The following is a brief description of Plan Benefits.

Daily Hospital Confinement Benefit

We will pay the Daily Hospital Confinement Benefit shown in the Schedule of Benefits if a Covered Person is Hospital Confined as an inpatient and all of the following conditions are met:

  1. the Hospital stay is Medically Necessary and the direct result, from no other causes, of Injuries or illness sustained in a Covered Accident or Sickness; and
  2. Confinement is at the direction and under the care of a Physician; and
  3. While the coverage is in effect.

Benefit payments will end on the first of the following dates:

  1. the date the Hospital stay ends; or
  2. the date the Covered Person dies; or
  3. the date the Maximum Benefit for this benefit is payable; or
  4. the date insurance under the Policy ends.

Daily Intensive Care/Coronary Care Unit Benefit

We will pay the Intensive Care Unit (ICU)/Coronary Care Unit (CCU) Benefit shown in the Schedule of Benefits if a Covered Person is Hospital Confined in the Intensive Care Unit and all of the following conditions are met:

  1. the ICU/CCU confinement is Medically Necessary and the direct result, from no other causes, of Injuries or illness sustained in a Covered Accident or Sickness; and
  2. ICU/CCU stay is at the direction and under the care of a Physician;
  3. While the coverage is in effect.

Benefit payments will end on the first of the following dates:

  1. the date the ICU/CCU stay ends; or
  2. the date the Covered Person dies; or
  3. the date the Maximum Benefit for this benefit is payable; or
  4. the date insurance under the Policy ends.

This benefit will be paid in lieu of the Daily Hospital Confinement benefit.

Daily Skilled Nursing Care Facility Benefit

We will pay the Skilled Nursing Care Facility Benefit shown in the Schedule of Benefits if, as the result of a Covered Accident or Sickness, a Covered Person is confined in a Skilled Nursing Care Facility within 3 straight days after a period of confinement for which Daily Hospital Confinement Benefits are payable. We will pay the benefit for each day the Covered Person is confined in a Skilled Nursing Care Facility up to the Maximum Benefit shown in the Schedule of Benefits. In computing the number of days payable under this benefit, the date of admission will be counted but not the date of discharge. We will pay for treatment if a Physician visits the Covered Person and certifies in writing the confinement is Medically Necessary.

Daily Emergency Room Visits Benefit for Sickness and Injury

We will pay the benefit shown in the Schedule of Benefits for Emergency Room Visits if a Covered Person requires Hospital emergency room treatment for a Medical Emergency as the result of a Covered Accident or Sickness.

“Emergency Room” means a trauma center or special area in a Hospital that is equipped and staffed to give people emergency treatment on an outpatient basis. An Emergency Room is not a clinic or Physician’s office.

Daily Ambulance Benefit

We will pay the Daily Ambulance Benefit shown in the Schedule of Benefits, subject to the following conditions, if the Covered Person requires ambulance services due to a Covered Accident or Sickness.

The ambulance services provided must be for transportation from the scene of the Covered Accident to the nearest Hospital that is able to provide appropriate care, or in the event of a Covered Sickness, the Medically Necessary transportation to a Hospital.

Optional Daily Inpatient Surgery Benefit

If you elect to include the Optional Surgery Benefits, We will pay the Daily Inpatient Surgery Benefit shown in the Schedule of Benefits if a Covered Person is ordered by a Physician to undergo Medically Necessary Surgery as the result of a Covered Accident or Sickness.

“Surgery” means the treatment of fractured and dislocated bones, operations that involve cutting or incision and/or suturing of wounds or any other surgical procedure, including the usual aftercare for such procedure, that is:

  1. necessary for treatment of the Covered Person; and
  2. performed in a Hospital.

Inpatient Surgery must be performed in the operating room of a Hospital.

Optional Daily Outpatient Surgery Benefit

If you elect to include the Optional Surgery Benefits, We will pay the Surgery Benefit shown in the Schedule of Benefits if a Covered Person is ordered by a Physician to undergo Medically Necessary Surgery as the result of a Covered Injury or Sickness.

“Surgery” means the treatment of fractured and dislocated bones, operations that involve cutting or incision and/or suturing of wounds or any other surgical procedure, including the usual aftercare for such procedure that is necessary for treatment of the Covered Person.

Outpatient Surgery must be performed in the outpatient department of a Hospital or an Ambulatory Surgical Center.

“Ambulatory Surgical Center” means a free standing facility providing ambulatory surgical or medical treatment other than a Hospital, clinic or Physician’s office. It must be qualified to provide the treatment under the standards set by the state in which it is located.

This does not include Surgery performed in a surgical suite or Physician’s office

EXCLUSIONS

The Policy does not cover any loss resulting in whole or part from, or contributed to by, or as a natural or probable consequence of any of the following:

  1. Suicide, attempted suicide or intentional self-inflicted Injury while sane or insane
  2. War or any act of war, declared or undeclared
  3. while the Covered Person is on Active Duty Service in any Armed Forces, National Guard, military, naval or air service or organized reserve corps;
  4. Active participation in a riot or insurrection;
  5. Treatment which arises out of, or in the course of fighting, brawling, assault or battery
  6. Treatment for Mental Illness or Nervous Disorders, except as specifically provided in the Policy
  7. Treatment for Substance Abuse, except as specifically provided in the Policy
  8. Injury or Sickness caused by, contributed to or resulting from the Covered Person’s use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person’s Physician
  9. Violation or attempt to violate any duly-enacted law or regulation, or commission or attempt to commit an assault or felony, or that occurs while engaged in an illegal occupation
  10. Services or treatment rendered by a Physician, Nurse or any other person who is employed or retained by the Policyholder; or an Immediate Family Member of the Covered Person
  11. Treatment in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay
  12. Travel or activity outside the United States, except for a Medical Emergency
  13. Participation in any motorized race or speed contest
  14. Aggravation or re-injury of a prior Injury that the Covered Person suffered prior to his or her coverage Effective Date, unless We receive a written medical release from the Covered Person’s Physician
  15. Injury to a Covered Person resulting from that Covered Person’s willful violation of the Policyholder’s rules or regulations. Willful violation includes, but is not limited to: a) working without protective clothing, helmets, gloves, etc., required by the Policyholder’s rules or regulations; or b) participating in any activity that is in violation of the Policyholder’s rules or regulations
  16. Pregnancy, except Complications of Pregnancy or childbirth unless conception occurred while coverage was in force under the Policy
  17. Elective Abortion, including complications. “Elective Abortion” means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed
  18. Experimental or Investigational drugs, services, supplies or procedure that is Experimental or Investigational at the time the procedure is done. For the purposes of this exclusion, “Experimental or Investigational” means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II or III). The procedure will also be considered Experimental or Investigational if the Covered Person is required to sign a consent form that indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, that is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered Experimental or Investigational. A drug, device or biological product is considered Experimental or Investigational if it does not have FDA approval or approval under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption
  19. Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications
  20. Treatment or services provided by a private duty nurse, unless provided for in the Policy
  21. Treatment of a detached retina unless caused by an Injury suffered from a Covered Accident
  22. Damage to or loss of dentures or bridges or damage to existing orthodontic equipment, except as specifically provided in the Policy
  23. Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy; or craniomandibular joint dysfunction and associated myofacial pain, except as specifically provided in the Policy
  24. Treatment for blood or blood plasma;
  25. Routine vision care
  26. Any Accident where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator’s license;
  27. Travel in or upon, alighting to or from, or working on or around any motorcycle or recreational vehicle including but not limiting to: two- or three-wheeled motor vehicle; four-wheeled all terrain vehicle (ATV); jet ski; ski cycle; snow mobile; or riding in a rodeo according to the Policy provisions; or any off road motorized vehicle not requiring licensing as a motor vehicle;
  28. Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from:
    1. While riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; or
    2. While being used for any test or experimental purpose; or
    3. While piloting, operating, learning to operate or serving as a member of the crew thereof; or
    4. while traveling in any such aircraft or device which is owned or leased by or on behalf of the Policyholder of any subsidiary or affiliate of the Policyholder, or by the Covered Person or any member of His household
    5. A space craft or any craft designed for navigation above or beyond the earth’s atmosphere; or
    6. An ultra light, hang gliding, parachuting or bungi cord jumping;

    Except as a fare paying passenger on a regularly scheduled commercial airline

  29. Rest cures or custodial care;
  30. Prescription Drugs unless specifically provided for under the Policy
  31. Elective or cosmetic surgery, except for reconstructive surgery on a diseased or injured part of the body;
  32. Physiotherapy services