Fractures Non-Surgical Repair Fracture 4 /Fracture Requiring Surgical Repair 5 Benefit Low Plan Benefit High Plan Hip $2,000/$4,000 $5,000/10,000 Leg $1,500/$3,000 $2,700/$5,400 Ankle $1,200/$2,400 $2,250/$4,500 Heel $1,200/$2,400 $2,250/$4,500 Kneecap $1,200/$2,400 $2,250/$4,500 Foot (excluding toes, heel) $1,200/$2,400 $2,250/$4,500 Upper arm $1,400/$2,800 $2,400/$4,800 Forearm, hand, wrist (except fingers) $1,200/$2,400 $2,250/$4,500 Finger, Toe $160/$320 $300/$600 Vertebral body $2,240/$4,480 $4,000/$8,000 Vertebral processes $960/$1,920 $1,750/$3,500 Pelvis (except coccyx) $2,250/$4,500 $4,000/$8,000 Coccyx $200/$400 $450/$900 Bones of the face (except nose) $800/$1,600 $1,300/$2,600 Nose $500/$1,000 $750/$1,500 Upper jaw $1,000/$2,000 $1,600/$3,200 Lower jaw $960/$1,920 $1,750/$3,500 Collarbone $1,100/$2,200 $2,200/$4,400 Rib $300/$600 $450/$900 Skull Simple (except bones of the face) $1,000/$2,000 $2,000/$4,000 Skull Depressed (except bones of face) $2,000/$4,000 $4,000/$8,000 Sternum $1,100/$2,200 $1,100/$2,200 Shoulder blade $1,200/$2,400 $2,250/$4,500 Chip Fractures: percentage of the Non-Surgical Repair 25% 25% 1 Laceration benefits are a total of all lacerations per accident. Payable once per covered accident. If your injury qualifies as both a laceration and puncture wound, only one benefit in the higher amount will be payable. 2 Complete separated joint that does not require a surgical repair. If you receive more than one dislocation in the same covered accident, a benefit is payable for all dislocations. However, the benefit amount will be no more than two times the benefit amount for the joint involved which pays the highest benefit amount. Other limitations and maximums may apply. 3 Completely separated joint that requires surgical repair. If you receive more than one dislocation in the same covered accident, a benefit is payable for all dislocations. However, the benefit amount will be no more than two times the benefit amount for the joint involved which pays the highest benefit amount. Other limitations and maximums may apply. 4 Fracture that does not require a surgical repair. If you receive more than one fracture in a covered accident, a benefit is payable for all fractures. However, the benefit will be no more than two times the benefit amount listed for the bone which pays the highest benefit amount. 5 Fracture that does require surgical repair. If the doctor diagnoses the fracture as a chip fracture, the benefit will be reduced to a percentage of what would have been paid for a Non-Surgical Repair Fracture of the same bone. If you receive more than one fracture in a covered accident, a benefit is payable for all fractures. However, the benefit will be no more than two times the benefit amount listed for the bone which pays the highest benefit amount.