| Maximum Benefits - Policy #1342 | |
| Wellness Benefit For Cancer screening tests such as mammogram, pap smear, chest X-ray, prostate screen. |
Up to $100 per calendar year. |
| Positive Diagnosis Test Payable for a test that leads to positive diagnosis of Cancer or Specified Disease within 90 days. |
Up to $300 per calendar year. |
| First Diagnosis Benefit One-time benefit when a covered person is First diagnosed with Cancer (other than Skin Cancer) or a Specified Disease. |
$3600 for insured person. $1800 for covered dependents. |
| Second and Third Surgical Opinions Covers written opinions received after a positive diagnosis and before surgery. |
Actual charges. |
| Non-Local Transportation Payable for transportation to a hospital, clinic or treatment center which is more than 60 miles and less than 700 miles from a Covered Person's home. |
Actual charges by a common carrier, or 50 cents per mile if a personal vehicle is used. |
| Adult Companion Lodging and Transportation Payable for one adult companion to stay with a Covered Person who is confined in a hospital that is more than 60 miles and less than 700 miles from his or her home. Covered expenses include a single room in a motel or hotel up to 60 days per confinement; and the actual cost of round trip coach fare by a common carrier or a mileage allowance for the use of a personal vehicle. |
Up to $50 per day for lodging. 50 cents per mile for transportation if a personal vehicle is used. |
| Ambulance For ambulance service if the Covered Person is taken to the hospital and admitted as an inpatient. |
Actual charges. |
| Surgery Covers actual surgeon's fee for an operation up to an amount based on the schedule in the policy. |
Up to $5400. Outpatient surgery at 150% of the schedule. |
| Anesthesia For services of an anesthesiologist during a Covered Person's surgery. |
Up to 25% of surgical benefit paid. Skin Cancer $ 100. |
| Donor Transplant Benefit Reimbursement for donor expenses. |
Surgical cost per schedule; common carrier coach fare for transportation; and hospital confinement benefit selected. |
| Ambulatory Surgical Center For surgery performed at an Ambulatory Surgical Center. |
Up to $250 per day. |
| Inpatient Drugs and Medicine Payable for drugs and medicine received while the Covered Person is hospital confined. |
Up to $50 per day. $1200 per calendar year. |
| Outpatient Anti-Nausea Drugs Payable for drugs prescribed by a physician to suppress nausea due to Cancer or Specified Disease treatment. |
Up to $500 per calendar year. |
| Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy and Immunotherapy Covers treatment administered by a Radiologist, Chemotherapist or Oncologist on an inpatient or outpatient basis. |
Up to $20,000 per calendar year. |
| Miscellaneous Therapy Charges Covers charges for physical exams, lab work or x-rays in connection with radiation and chemotherapy treatment. |
Up to $500 per calendar year. |
| Blood, Plasma and Platelets For blood, plasma and platelets, and transfusions; including administration. |
Actual charges. |
| Physician's Attendance For one visit per day by a physician while hospital confined. |
Up to $ 40 per day. |
| Private Duty Nursing For private nursing services ordered by attending physician while hospital confined. |
Up to $180 per day. |
| Skin Cancer For surgical removal of Skin Cancer when a physician who is not a pathologist diagnoses it. |
Up to $100 for removal of first skin Cancer; up to $50 after the first. |
| Breast Prosthesis Covers the prosthesis and its implantation if it is required due to breast cancer. |
Actual charges. |
| Miscellaneous Hospital Expense For Inpatient hospital charges not covered under other benefits of the policy. |
10% of combined benefits payable under the policy. |
| Artificial Limb or Prosthesis Covers implantation of an artificial limb or prosthesis when an amputation is performed. |
$2,000 lifetime max per amputation |
| Physical or Speech Therapy Payable when therapy is needed to restore normal bodily function. |
Up to $50 per session. |
| Extended Care Facility Limited to number of days of prior hospital confinement. Must begin within 14 days after hospital confinement, and be at the direction of the attending physician. |
Up to $50 per day. |
| At Home Nursing Limited to number of days of prior hospital confinement. Must begin immediately following a hospital confinement, and be authorized by the attending physician. |
Up to $150 per day. |
| New or Experimental Treatment Payable if attending physician judges such treatment necessary, and treatment is received in the United States. |
Up to $7,500 per calendar year. |
| Hospice Care Payable if a Covered Person is diagnosed terminally ill and the attending Freephysician approves Hospice Care. All care must be received within 14 days of hospital confinement. |
Up to $75 per day for a Free Standing Hospice Center; or $75 per day for a Hospice Care Team for one home visit. |
| HMO Benefit Payable if the Covered Person's primary medical insurance is through an HMO, and he or she cannot provide an itemized bill. Paid in place of certain other benefits under the policy. |
Inpatient - $300 per day for each $100 of daily hospital confinement benefit chosen. Outpatient - $600 per day. |
| Government or Charity Hospital Payable if the Covered Person is confined in a U.S. Government Hospital or a hospital that does not charge for its services. Paid in place of all other benefits under the policy. |
$250 per day. |
| Disability Compensation Payable if the Covered Person has been diagnosed as having Cancer or a Specified Disease, and has other health insurance that will reduce its benefits because of this policy. If the Covered Person elects this benefit, it will be paid in place of all other benefits under the policy. |
$1,750 / week for up to 52 weeks while hospitalized .$ 500 / week for up to 26 weeks while at home if diagnosed as terminally ill while hospitalized and then discharged. $ 500 / week for up to 52 weeks while in a licensed care facility. Benefit is not payable for more than 104 weeks for all confinements. |
| Waiver of Premium After 60 continuous days of disability due to Cancer or Specified Disease, we will waive premiums starting on the first day of policy renewal. |
Yes. |
| Hospital Confinement Payable for each day a Covered Person is charged the daily room rate by a Hospital, for up to 60 days continuous stay. The benefit for covered children under age 21 is two times the Covered Person's daily benefit. |
$100 to $400 per day, in $100 increments as chosen by the Covered Person. |
| Extended Benefits Payable if hospital confinement lasts more than 60 continuous days. Payable in lieu of all other benefits under the policy. |
Reasonably and Customary hospital charges. |
| Home Recovery Benefit Payable during a recovery period as defined. Must begin immediately following hospital confinement of more than 7 days. |
$25 per day per recovery period. |