Bene昀椀ts Overview ADDITIONAL BENEFITS EMPLOYEE/ SPOUSE/CHILDREN EMERGENCY ROOM TREATMENT We will pay the amount shown for injuries received in a covered accident if you receive treatment in a hospital emergency room and receive initial treatment within 72 hours after the covered accident. This bene昀椀t is payable only once per 24-hour period and only once per covered accident. $200 We will not pay the Emergency Room Treatment Bene昀椀t and the Medical Fees Bene昀椀t for the same covered accident. We will pay the highest eligible bene昀椀t amount. EMERGENCY ROOM OBSERVATION We will pay the amount shown for injuries received in a covered accident if you receive treatment in a hospital emergency room, are held in a hospital for observation for at least 24 hours, and receive initial treatment within 72 hours after the accident. $100 This bene昀椀t is payable only once per 24-hour period and only once per covered accident. This bene昀椀t is payable in addition to Emergency Room Treatment Bene昀椀t. MAJOR DIAGNOSTIC TESTING We will pay the amount shown if, because of injuries sustained in a covered accident, you require one of the following exams, and a charge is incurred: computerized tomography (CT scan); computerized axial tomography (CAT); magnetic resonance imaging (MRI); electroencephalography (EEG). $200 These exams must be performed in a hospital or a doctor’s of昀椀ce. This bene昀椀t is limited to one payment per covered accident. POST TRAUMATIC STRESS DISORDER DIAGNOSIS Post-traumatic Stress Disorder (PTSD) is a mental health condition triggered by a covered accident. We will pay the amount shown if you are diagnosed with post-traumatic stress disorder. You must meet the $200 diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental disorders IV (DSM IV-TR), and be under the active care of either a psychiatrist or Ph.D.-level psychologist. This bene昀椀t is payable only once per covered accident. AMBULANCE/ $200 AIR AMBULANCE ambulance If you require transportation to a hospital by a professional ambulance or air ambulance service within $1,000 90 days after a covered accident, we will pay the amount shown. air ambulance BLOOD/PLASMA $100 If you are injured, and receive blood or plasma within 90 days after the covered accident, we will pay the bene昀椀t shown. APPLIANCES If a doctor advises you to use a medical appliance, we will pay the bene昀椀t shown. $100 Medical appliance means crutches, wheelchairs, leg braces, back braces, and walkers. The plan has limitations and exclusions that may affect benefits payable. The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions. This brochure is for illustrative purposes only. Refer to your certificate for complete details, definitions, limitations, and exclusions.