| VALUE ACCESS GUARANTEE SCHEDULE OF INSURED BENEFITS |
Option 5 |
| Waiting Period after Coverage Effective date: |
|
| Injury |
0 Days |
| Illness |
30 Days |
| Doctors Office Visit Indemnity Benefit (Paid per Visit): |
$50 |
| Maximum Visits per Calendar Year per Individual |
5 |
| Maximum Visits per Calendar Year per Family (This benefit is not subject to the Preexisting Conditions Limitation) |
10 |
| Daily In-Hospital Indemnity Benefit: |
|
| Paid for each day of hospital confinement |
$500 |
| Maximum number of days per confinement |
30 days |
| Surgery Indemnity Benefit: |
|
| The surgery benefit is based on multiplying the Payment Factor for the procedure listed in the Surgical Schedule, by the Surgical Procedure Unit. |
Up to $2,400 |
| Surgical Procedure Units: |
16 |
| Maximum Surgical Sessions per Calendar Year per Individual |
2 |
| Anesthesia Indemnity Benefit: |
|
| Payment is based on a Percentage of the Surgical Indemnity Benefit |
20% |
| Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit for each day of testing: |
$50 |
| Maximum number of Testing Days per Calendar Year per Individual |
5 |