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