|
Plan name: |
Voluntary Accident |
| Plan year: | 2022
|
|
Group number: |
5973711 |
|
Carrier: |
MetLife |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
| Benefit Type | Low Plan Benefits | High Plan Benefits |
| Accidental Injury Benefits | ||
| Fracture | $100 – $8,000 | $200 – $10,000 |
| Dislocation | $100 – $8,000 | $200 – $10,000 |
| Second- or Third-Degree Burn
(depending on degree of burn and percentage of burnt skin) |
$75 – $10,000 | $100 – $15,000 |
| Concussion | $250 | $500 |
| Coma | $7,500 | $10,000 |
| Laceration | $50 – $400 | $75 – $700 |
| Broken Tooth | Crown: $200 / Filling: $25 / Extraction: $100 | Crown: $300 / Filling: $50 / Extraction: $150 |
| Eye Injury | $300 | $400 |
| Accident – Medical Services and Treatment | ||
| Ambulance | Ground: $300 / Air: $1,000 | Ground: $400 / Air: $1,250 |
| Emergency Care
(depending on location of care) |
$75 – $150 | $100 – $200 |
| Non-Emergency Initial Care | $75 | $100 |
| Physician Follow-Up | $75 | $100 |
| Therapy Services (including physical therapy) | $35 | $50 |
| Medical Testing | $150 | $200 |
| Medical Appliances
(depending on the appliance) |
$75 – $750 | $150 – $1,000 |
| Transportation | $300 | $400 |
| Pain Management (for epidural anesthesia) | $75 | $100 |
| Prosthetic Device | One device: $750
More than one device: $1,500 |
One device: $1,000
More than one device: $2,000 |
| Modification | $1,000 | $1,500 |
| Blood/Plasma/Platelets | $400 | $500 |
| Surgical Repair | $150-$1,500 | $200-$2,000 |
| Exploratory Surgery | $150 | $200 |
| Other Outpatient Surgery | $300 | $400 |
| Hospital Benefits | ||
| Admission | $1,000 for the day of admission | $1,500 for the day of admission |
| Intensive Care Unit (ICU) | $1,000 for the day of admission | $1,500 for the day of admission |
| Regular or ICU Confinement – up to 15 days/accident | $200 per day | $300 per day |
| Inpatient Rehabilitation – up to 15 days/accident | $150 per day | $200 per day |
| Accidental Death Benefit | ||
| Accidental Death Benefit | $25,000
$75,000 for accidental death on common carrier |
$50,000
$150,000 for accidental death on common carrier |
| Accidental Dismemberment, Functional Loss & Paralysis Benefits | ||
| Dismemberment/Functional Loss | $1,000 – $20,000 | $1,000 – $40,000 |
| Paralysis | $10,000 – $20,000 | $20,000 – $40,000 |
| Other Benefits | ||
| Lodging Benefit – for a companion of a covered person who is hospitalized | $100 per day | $200 per day |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
| Accident Insurance | Monthly Cost to You – After Tax | |
| Coverage Options | Low Plan | High Plan |
| Employee | $9.95 | $14.81 |
| Employee & Spouse | $19.64 | $29.10 |
| Employee & Child(ren) | $22.16 | $32.69 |
| Employee & Spouse/Child(ren) | $27.46 | $40.55 |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.