Accident

Emergency Treatment

$125

Ambulance

$400

Air Ambulance

$2,000

X-Ray Benefit

$50

Hip

$4,000

$8,000

Knee

$2,000

$4,000

Ankle – Bone or Bones of the Foot

$1,600

$3,200

Collarbone (sternoclavicular)

$1,000

$2,000

Lower Jaw, Shoulder, Elbow, Wrist

$600

$1,200

Bone or Bones of the Hand

$600

$1,200

Collarbone (acromioclavicular and separation)

$200

$400

One Toe or Finger

$200

$400

Depressed Skull

$5,000

$10,000

Non-Depressed Skull

$2,000

$4,000

Hip, Thigh

$3,000

$6,000

Body of Vertebrae, Pelvis, Leg

$1,500

$3,000

Bones of Face or Nose

$700

$1,400

Upper Jaw, Maxilla

$700

$1,400

Upper Arm between Elbow and Shoulder

$700

$1,400

Lower Jaw, Mandible; Kneecap, Ankle, Foot

$600

$1,200

Shoulder Blade, Collarbone, Vertebral Process

$600

$1,200

Forearm, Wrist, Hand

$600

$1,200

Rib

$500

$1,000

Coccyx

$400

$800

Finger, Toe

$200

$400

Burn (based on size and degree)

$1,500 to $18,000

Burn - Skin Graft for 2nd or 3rd degree burns

50% Burn benefit

Coma

$20,000

Concussion

$200

Emergency Dental Work

$200 / $600

Lacerations (based on size)

$50 to $1,200

Employee/ Spouse

$50,000

$200,000

Child(ren)

$10,000

$40,000

Eye Injury

$400

Ruptured Disc

$1,200

Tendon/Ligament/Rotator Cuff

$1,200 - 1 / $1,800 - 2+

Torn Knee Cartilage

$1,250

Blood/Plasma/Platelets

$500

Surgery (arthroscopic or exploratory)

$250

Surgery (cranial, open abdominal or thoracic)

$2,000

Surgery (hernia)

$250

Lodging (family member or companion)

$200/night up to 30 days

Transportation (per round trip)

$600 up to 3

Hospital Admission¹ (per accident)

$1,500

Hospital ICU Admission¹ (per accident)

$ 2,500

Hospital Confinement² (per accident)

$300/day up to 365 days

Hospital ICU Confinement² (per accident)

$600/day up to 15 days

¹Hospital Admission and Hospital (ICU) Admission benefit
will not be paid for the same covered accident simultaneously
²Hospital Confinement and the Hospital ICU Confinement benefit
will not be paid simultaneously

Accident Follow-Up Dr. Visit (per accident)

$50 up to 4

Appliances (such as wheelchair, crutches)

$200

Medical Imaging Study (per accident-limit 1)

$400/accident/year

Occupational or Physical Therapy

$40/day up to 10 days

Pain Management (Epidural Anesthesia)

$150 (limit 1 per accident)

Prosthetic Devices/Artificial Limb

$1,000 - one

$2,000 - two or more

Rehabilitation Unit Confinement³

$150/day up to 15 days/

accident: 30 days/year

³Hospital Confinement benefit and Rehabilitation Unit Confinement benefit will
not be paid simultaneously

Loss of Finger/Toe

$1,500 - 1/ $3,000 - 2+

Loss or Loss of Use of Hand/Foot/Sight of Eye

$15,000 - 1/ $30,000-2+

For severe injuries that result in the total and irrecoverable

Loss of one hand and one foot, both hands or
both feet;

Loss or loss of use of one arm and one leg, both
arms or both legs;

Loss of the sight of both eyes, hearing of both
ears, ability to speak

Employee $75,000

Spouse $75,000

Child(ren) $37.500

Employee Only

$9.28

Employee + Spouse

$15.02

One Parent Family

$17.16

Family

$12.61