital Confinement benefit concurrently.
Knee Cartilage
Torn
- $
750
- one per covered person per covered a
cc
i
d
e
n
t
Benefit payable if, as the result of a covered accident, a covered person is treated by a doctor for a torn knee cartilage within 60 days
after the covered accident. The torn knee cartilage must be repaired through surgery within 12 months after the covered accident, and
a charge must be incurred for the repair. If exploratory arthroscopic surgery is performed and no repair is done, or if the cartilage is
shaved (debridement), we will pay under the Surgery - Exploratory and Arthroscopic benefit.
L
a
c
e
r
a
t
i
o
n
$100
- Total of all lacerations is less than two inches long (less than 5.08 centimeters) and repaired by stitches
$400
- Total of all lacerations is at least two but less than six inches long (5.08 to 15.23 centimeters) and repaired by stitches
$800
- Total of all lacerations is six inches or longer (15.24 centimeters or longer) and repaired by stitches
$50
- Laceration(s) with no repair
Benefit payable if, as the result of a covered accident, a covered person has a laceration that is repaired by a doctor within 72 hours
after the covered accident, and a charge must be incurred for the repair. If benefits are payable for a laceration on a finger, toe, hand,
foot or eye and the insured later loses that finger, toe, hand, foot, or eye as the result of the same covered accident, the amount we
paid under the Laceration benefit will be subtracted from the Accidental Dismemberment (Loss of a Finger, Toe, Hand, Foot or Sight
of an Eye) benefit.
L
o
dg
i
n
g
-
$150
per night up to 30 days per covered a
cc
i
d
e
n
t
Payable for a companion’s motel/hotel stays during the period of time the covered person is confined to the hospital as the result of a
covered accident, and a charge is incurred. Hospital must be more than 50 miles from the residence of the covered person.
Medical Imaging Study -
$300
payable once per covered person per covered accident and once per calendar
y
e
a
r
Benefit payable if, as the result of a covered accident, a covered person receives one of the following imaging studies. Study must be
prescribed by a doctor and performed in an office or in a hospital on an inpatient or outpatient basis, and a charge must be incurred.
Studies include: Computed Tomography (CT) imaging or Computed Axial Tomography (CAT Scan), Electroencephalogram (EEG),
or Magnetic Resonance (MR) or Magnetic Resonance Imaging (MRI).
Occupational
Or
Physical
T
h
e
r
a
p
y
-
$35
per day up to
10
days per covered person per covered a
cc
i
d
e
n
t
Benefit payable if, as the result of a covered accident, a covered person requires occupational or physical therapy treatment. Therapy
must begin within 60 days after the covered accident and be completed within six months after the covered accident, and a charge
must be incurred. Must be prescribed by a doctor and rendered by a licensed physical or occupational therapist and performed in an
office or in a hospital on an inpatient or outpatient basis.
Accident 1.0-NS-O
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Prosthetic Device
/
A
r
t
i
f
i
c
i
a
l
L
i
m
b
$750
- One prosthetic device or artificial limb
$1,500
- Two or more devices or artificial limbs.
Benefit payable if, as the result of a covered accident, a covered person requires a prosthetic device/artificial limb prescribed by a
doctor for functional use when the covered person loses a hand, foot, or sight of an eye. Must be received within one year of the
covered accident, and a charge must be incurred. This benefit is not payable for hearing aids, dental aids, including false teeth, eye
glasses or for cosmetic prosthesis such as hair wigs. We will not pay for joint replacement such as an artificial hip or knee.
Rehabilitation
Unit
Confinement
-
$150
per day, up to
15
days per covered person per covered accident, and a
maximum
of 30 days per calendar
y
e
a
r
Benefit payable if, as the result of a covered accident, a covered person is transferred to a rehabilitation unit immediately after a period
of hospital confinement due to a covered accident, and a charge is incurred. We will not pay both the Rehabilitation Unit Confinement
benefit and the Hospital Confinement benefit concurrently.
Ruptured
Disc - $750
Benefit payable if, as the result of a covered accident, a covered person receives a ruptured disc in his spine. The ruptured disc must be
treated by a doctor within 60 days after the covered accident and repaired through surgery within one year after the accident. A charge
must be incurred for the repair.
Surgery - Cranial, Open
Abdominal
and
T
h
o
r
a
c
i
c
$
1
,
500
Hernia $
1
50
Cranial, open abdominal and thoracic surgery benefit payable if as a result of a covered accident, a covered person undergoes cranial,
open abdominal or thoracic surgery other than hernia repair within 72 hours of a covered accident and a charge is incurred. Surgery
must be for repair of internal injuries. Hernia surgery benefit payable if, as the result of a covered accident, a covered person undergoes
hernia surgery. The hernia must be diagnosed within 30 days, and surgery must be performed within 60 days after the covered
accident. A charge must be incurred for the repair. If cranial, open abdominal or thoracic (other than hernia repair) surgery and hernia
surgery are performed as a result of the same covered accident, we will pay only the Cranial, Open Abdominal or Thoracic benefit.
Surgery -
E
x
p
l
o
r
a
t
o
r
y
and
Arthroscopic
- $300
Payable if any covered person undergoes exploratory or arthroscopic surgery within 60 days of covered accident to explore or repair
injuries received as the result of a covered accident. Hernia repair is not covered under this benefit.
T
e
n
d
o
n
/
L
i
g
a
m
e
n
t
/
R
o
t
a
t
o
r
C
u
ff
$750
- Repair of one tendon, ligament or rotator cuff
$1,500
- Repair of two or more of the above.
Benefit payable if, as the result of a covered accident, a covered person receives a torn, ruptured or severed tendon/ligament/rotator
cuff. It must be treated by a doctor within 60 days, and repaired through surgery within one year after the covered accident, and a
charge must be incurred.
T
r
a
n
s
p
o
r
t
a
t
i
o
n
-
$600
per round trip up to three round trips per covered person per covered a
cc
i
d
e
n
t
Benefit payable if, as the result of a covered accident, a covered person must travel more than 50 miles one way for special treatment
and confinement in a hospital, and a charge is incurred. Treatment must be prescribed by a doctor and not available locally. This
benefit is not payable for transportation by ambulance or air ambulance.
X-ray $60
Payable if any covered person incurs a charge for and receives an x-ray as the result of a covered accident. The test must be prescribed
by a doctor and performed in a doctor’s office or a hospital on an inpatient or outpatient basis and performed within 90 days of the
covered accident.
IMPORTANT
WORDS
IN THE
P
O
L
I
C
Y
Accident means an unintended or unforeseen bodily injury sustained by a covered person, wholly independent of disease, bodily
infirmity, illness, infection, or any other abnormal physical condition.
Confined or
Confinement
means the assignment to a bed as a resident inpatient in a hospital on the advice of a doctor or
confinement in an observation unit within a hospital for a period of no less than 20 continuous hours on the advice of a doctor.
A Covered Accident is an accident which: occurs on or after the effective date of the policy; occurs while the policy is in force; is of
the Accident Type listed on the Policy Schedule page; and is not excluded by name or specific description in the policy.
Accident 1.0-NS-O
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77816
A Doctor or
Physician
means a person who: is licensed by the state to practice a healing art; and performs services for a covered
person which are allowed by his license. Doctor or physician does not include any covered person or anyone related to any covered
person by blood or marriage, a business or professional partner of any covered person, or any person who has a financial affiliation or
a business interest with any covered person.
An
E
m
e
rg
e
n
c
y
Room
is a specified area within a hospital that is designated for the emergency care of accidental injuries. This
area must: be staffed and equipped to handle trauma; be supervised and provide treatment by doctors; and provide care seven days
per week, 24 hours per day.
A
Hospital
means a place which: is run according to law on a full-time basis; provides overnight care of injured and sick people; is
supervised by a doctor; has full-time nurses supervised by a registered nurse; and has at its locations or uses on a pre-arranged basis:
X- ray equipment, a laboratory and an operating room where surgical operations take place.
Notwithstanding the above, a hospital is not: a nursing home; an extended care facility; a skilled nursing facility; a rest home or home
for the aged; a rehabilitation center; a place for alcoholics or drug addicts; or an assisted living facility.
A
Hospital
I
n
te
n
s
i
v
e
Care Unit means a place which: is a specifically designated area of the hospital called an intensive care unit
that provides the highest level of medical care and is restricted to patients who are critically ill or injured and who require intensive
comprehensive observation and care; is separate and apart from the surgical recovery room and from rooms, beds and wards
customarily used for patient confinement; is permanently equipp
ed with special lifesaving equipment for the care of the critically ill or
injured; is under constant and continuous observation by a specially trained nursing staff assigned exclusively to the intensive care unit
on a 24 hour basis; and has a doctor assigned to the intensive care unit on a full-time basis.
A hospital intensive care unit is not any of the following step down units: a progressive care unit; an intermediate care unit; a private
monitored room; sub-acute intensive care unit; an observation unit; or any facility not meeting the definition of a hospital intensive
care unit as defined in the policy.
A
Hospital
Sub-Acute
I
n
te
n
s
i
v
e
Care Unit means a place which: is a specifically designated area of the hospital that provides a
level of medical care below intensive care, but above a regular private or semi-private room or ward; is separate and apart from the
surgical recovery room and from rooms, beds and wards customarily used for patient confinement; is permanently equipped with
special lifesaving equipment for the care of the critically ill or inju
red; and is under constant and continuous observation by a specially
trained nursing staff.
A hospital sub-acute intensive care unit may be referred to by other names such as progressive care, intermediate care, or a step-down
unit, but it is not a regular private or semi-private room, or a ward with or without monitoring equipment.
An
I
nju
r
y
means a wound to a covered person’s body that is caused solely by or is the result of a covered accident.
An
Observation
Unit is a specified area within a hospital, apart from the emergency room, where a patient can be monitored
following outpatient surgery or treatment in the emergency room by a doctor; and which: is under the direct supervision of a doctor or
registered nurse; is staffed by nurses assigned specifically to that unit; and provides care seven days per week, 24 hours per day.
An
Occupational
T
h
e
r
a
p
i
s
t
is a person, who: possesses the designation “Occupational Therapist Registered (OTR);” is licensed
by the state to practice occupational therapy; performs services which are allowed by his license and performs services for which
benefits are provided by the policy. For purposes of this definition, occupational therapist does not include any covered person or
anyone related to any covered person by blood or marriage.
An Off-Job Accident means an accident that occurs while a covered person is not working at any job for pay or
benefits. An On-Job Accident means an accident that occurs while a covered person is working at any job for pay or
benefits.
A
Physical
T
h
e
r
a
p
i
s
t
is a person who: is licensed by the state to practice physical therapy; performs services which are allowed by
his license; performs services for which benefits are provided by the policy; and practices according to the Code of Ethics of the
American Physical Therapy Association. For purposes of this definition, physical therapist does not include any covered person or
anyone related to any covered person by blood or marriage.
A
Rehabilitation
Unit means an appropriately licensed facility that provides rehabilitation care services on an inpatient basis.
Rehabilitation care services consist of the combined use of medical, social, educational, and vocational services to enable patients
disabled by accidental injury to achieve the highest possible functional ability. Services are provided by or under the supervision of an
organized staff of physicians. The rehabilitation unit may be part of
a hospital or a freestanding facility. A rehabilitation unit is not a
nursing home, an extended care facility, a skilled nursing facility, a rest home or home for the aged, a hospice care facility, a place for
alcoholics or drug addicts, or an assisted living facility.
An Urgent Care
Facility
means a place other than a doctor’s office, hospital or emergency room that provides emergency care
and treatment for injured people.
WHAT
IS NOT COVERED BY THE
P
O
L
I
C
Y
We will not pay benefits for losses that are caused by or are the result of any covered person’s:
engaging in hang-gliding, bungee jumping, parachuting, sailgliding, parasailing, parakiting, jumping, parachuting, or falling from
any aircraft or hot air balloon, including those which are not motor-driven or any similar activities.
committing or attempting to commit a felony or engaging in an illegal occupation.
riding in or driving any motor-driven vehicle in a race, stunt show or speed test.
Accident 1.0-NS-O
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77816
practicing for or participating in any semi-professional or professional competitive athletic contests for which any type
of compensation or remuneration is received.
having any sickness or declining process caused by a sickness, including physical or mental infirmity. We also will not pay benefits
to diagnose or treat the sickness. Sickness means any illness, infection, disease or any other abnormal physical condition which
is not caused by an injury.
committing or trying to commit suicide or his injuring himself intentionally, whether he is sane or not.
being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority.
Losses
as a result of acts of terrorism or nuclear release committed by individuals or groups will not be excluded from coverage unless
the covered person who suffered the loss committed the act of terrorism or nuclear release.
In
addition to the
exclusions
listed above, we also will not pay the
Catastrophic
Accident benefit for injuries that are
c
a
u
s
e
d
by or are the result o
f
:
injuries to a dependent child received during his birth.
any covered person’s being intoxicated or under the influence of any narcotics unless administered on the advice of his doctor.