www.reliancematrix.com Reliance Matrix is a branding name. Reliance Standard Life Insurance Company (Home Office Schaumburg, IL) is licensed in all states (except New York), the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. First Reliance Standard Life Insurance Company (Home Office New York, NY) is licensed in New York and Delaware. Standard Security Life Insurance Company of New York (Home Office New York, NY) is licensed in all states. Absence services are provided by Matrix Absence Management, Inc. Product features and availability may vary by state. BENEFIT PLAN B Covering 25% but less than 35% of the body $800 Covering 35% or greater of the body $1,600 3rd Degree Burns Covering less than 10% of the body $1,600 Covering 10% but less than 25% of the body $3,200 Covering 25% but less than 35% of the body $6,400 Covering 35% or greater of the body $12,800 Skin Graft 50% Chiropractic Services (per visit) Limit 12 per calendar year per family $37.50 per session, 6 sessions maximum Coma $10,000 Concussion $200 Dental Injury $300 for Crown; $100 for Extraction Diagnostic Examination $200 per CT/MRI scan Dislocations Surgical / Non-Surgical Ankle $2,700 / $1,350 Collarbone $2,700 / $1,350 Elbow $1,350 / $675 Finger $450 / $225 Foot $2,700 / $1,350 Hand $1,350 / $675 Hip $7,200 / $3,600 Knee $4,500 / $2,250 Lower Jaw $1,350 / $675 Shoulder $1,350 / $675 Toe $450 / $225 Wrist $1,350 / $675 Partial Dislocation Amount of benefit for non-surgical dislocation 50% Multiple Dislocations Amount of highest benefit for any one dislocation among all dislocations sustained 200% Emergency Treatment $300 Epidural Anesthesia Injection $200 per injection, 2 maximum Eye Injury $200 for removal of foreign object, $400 for surgical repair Fractures Surgical / Non-Surgical Ankle $1,350 / $675 Arm $1,350 / $675 Bones of Face $675 / $337.50 Coccyx $675 / $337.50 Collarbone $1,350 / $675 Elbow $1,350 / $675 Finger $225 / $112.50 Foot $1,350 / $675 Hand $1,350 / $675 Hip $7,200 / $3,600 Kneecap $1,350 / $675 Leg $3,600 / $1,800 Jaw $1,350 / $675 Nose $675 / $337.50 Pelvis $3,600 / $1,800