Accident Benefits Summary

Plan Summary for : 12856000 - Total Education Solutions Scheduled Benefit Accident EMERGENCY CARE & DIAGNOSTICS Plan 1 Plan 2 Ambulance - Ground $750 pp/pa $1,000 pp/pa 1 trip(s) per covered accident Ambulance - Air $2,000 pp/pa $2,000 pp/pa 1 trip(s) per covered accident Emergency Room $200 pp/pa $250 pp/pa 1 trip(s) per covered accident Major Diagnostic Testing $300 pp/pa $400 pp/pa (MRI, CT Scan, EEG) 1 exam(s) per covered accident X-Ray $150 pp/pa $200 pp/pa 1 test(s) per covered accident Pain Management/Epidural $50 pp/pa $75 pp/pa 1 visit(s) per covered accident Initial Doctor's Visit $100 pp/pa $150 pp/pa ACCIDENT HOSPITALIZATION & SURGICAL BENEFITS Hospital Admission $1,500 pp/pa $2,000 pp/pa ICU Admission $3,000 pp/pa $4,000 pp/pa Hospital Confinement $400 per day $600 per day Up to 365 day(s) per accident ICU $600 per day $800 per day Up to 30 day(s) per accident Rehabilitation/Skilled Nursing Facility $300 per day $420 per day Up to 90 day(s) per accident Blood/Plasma/Platelets $300 pp/pa $400 pp/pa Surgery - Open Abdominal, Thoracic $3,000 per surgery $4,000 per surgery Surgery - Cranial $3,000 per surgery $4,000 per surgery Surgery - Hernia $400 per surgery $600 per surgery Surgery - Exploratory or Without Repair $500 per surgery $750 per surgery Outpatient/Miscellaneous Surgery $200 per surgery $300 per surgery Transportation $600 per trip $800 per trip Up to 3 trip(s) per accident Family Lodging $150 per night $175 per night Up to 30 nights Coma $4,000 pp/pa $6,000 pp/pa After 7 day duration FOLLOW UP CARE Follow Up Doctor's Visit $100 pp/pa $150 pp/pa 1 visit(s) per covered accident Physical Therapy $75 per visit $100 per visit Up to 10 visits per accident Chiropractic Visit $75 per visit $100 per visit Up to 10 visits per accident Medical Equipment $200 pp/pa $300 pp/pa 1 appliance(s) per covered accident Prosthetic Device $1,500 pp/pa $2,000 pp/pa 1 device per covered accident COMMON INJURIES Burns Second Degree: 20 - 100 square centimeters $75 pp/pa $150 pp/pa Second Degree: 101 - 225 square centimeters $150 pp/pa $300 pp/pa