| |
| VALUE ACCESS GUARANTEE SCHEDULE OF INSURED BENEFITS |
Option C |
| Waiting Period |
|
| For Accidental Injury |
0 |
| For Sickness Illness |
0 |
| In-Hospital Benefit * |
|
| Each Day of Confinement |
$750 |
| * 30 days is the max # of days |
30 |
| Hospital ICU * |
|
| Indemnity Benefit |
$3,000 |
* 10 days is the max # of days
(Not paid in addition to In-Hospital Benefits) |
10 |
| Surgery |
|
| Surgical Procedure Units |
33 |
| Benefit Range/Surgical Session |
$165 - $5,000 |
| Max Surgical Sessions/Calendar Year |
2 |
| Payment Base: |
Surgical Benefit |
| Anesthesia |
|
| Anesthesia (Percent of Surgical Indemnity Benefit) |
20% |
| Doctor Office Visit |
|
| Amount per Visit |
N/A |
| Max Visit per yr (individual/family) |
N/A |
| Preventive Care Visit |
|
| Amount per Visit |
N/A |
| Max Visit per yr |
N/A |
| ER Accident & Sickness |
|
| Amount per Visit |
$188 |
| Max Visits |
1 |
| Ambulance Benefits |
|
| Amount per Visit |
$375 |
| Max Visits |
1 |
| Rate/month, Single |
$128.00 |
| Rate/month, Family |
$326.00 |
|
|