Emergency Dental Work Benefit Payable for repair to natural teeth, free of decay, when treated by a Physician or dentist. Initial dental treatment must be received within 3 days of the Accident. Epidural Pain Management Benefit Payable when a Person receives an epidural injection into the epidural space for management of pain due to an Injury. This benefit is not payable for an epidural administered before a surgical procedure. Exploratory Surgery Benefit Payable when an exploratory surgical operation without surgical repair is performed. Eye Injury Benefit Payable for one or both eyes requiring treatment by a Physician due to an Accident. Family Member Lodging and Meals Benefit Payable for lodging and meals for a family member to be near a Person who is Hospital Confined in a non-local Hospital. The Hospital must be at least 50 miles away, one way, using the most direct route from the family member’s residence. Fractures Benefit Varies based on the bone involved, type of fracture and type of treatment. If the Person fractures more than one bone, payment is made for all fractures up to two times the amount for the bone involved that has the highest benefit amount. Gunshot Wound Benefit Payable if gunshot wound does not cause Person to die; is caused by a shot from a Conventional Firearm; requires treatment by a Physician within 24 hours of Accident; and requires Confinement. If Dismemberment occurs, only the highest benefit will be paid. The Dismemberment must occur within 90 days after the Accident. Hospital Admission Benefit Pays the first day a Person is Confined to a Hospital. Hospital Confinement Benefit Pays a daily benefit for a Hospital Confinement up to 365 days. This benefit does not pay on the same day a Hospital Admission or ICU Admission benefit is paid. Intensive Care Unit (ICU) Admission Benefit Pays the first day a Person is Confined to an ICU. If Hospital Admission and ICU Admission Benefits are payable for the same day, only the ICU Admission Benefit will be paid. Intensive Care Unit (ICU) Confinement Benefit Pays a daily benefit for an ICU Confinement up to 30 days. This benefit does not pay on the same day a Hospital Admission or ICU Admission benefit is paid. This benefit is payable in addition to the Hospital Confinement Benefit. Internal Injuries Benefit Payable for an open abdominal or thoracic surgery performed within 3 days of the Accident. Lacerations Benefit This benefit varies based on the method of repair and total length of all lacerations due to an Accident. Medical Imaging Benefit Payable for a Computerized Tomography (CT or CAT), Magnetic Resonance Imaging (MRI), Single-Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET) or an ultrasound for diagnosing an Injury due to an Accident. Miscellaneous Surgery Benefit Payable when a Person receives a surgery requiring general anesthesia due to an Accident that is not payable under any other benefit. Epidural injections are not paid under this benefit. Outpatient Hospital or Ambulatory Surgical Center Benefit Pays when a surgical procedure is performed on an outpatient basis in a Hospital or Ambulatory Surgical Center. We will only pay one Outpatient Hospital or Ambulatory Surgical Center Benefit in a 24-hour period even if more than one surgical procedure is performed. This benefit will not be paid for surgery performed in an Emergency Room, Urgent Care Facility or in a Physician’s Office. Paralysis Benefit The duration of the Paralysis must be a minimum of 90 consecutive days. If more than one type of Paralysis occurs due to the same Accident, only the highest benefit will be paid. Paid once per lifetime per Person. A Covered Person (thereafter referred to as “Person”) under AF™ Limited Benefit Accident Only Insurance policy may be eligible for the following benefits when a Covered Accident (thereafter referred to as “Accident”) happens. All benefits are paid once per Person per Accident unless otherwise specified. All benefits are only paid as a result of Injuries received in an Accident that occurs while coverage is active. All treatment, procedures, and medical equipment must be diagnosed, recommended and treated by a Physician. These references are not intended to change or modify any definitions in the AO22 policy series. Initial Treatment Benefit Payable for the first treatment received within 30 days of the Accident. The initial treatment must be administered by a Physician or Medical Professional. Follow-Up Treatment Benefit Payable for up to six follow- up treatments when initial medical treatment was received within 30 days of the Accident. Not payable for a visit in which a Physical, Occupational, or Speech Therapy benefit is paid. Accident Screening Benefit Payable when a Person receives one of the following screenings rendered by a Physician: bone density screening; Epworth Sleepiness Scale for the purpose of diagnosing a sleeping disorder; hemoglobin A1C; routine physical exam; sports physicals; or stress test. This benefit is payable once per policy per Calendar Year. This benefit does not cover dental exams or eye exams. An Accident is not required for this benefit to be payable. This benefit is not payable for services performed as treatment for an Injury. Accidental Death and Dismemberment Benefit The applicable benefits apply when an Accidental Death or Dismemberment occurs within 90 days of an Accident. In the event that Accidental Death and Dismemberment result from the same Accident, only the Accidental Death Benefit will be paid. Ambulance Benefit If air and ground/water ambulance transportation is required for the same Accident, only the highest benefit will be paid. Anesthesia Benefit Payable for the services of an anesthesiologist for a surgery performed due to an Accident. Hospital Confinement is not required to receive this benefit. We will only pay one Anesthesia Benefit per Person in a 24-hour period even if more than one surgical procedure is performed. This benefit is not payable for local anesthesia. Appliances Benefit Payable for one of the following as prescribed by a Physician: wheelchair, motorized scooter, walker, walking boot, brace, cane, crutches, or any other medical device used for mobility. Not payable for Prosthetic Devices. Blood, Plasma and Platelets Benefit Payable for blood, plasma and platelets. This benefit does not provide benefits for immunoglobulins. Burns Benefit Payable for 2nd and 3rd degree burns when treated by a Physician within 3 days of the Accident. Coma Benefit Must be diagnosed by a Physician and continue for at least 14 days. Coma does not include medically induced coma or a coma which results directly from alcohol or drug use. Concussion Benefit Payable for a Person who sustains a concussion and is diagnosed by a Physician within 7 days of the Accident. If both a Concussion and a Traumatic Brain Injury occur in the same Accident, only the highest benefit will be paid. Dislocations Benefit Amount payable varies by the joint involved, type of treatment, and type of anesthesia. If a Person receives more than one Dislocation in an Accident, we will pay for all Dislocations up to two times the amount shown in the Schedule of Benefits for the Dislocation involved that has the highest benefit amount. No other amount will be paid under this benefit. Benefits are payable only for the first dislocation of a joint which occurs while this policy is active. Plan Benefit Highlights