| Benefit Description | Level 1 | Level 2 | Level 3 | Level 4 | Level 5 | Level 6 |
| Hospital Confinement Benefit+ |
| Benefits are payable as shown for each day that an Insured Person is Confined to a Hospital due to an Injury or Sickness. The benefit is payable from the first day of Confinement.
+Maximum Number of Days per Period of Confinement in Pennsylvania is 31 days. |
| Benefit Amount per Day | $150 | $250 | $350 | $500 | $750 | $1,000 |
| Maximum Number of Days per Period
of Confinement | 30 | 30 | 30 | 30 | 30 | 30 |
| Maximum Number of Confinements per Calendar Year | unlimited | unlimited | unlimited | unlimited | unlimited | unlimited |
| Intensive Care Unit Confinement Benefit |
| Benefits are payable as shown for each day that the Insured Person is Confined in an Intensive Care Unit due to an Injury or Sickness. The benefit is payable from the first day of Confinement. This benefit is in addition to any other Confinement benefit under the Policy. |
| Benefit Amount per Day | $150 | $250 | $350 | $500 | $750 | $1,000 |
| Maximum Number of Days per Calendar Year | 5 | 5 | 5 | 5 | 5 | 5 |
| In-Hospital Surgical Benefit |
| Benefits are payable as shown for each day an Insured Person has a surgery due to an Injury or Sickness. Inpatient surgical operations must be performed while the Insured Person is Hospital Confined. Benefits are not payable for surgical operations performed in a Physician’s office. |
| Benefit Amount per Day | N/A | $500 | $500 | $700 | $700 | $1,000 |
| Maximum Number of Days per Calendar Year | N/A | 1 | 1 | 1 | 1 | 1 |
| Outpatient Surgical Benefit |
| Benefits are payable as shown for each day an Insured Person has a surgery due to an Injury or Sickness. Outpatient surgical operations must be performed in a Hospital outpatient surgery facility or a free-standing Outpatient surgery center. If an Insured Person is subsequently Hospital Confined, the surgery will be considered an Inpatient surgical operation. Benefits are not payable for surgical operations performed in a Physician’s office. |
| Benefit Amount per Day | $500 | $750 | $1,500 | $1,500 | $1,500 | $1,500 |
| Maximum Number of Days per Calendar Year | 1 | 1 | 1 | 1 | 1 | 1 |
| Anesthesia Benefit |
| Benefits are payable as shown for each day the Surgery benefit is paid and anesthesia is administered to an Insured Person. |
| Benefit Amount per Day
(Percentage of surgical benefit amount) | N/A | 25% | 25% | 25% | 25% | 25% |
| Outpatient Physician Office Visit Benefit |
| Benefits are payable as shown for each day an Insured Person receives treatment for Injury or Sickness in a Physician’s office or Urgent Care Facility. |
| Benefit Amount per Day
| $60 | $60 | $60 | $70 | $70 | $80 |
| Maximum Number of Days per Calendar Year | 6 | 6 | 8 | 8 | 8 | 10 |
| Outpatient Diagnostic Laboratory Tests Benefit* |
| Benefits are payable as shown for each day an Insured Person undergoes an Outpatient diagnostic laboratory test for processing in a laboratory for diagnosis of an Injury or Sickness for which symptoms have been presented. The tests must be ordered by the Insured Person’s attending Physician. The Outpatient diagnostic laboratory test must be submitted to an Outpatient facility or, if submitted to a Hospital, submitted while the Insured Person is an Outpatient. Only one benefit is payable per day, no matter how many Outpatient diagnostic laboratory tests an Insured Person undergoes in a single day.
*Routine or wellness lab screens and tests are not covered. |
| Benefit Amount per Day | $30 | $40 | $50 | $50 | $60 | $70 |
| Maximum Number of Days per Calendar Year | 3 | 3 | 3 | 3 | 3 | 3 |
| Outpatient Diagnostic Tests Benefit** |
| Benefits are payable as shown for each day an Insured Person has one or more x-rays, radiological tests and/or other non-laboratory medical tests performed for diagnosis of an Injury or Sickness for which symptoms have been presented. The tests must be ordered by the Insured Person’s attending Physician. The test must be performed in an Outpatient facility or, if performed in a Hospital, performed while the Insured Person is an Outpatient. Only one benefit is payable per day, no matter how many diagnostic tests are performed in a single day.
**Laboratory tests and routine wellness screens and tests are not covered. |
| Benefit Amount per Day | $50 | $50 | $60 | $50 | $60 | $70 |
| Maximum Number of Days per Calendar Year | 3 | 3 | 3 | 3 | 3 | 3 |
| Outpatient Advanced Diagnostic Tests Benefit |
| Benefits are payable as shown for each day an Insured Person has an Advanced Diagnostic Test performed for diagnosis of an Injury or Sickness for which symptoms have been presented. The tests must be ordered by the Insured Person’s attending Physician. The tests must be performed in an Outpatient facility or, if performed in a Hospital, performed while the Insured Person is an Outpatient. Only one benefit is payable per day, no matter how many Advanced Diagnostic Tests are performed in a single day. This benefit is in addition to the Outpatient Diagnostic Tests benefit. |
| Level One Benefit Amount per Day
(Ultrasound, Mammogram, Stress Test,
Echocardiogram, EEG, or EKG) | N/A | $50 | $100 | $100 | $100 | $150 |
| Level Two Benefit Amount per Day
(CT or CAT, MRI, MRA or PET) | N/A | $150 | $300 | $300 | $300 | $450 |
| Maximum Number of Days per
Calendar Year
(Level One and Two Combined) | N/A | 3 | 3 | 3 | 3 | 3 |
| Ambulance Transportation Benefit |
| Benefits are payable as shown for each day an Insured Person is transported by a duly licensed ambulance service to the nearest facility equipped to treat an Insured Person’s Injury or Sickness. The transportation must occur within 72 hours of the Accident or onset of the Sickness. This does not include transportation solely to the Insured Person’s personal Physician or to secure treatment from a Physician or a facility of greater renown. Only one benefit is payable per day, no matter how the transportation is provided or how many transportations are provided in a single day. If more than one type of transportation is provided (air, ground or water) in the same day, the higher benefit will be paid. |
| Benefit for Ground/Water Ambulance
per Day | $100 | $150 | $200 | $250 | $300 | $300 |
| Benefit for Air Ambulance per Day | $300 | $450 | $600 | $750 | $900 | $900 |
| Maximum Number of Days per Calendar Year | 1 | 1 | 1 | 1 | 1 | 1
|
| Emergency Room for Injuries Benefit |
| Benefits are payable as shown for each day an Insured Person receives treatment in a Hospital emergency room due to an Injury. The treatment must begin within 72 hours of the Accident. |
| Benefit Amount per Day | $300 | $300 | $300 | $500 | $500 | $500 |
| Maximum Number of Days per Calendar Year | 2 | 2 | 2 | 2 | 2 | 2 |
| Emergency Room for Sickness Benefit |
| Benefits are payable as shown for each day an Insured Person receives treatment in a Hospital emergency room due to a Sickness. |
| Benefit Amount per Day | $50 | $50 | $75 | $75 | $100 | $100 |
| Maximum Number of Days per Calendar Year | 2 | 2 | 2 | 2 | 2 | 2 |
| Outpatient Accident Benefit |
| Benefits are payable as shown for each day an Insured Person receives treatment for an Injury. Treatment must be provided by a Physician in the Physician’s office, clinic, Urgent Care Facility or Hospital emergency room. The first treatment must be received within 72 hours of the Accident. |
| Benefit Amount per Day | N/A | N/A | N/A | $100 | $100 | $100 |
| Maximum Number of Days per Accident | N/A | N/A | N/A | 1 | 1 | 1 |
| Maximum Number of Accidents per Calendar Year | N/A | N/A | N/A | 2 | 3 | 3 |
| Wellness Benefit* |
| Benefits are payable as shown for each day an Insured Person has any of the following health screenings, examinations or tests performed by or under the supervision of or recommendation of a Physician for the purpose of looking for disease before symptoms occur: Blood test for triglycerides, Bone marrow testing, Breast ultrasound, Cancer Antigen 125 blood test, Cancer Antigen 15-3 blood test, Carcinoembryonic antigen (CEA) blood test, Chest X-ray, Colonoscopy, Fasting blood glucose test, Flexible sigmoidoscopy, Hemoccult stool analysis, Immunizations, Mammography, Pap test, Physical examinations, Prostate Specific Antigen (PSA) blood test, Serum cholesterol test to determine HDL/LDL level, Serum Protein Electrophoresis (SPEP) blood test, Stress test on a bicycle or treadmill, Thermography. Health screenings, examinations or tests intended to diagnosis, treat or monitor a Sickness or Injury after symptoms occur are not covered under this benefit. Only one benefit is payable per day, no matter how many health screenings, examinations or tests are performed in a single day. |
| Benefit Amount per Day | $100 | $100 | $100 | $150 | $150 | $150 |
| Maximum Number of Days per Calendar Year
Insured Persons age 1+
Insured Persons under age 1 | 3
4 | 3
4 | 3
4 | 3
4 | 3
4 | 3
4 |
