Personal Accident Indemnity Plan - wabash.edu

1 Level 1 Personal AccidentIndemnity PlanAccident-Only Insurance PolicyPlan Benefits Emergency Treatment Follow-Up Treatment Initial Hospitalization Hospital Confinement Physical Therapy Accidental-Death Wellness Plus .. much moreForm A34175 BIC(4/05)*Hospital confinement is defined as a covered person s confinement to a bed in a hospital for which a room charge is made. Theconfinement must be on the advice of a physician and medically necessary. Benefits are also payable for confinement in hospitalsoperated by or for the United States government. Confinement must start within 30 days of the Accident Indemnity PlanPolicy Series A-34000 Benefits are payable for a covered person s death,dismemberment, or injury caused by a covered Accident thatoccurs on or off the Emergency Treatment BenefitAflac will pay $120 for the insured and the spouse, and $70 forchildrenif a covered person receives treatment for injuriessustained in a covered Accident .

2 This benefit is payable forX-rays, treatment by a physician, or treatment received in ahospital emergency room. Treatment must be received within72 hours of the Accident for benefits to be payable. Thisbenefit is payable once per 24-hour period and only once percovered Accident , per covered person. Accident Follow-Up Treatment BenefitAflac will pay $25for one treatment per day for up to amaximum of six treatments per covered Accident , per coveredperson for follow-up treatment received for injuries sustainedin a covered Accident . Treatment must begin within 30 days ofthe covered Accident or discharge from the must be furnished by a physician in a physician soffice or in a hospital on an outpatient basis. This benefit isnot payable for the same visit that the Physical TherapyBenefit is Accident Hospitalization Benefit Aflac will pay $1,000when a covered person is confined to ahospital for at least 24 hours for injuries sustained in acovered Accident .

3 If the covered person is admitted directly toan intensive care unit, Aflac will pay $1,500. This benefit ispayable only once per hospital confinement* or intensive careunit confinement and is payable only once per calendar year,per covered Hospital Confinement BenefitAflac will pay $200 per day for which a covered person ischarged for a room for hospital confinement* of at least 18hours for treatment of injuries sustained in a covered benefit is payable up to 365 days per covered Accident ,per covered person. The Accident Hospital ConfinementBenefit and the Rehabilitation Unit Benefit will not be paidon the same day; only the highest eligible benefit will be Care Unit Confinement BenefitAflac will pay an additional $400 per day for each day a coveredperson is receiving the Accident Hospital ConfinementBenefit and is confined to and charged for a room in anintensive care unit.

4 This benefit is payable up to 15 days percovered Accident , per covered person. Confinements muststart within 30 days of the Specific-Sum Injuries BenefitAflac will pay $25 $10,000 for:DislocationsBurnsSkin GraftsEye InjuriesLacerationsFracturesBroken TeethComasBrain ConcussionsParalysisSurgical ProceduresTreatment must be performed on a covered person forinjuries sustained in a covered Accident . We will pay for nomore than two dislocations per covered Accident , per coveredperson. Dislocations must be diagnosed within 72 hours ofthe covered Accident . Benefits are payable for only the firstdislocation of a joint. If a physician reduces a dislocationwith local or no anesthesia, we will pay 25% of the amountshown for the closed reduction dislocation. A physician musttreat burns within 72 hours after a covered Accident . A totalof 50% of the burn benefit will be paid for one or more skingrafts.

5 Lacerations requiring sutures must be repaired underthe attendance of a physician within 72 hours after thecovered Accident . Fractures must be diagnosed by aphysician by X-ray within 14 days after a covered chip fractures and other fractures not reduced by open orclosed reduction, we will pay 25% of the benefit amountshown for the closed reduction. We will pay for no morethan two fractures per covered Accident , per covered will pay no more than one benefit for broken teeth percovered Accident , per covered person. Coma duration mustbe at least seven days and must require intubation forrespiratory assistance. Paralysis must result from spinal cordinjuries that are received in a covered Accident and thatresult in complete and total loss of use of two or more limbsfor a period of at least 30 days, and the loss must beconfirmed by a physician. Surgical procedures must beperformed within one year of a covered Accident .

6 Two ormore surgical procedures performed through the sameincision will be considered one operation, and benefits willbe paid based upon the most expensive procedure. Only onemiscellaneous surgery benefit is payable per 24-hour periodeven though more than one procedure may be performed. major Diagnostic ExamsAflac will pay $150if a covered person requires one of thefollowing exams for injuries sustained in a covered Accident :CT (computerized tomography) scan, MRI (magneticresonance imaging), or EEG (electroencephalogram). Theexam must be performed in a hospital, a physician s office, oran ambulatory surgical center, and a charge must be benefit is limited to one payment per calendar year, percovered Therapy BenefitAflac will pay $25for one treatment per day up to a maximumof ten treatments per covered Accident , per covered person if aphysician advises the person to seek treatment from a physicaltherapist.

7 Physical therapy must be for injuries sustained in acovered Accident and must start within 30 days of the coveredaccident or discharge from the hospital. Treatment must takeplace within six months after the Accident . This benefit is notpayable for the same visit that the Accident Follow-UpTreatment Benefit is Unit BenefitAflac will pay $100 per daywhen a covered person is chargedfor confinement in a hospital and transferred to a bed in arehabilitation unit of a hospital for a covered injury. Thisbenefit is limited to 30 days for each covered person perperiod of hospital confinement and is limited to a calendaryear maximum of 60 days. The Accident HospitalConfinement Benefit and the Rehabilitation Unit Benefit willnot be paid on the same day; only the highest eligible benefitwill be period of hospital confinement is a time period ofconfinement that starts while this policy is in force.

8 If theconfinement follows a previously covered confinement, it willbe deemed a continuation of the first unless it is the result ofan entirely unrelated injury or the confinements are separatedby 30 days or more. Appliances BenefitAflac will pay $100if a covered person requires, as advised bya physician, the use of a medical appliance as an aid inpersonal locomotion resulting from injuries sustained in acovered Accident . This benefit is payable for crutches,wheelchairs, leg braces, back braces, and walkers and ispayable once per covered Accident , per covered BenefitAflac will pay $500if a covered person requires a prostheticdevice as a result of injuries sustained in a covered benefit is payable once per covered Accident , per coveredperson and is not payable for hearing aids, wigs, or dentalaids, to include false BenefitAflac will pay $100if a covered person requires blood, plasma,or platelets for the treatment of injuries sustained in a coveredaccident.

9 This benefit is not payable for immunoglobulins andis payable only once per covered Accident , per covered BenefitAflac will pay $150 for ground ambulance transportation or$1,000 for air ambulance transportationif a covered personrequires ambulance transportation to a hospital or emergencycenter for injuries sustained in a covered Accident . A licensedprofessional ambulance company must provide thetransportation within 72 hours of the covered BenefitAflac will pay $400per round trip to a hospital if a coveredperson requires special treatment and hospital confinement*for injuries sustained in a covered Accident . The hospital mustbe more than 100 miles from the covered person s residenceor site of the Accident . This benefit will be paid for only thecovered person for whom the treatment is prescribed, or if thetreatment is for a dependent child and commercial travel isnecessary, one of the dependent child s parents or legalguardians who travels with the child will also receive thisbenefit.

10 The local attending physician must prescribe thetreatment, and the treatment must not be available benefit is payable for up to three round trips per calendaryear, per covered person. This benefit is not payable fortransportation by ambulance or air ambulance to the Lodging BenefitAflac will pay $100per night for one motel/hotel room for amember of the immediate family to accompany the coveredperson if treatment of injuries sustained in a covered accidentrequires hospital confinement.* The hospital and motel/hotelmust be more than 100 miles from the covered person sresidence. This benefit is payable up to 30 days per coveredaccident and only during the time the covered person isconfined in the brochure is for illustration purposes to the policy for complete details, limitations, and and -Dismemberment BenefitsAflac will paythe following benefit for death if it is the resultof injuries sustained in a covered Accident :Insured/SpouseChildCommon-Carri er Accidents$100,000$15,000A covered person must be a passenger at the time of thecommon-carrier Accident , and a proper authority must havelicensed the vehicle to transport passengers for a vehicles are limited to airplanes, trains,buses, trolleys, and boats that operate on a regularly scheduledbasis between predetermined points or cities.