The benefit also includes $10,000 of AD&D coverage. See certificate for breakdown of benefits.

Transcription

1 ACCIDENT MEDICAL BENEFIT Underwritten and insured by: If you are injured in a covered accident and receive treatment from a physician, you are eligible for benefits during the benefit period of 52 weeks; you will be paid up to the amount shown in the Benefit Schedule for X-rays, Physician Services, Emergency Room Services, Supplies and Appliances. This benefit is payable if you received initial treatment within 12 weeks after the accident. After satisfying a $100 deductible; benefits are payable up to $5,000. ACCIDENTAL DEATH AND DISMEMBERMENT The benefit also includes $10,000 of AD&D coverage. See certificate for breakdown of benefits. LIMITATIONS & EXCLUSIONS This Certificate does not provide benefits for Treatment, services or supplies which: o Are not Medically Necessary; o Are not prescribed by a Doctor as necessary to treat an Injury; o Are determined to be Experimental/Investigational in nature; o Are received without charge or legal obligation to pay; o Are received from persons employed or retained by the Policyholder or any Family Member, unless otherwise specified. o Are not specifically listed as Covered Charges in this Certificate. Injury by acts of war, whether declared or not. Injury received while traveling or flying by air, except as a fare paying passenger on a regularly scheduled commercial airline. Injury covered by Worker s Compensation or the Occupational Disease Law. CAMOEX102 Dental treatment, except as specifically stated. Injury sustained while committing or attempting to commit a felony. Prescription Drugs except as specifically stated. Suicide or attempted suicide while sane. CAMOEX300 Loss resulting from being legally intoxicated or under the influence of alcohol as defined by the laws of the state in which the Injury occurs. Loss resulting from being under the influence of any drugs or narcotic unless administered on the advice of a Doctor. CAXXEX400 Injury sustained while participating in or practicing for any professional, intercollegiate or club sports activity, except as specifically provided. CAXXEX500 Injury which occurs while the Insured is on active duty service in any armed forces. Reserve or National Guard active duty for training is not excluded unless it extends beyond 31 days. Injury sustained flying in an ultra light, hang gliding, parachuting or bungi-cord jumping, by flight in a space craft or any craft designed for navigation above or beyond the earth s atmosphere. Injury sustained where the Insured is the operator and does not possess a current and valid motor vehicle operator s license, except in a Driver s Education Program. Treatment in any Veteran s Administration or federal Hospital, except if there is a legal obligation to pay. Cosmetic surgery, except for reconstructive surgery on an injured part of the body. CAXXEX600 Covered Charges incurred outside of the United States or its possessions, CAXXEX700 "Guarantee Trust Life Insurance Company (GTL) provides the Accident Medical coverage and the Accidental Death and Dismemberment coverage. GTL does not provide nor is affiliated with the discount products provided as part of Strata 1 Health Card."

2 ACCIDENT MEDICAL BENEFIT Underwritten and insured by: If you are injured in a covered accident and receive treatment from a physician, you are eligible for benefits during the benefit period of 52 weeks; you will be paid up to the amount shown in the Benefit Schedule for X-rays, Physician Services, Emergency Room Services, Supplies and Appliances. This benefit is payable if you received initial treatment within 12 weeks after the accident. After satisfying a $100 deductible; benefits are payable up to $15,000. ACCIDENTAL DEATH AND DISMEMBERMENT The benefit also includes $30,000 of AD&D coverage. See certificate for breakdown of benefits. LIMITATIONS & EXCLUSIONS This Certificate does not provide benefits for Treatment, services or supplies which: o Are not Medically Necessary; o Are not prescribed by a Doctor as necessary to treat an Injury; o Are determined to be Experimental/Investigational in nature; o Are received without charge or legal obligation to pay; o Are received from persons employed or retained by the Policyholder or any Family Member, unless otherwise specified. o Are not specifically listed as Covered Charges in this Certificate. Injury by acts of war, whether declared or not. Injury received while traveling or flying by air, except as a fare paying passenger on a regularly scheduled commercial airline. Injury covered by Worker s Compensation or the Occupational Disease Law. CAMOEX102 Dental treatment, except as specifically stated. Injury sustained while committing or attempting to commit a felony. Prescription Drugs except as specifically stated. Suicide or attempted suicide while sane. CAMOEX300 Loss resulting from being legally intoxicated or under the influence of alcohol as defined by the laws of the state in which the Injury occurs. Loss resulting from being under the influence of any drugs or narcotic unless administered on the advice of a Doctor. CAXXEX400 Injury sustained while participating in or practicing for any professional, intercollegiate or club sports activity, except as specifically provided. CAXXEX500 Injury which occurs while the Insured is on active duty service in any armed forces. Reserve or National Guard active duty for training is not excluded unless it extends beyond 31 days. Injury sustained flying in an ultra light, hang gliding, parachuting or bungi-cord jumping, by flight in a space craft or any craft designed for navigation above or beyond the earth s atmosphere. Injury sustained where the Insured is the operator and does not possess a current and valid motor vehicle operator s license, except in a Driver s Education Program. Treatment in any Veteran s Administration or federal Hospital, except if there is a legal obligation to pay. Cosmetic surgery, except for reconstructive surgery on an injured part of the body. CAXXEX600 Covered Charges incurred outside of the United States or its possessions, CAXXEX700 "Guarantee Trust Life Insurance Company (GTL) provides the Accident Medical coverage and the Accidental Death and Dismemberment coverage. GTL does not provide nor is affiliated with the discount products provided as part of Strata 1 Health Card."

3 Optional Benefits Short Term Disability Underwritten by: Optional Short Term Disability Insurance (Not available for dependents). Short Term Disability Insurance provides a reasonable replacement of monthly earnings to individuals who become impaired by an accident or sickness (non occupational). Guaranteed Issue up to $1,750 Per Month 6 Month Benefit Period 14 Days Accident / 14 Days Sickness Waiting Period Plan Available to all new ITG Members Accident Coverage On or Off the Job Plan Features No limit on the number of claims. Supplements and pays regardless of any other insurance programs. Benefits available for spouse and/or dependent children. Provides 24 hour protection. Benefits for both inpatient and outpatient treatment of covered accidents. Guarantee Issue No underwriting required to qualify for coverage. Settlement Deduction Premiums are paid by convenient Settlement deduction. Accident Benefits Complete Fractures (diagnosis and treatment within 90 days) Hip/Thigh $2,000 $3,000 Vertebrae $1,800 $2,700 Pelvis $1,600 $2,400 Skull (Depressed) $1,500 $2,250 Leg $1,200 $1,800 Forearm/Hand/Wrist $1,000 $1,500 Foot/Ankle/Knee Cap $1,000 $1,500 Shoulder Blade/Collar Bone $800 $1,200 Lower Jaw (Mandible) $800 $1,200 Skull (Simple) $700 $1,050 Upper Arm/Upper Jaw $700 $1,050 Facial Bones (Except teeth) $600 $900 Vertebral Processes $400 $600 Coccyx/Rib/Finger/Toe $160 $240 Complete Dislocations (diagnosis and treatment within 90 days) Hip $1,350 $2,025 Knee (not kneecap) $975 $1,462.5 Shoulder $750 $1,125 Foot/Ankle $600 $900 Hand $525 $787.5 Lower Jaw $450 $675 Wrist $375 $562.5 Elbow $300 $450 Finger/Toe $120 $180 Paralysis (lasting more than three months) Member & Spouse Children Quadriplegia $5,000 $2,500 Paraplegia $2,500 $1,250 Lacerations (treatment and repair within 72 hours) Up to 2 long $25 9

4 2 6 long $100 Over 6 long Injuries Requiring Surgery Eye Injuries (treatment and surgery within 90 days) $125 Removal of foreign body (requiring no surgery) $25 Tendons/Ligaments* (treatment within 60 days, surgical repair within 90 days) Single Multiple If the insured fractures a bone or dislocates a joint, and tears, severs, or ruptures a tendon or ligament in the same accident, we will pay one benefit. We will pay the largest of the scheduled benefit amounts for fractures, dislocations, or tendons and ligaments. Ruptured Disc (treatment within 60 days, surgical repair within one year) Injury occurs during first certificate year Injury occurs after first certificate year Torn Knee Cartilage (within 60 days) Injury occurs during first certificate year Injury occurs after first certificate year Burns (treatment within 72 hours) Second Degree Less than 10% of body surface covered At least 10%, but not more than 25% of body surface covered At least 25%, but not more than 35% of body surface covered More than 35% of body surface covered Third Degree Less than 10% of body surface covered At least 10%, but not more than 25% of body surface covered At least 25%, but not more than 35% of body surface covered More than 35% of body surface covered $300 $50 $50 $100 $500 $1,000 $500 $3,000 $7,000 $10,000 Concussion (resulting in electroencephalogram abnormality) $100 Coma (lasting 30 days or more) $5,000 Internal Injuries (resulting in open abdominal or thoracic surgery) $500 Exploratory Surgery (without repair, i.e. arthroscopy) $125 Emergency Dental Work Repaired with crown Resulting in extraction Medical Fees (for each accident) Member or Spouse $62.50 Child(ren) $37.50 Accident Follow up Treatment $12.50 Physical Therapy $12.50 Air Ambulance $250 Ambulance $50 Transportation (within 90 days) Train or Plane $150 Bus $75 Blood/Plasma $100 Prosthesis $250 Appliance $50 Family Lodging Benefit (per night) $50 Wellness $30 Hospital Admission $500 Hospital Confinement (per day) $100 Hospital Intensive Care (per day) Accidental Death & Dismemberment (within 90 days) Employee Spouse Children Accidental Death $25,000 $5,000 $2,500 Accidental Common Carrier Death $50,000 $25,000 $7,500 Single Dismemberment $3,125 $1,250 $625 Double Dismemberment $12,500 $5,000 $2,500 Loss of One or More Fingers or Toes $625 $250 $125 Partial Amputation of Finger(s) or Toe(s) (including at least one joint) $100 $100 $100 $75 $25 10

5 Optional Benefits Short Term Disability Underwritten by: Optional Short Term Disability Insurance (Not available for dependents). Short Term Disability Insurance provides a reasonable replacement of monthly earnings to individuals who become impaired by an accident or sickness (non occupational). Guaranteed Issue up to $1,750 Per Month 6 Month Benefit Period 14 Days Accident / 14 Days Sickness Waiting Period Plan Available to all new ITG Members Accident Coverage On or Off the Job Plan Features No limit on the number of claims. Supplements and pays regardless of any other insurance programs. Benefits available for spouse and/or dependent children. Provides 24 hour protection. Benefits for both inpatient and outpatient treatment of covered accidents. Guarantee Issue No underwriting required to qualify for coverage. Settlement Deduction Premiums are paid by convenient Settlement deduction. Accident Benefits Complete Fractures (diagnosis and treatment within 90 days) Hip/Thigh $2,000 $3,000 Vertebrae $1,800 $2,700 Pelvis $1,600 $2,400 Skull (Depressed) $1,500 $2,250 Leg $1,200 $1,800 Forearm/Hand/Wrist $1,000 $1,500 Foot/Ankle/Knee Cap $1,000 $1,500 Shoulder Blade/Collar Bone $800 $1,200 Lower Jaw (Mandible) $800 $1,200 Skull (Simple) $700 $1,050 Upper Arm/Upper Jaw $700 $1,050 Facial Bones (Except teeth) $600 $900 Vertebral Processes $400 $600 Coccyx/Rib/Finger/Toe $160 $240 Complete Dislocations (diagnosis and treatment within 90 days) Hip $1,350 $2,025 Knee (not kneecap) $975 $1,462.5 Shoulder $750 $1,125 Foot/Ankle $600 $900 Hand $525 $787.5 Lower Jaw $450 $675 Wrist $375 $562.5 Elbow $300 $450 Finger/Toe $120 $180 Paralysis (lasting more than three months) Member & Spouse Children Quadriplegia $5,000 $2,500 Paraplegia $2,500 $1,250 Lacerations (treatment and repair within 72 hours) Up to 2 long $25 9