Your Hospital/Medical/Surgical Insurance Policy Benefits1 |
We Pay: |
Daily Room Benefit |
|
Beginning the second day of confinement, we will pay this amount for each day you are confined in the hospital. |
$500 |
If you are in intensive care, you will receive this amount in addition to the Daily Room Benefit Amount. |
$1,000 |
Surgical Benefits |
Up to $5,000 |
Surgical Benefit |
|
Benefits are paid based on specific covered surgeries; ask your Agent or see the summary/outline of coverage for more details! |
|
Hospital Inpatient Miscellaneous Expenses (for which you incur) |
|
$0 - $1,999 |
$100 |
$2,000 - $4,999 |
$1,000 |
$5,000 - $9,999 |
$4,500 |
$10,000 - $19,999 |
$9,000 |
$20,000 and over |
$15,000 |
Outpatient Surgery Miscellaneous Expenses (for which you incur): |
|
$0 - $99 |
$25 |
$100 - $499 |
$75 |
$500 - $999 |
$450 |
$1,000 - $2,499 |
$1,050 |
$2,500 - $4,999 |
$2,250 |
$5,000 and over |
$3,500 |
Pap Smear Benefit4 |
$75 |
Mammogram Benefit2 |
$100 |
Prostate Cancer Screening Benefit3 |
$50 |
Childhood Immunization Benefit |
$35 |
Outpatient Surgery X-Ray and Laboratory Benefit |
$50 |
Outpatient Non-Surgical Miscellaneous Benefit |
|
This benefit includes visits to a doctor’s office. |
$25/visit |
General Anesthesia Benefit |
$500 |
Nuclear Diagnostic Benefit |
|
Benefits for CAT scans are included in this benefit. |
$250 |
Ambulance Benefit |
$250 |
Air Ambulance Benefit |
$1,000 |
Home Health Care Benefit |
$40/visit |
Speech, Occupational, or Physical Therapy Benefit |
$40/visit |
P345(GA:P345GA; ID:P345ID; OK:P345OK; TN:P345TN; TX:P345TX)
1 Benefits may change if the same change is made on all insurance policies of this form (SC: and class) in your state (not applicable in AR, IL, OH, VA)
2 In OK; we pay $115
3 In OK; we pay $65
4 In OR; Pelvic Exam and Pap Smear Benefit