Benefit Details
Sickness Benefit Limits
Excess of any other insurance
Aggregate Limit Per Sickness |
$1,000 |
|---|---|
Inpatient Hospitalization limit |
Subject to aggregate |
1st $500 at 100%, balance at 80% |
inlcuded |
Semi-private room and board |
included |
Miscellaneous |
included |
Outpatient Sickness Limits at 100% |
$1,000 |
|---|---|
Blanket Outpatient Sickness Benefit |
$1,000 |
Outpatient Mental Health/Substance Abuse |
$1,000 |
Emergency Room |
$1,000 |
Diagnostic X-Ray and Lab |
Included in Blanket Outpatient Sickness Benefit and Mental Health/Substance Abuse |
Physician Office Visits |
Included in Blanket Outpatient Sickness Benefit and Mental Health/Substance Abuse |
Reimbursement for Prescriptions |
Included in Blanket Outpatient Sickness Benefit and Mental Health/Substance Abuse |
Not subject to Aggregate |
|
|---|---|
Dental (non-injury) |
$100 |
Wellness/preventive |
$100 |
Mandatory Accident Benefit (per accident) |
$5,000 |
|---|