Voluntary Hospital Indemnity

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Plan name:	Voluntary Hospital Indemnity
Plan year:	2021
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.

Hospital Benefits
Subcategory	Benefit Limits (Applies to Sub-Category)	Benefit	Low Plan	High Plan
Admission Benefit	1 time(s) per calendar year	Admission	$500	$1,000
Admission Benefit	1 time(s) per calendar year	ICU Supplemental Admission (Benefit paid concurrently with the Admission benefit when a Covered Person is admitted to ICU)	$500	$1,000
Confinement Benefit	15 days per calendar year ICU Supplemental Confinement will pay an additional benefit for 15 of those days	Confinement	$100	$200
Confinement Benefit		ICU Supplemental Confinement (Benefit paid concurrently with the Confinement benefit when a Covered Person is admitted to ICU)	$100	$200
Newborn Confinement Benefit	2 day(s) per confinement	Newborn Confinement	$25	$50

Coverage Options	Low Plan	High Plan
Monthly Cost to You – After Tax
Employee	$9.85	$19.69
Employee & Spouse	$21.78	$43.57
Employee & Child(ren)	$16.37	$32.74
Employee & Spouse/Child(ren)	$28.31	$56.62