Bene昀椀ts Overview MAJOR INJURIES – continued EMPLOYEE/ SPOUSE/CHILDREN DISLOCATIONS (closed reduction) Dislocation* means a completely separated joint. If a doctor diagnoses and Hip $3,000 treats the dislocation within 90 days after the covered accident, we will pay the amount shown. If the dislocation requires Knee (not kneecap) $1,950 open reduction, we will pay 200% of the appropriate amount shown. Shoulder $1,500 Multiple Dislocations* means having more than one dislocation requiring Foot/Ankle $1,200 either open or closed reduction. For each dislocation, we will pay the amounts Hand $1,050 shown. We will not pay more than 200% of the bene昀椀t amount for the dislocated Lower Jaw $900 joint that has the highest bene昀椀t amount. Partial dislocation* means the Wrist $750 joint is not completely separated. If a doctor diagnoses and treats the partial dislocation, we will pay 25% of the Elbow $600 amount shown for the affected joint. Finger/Toe $240 * If a dislocation requires open reduction, we will pay double the amount shown. SPECIFIC INJURIES EMPLOYEE/ SPOUSE/CHILDREN RUPTURED DISC (treatment within 60 days; surgical repair within one year) Injury occurring during 昀椀rst certi昀椀cate year $100 Injury occurring after 昀椀rst certi昀椀cate year $400 TENDONS/LIGAMENTS (treatment within 60 days; surgical repair within 90 days) $600 If you tear, sever, or rupture a tendon or ligament in a covered accident, we will pay one bene昀椀t. We will (Multiple) pay the largest of the scheduled bene昀椀t amounts for tendons and ligaments repaired. $400 (Single) TORN KNEE CARTILAGE (treatment within 60 days; surgical repair within one year) Injury occurring during 昀椀rst certi昀椀cate year $100 Injury occurring after 昀椀rst certi昀椀cate year $400 EYE INJURIES Treatment and surgical repair within 90 days $250 Removal of foreign body nonsurgically, with or without anesthesia $50 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.