DESCRIPTION OF BENEFITS PARTICIPANT ACCIDENT INSURANCE

 I.      ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT

 If Injury to the Covered Person results in any of the Covered Losses shown below, within 365 days of the Accident that caused the loss, we will pay the percentage of the applicable AD&D Principal Sum shown below for that loss.  If multiple losses occur, only one benefit, the largest, will be paid for all Covered Losses due to the same Covered Accident.

   Schedule of Covered Losses

      Loss of:                                                                                     Benefit:

                                                                                     (Percentage of Principal Sum)

Life..........................................................................................100%

Quadriplegia..............................................................................100%

Two or More Members................................................................. 100%

One Member..............................................................................50%

Hemiplegia................................................................................50%

Paraplegia.................................................................................50%

Uniplegia...................................................................................25%

Thumb and Index Finger of the Same Hand........................................ 25%

Four fingers of the Same Hand......................................................... 25%

 “Member” means Loss of Hand or Foot, Loss of Arm or Leg, Loss of Sight, Loss of Speech and Loss of Hearing.  “Loss of a hand or foot” means complete severance through or above the wrist or ankle joint.  “Loss of Arm or Leg” means complete Severance through or above the elbow or knee joint. “Loss of sight” means total and permanent loss of sight of one/both eyes that is irrecoverable, including by surgical and artificial means.   “Loss of speech” means total and permanent loss of audible communication that is irrecoverable by natural, surgical or artificial means.  “Loss of hearing” means permanent total deafness in both ears such that it cannot be corrected by any aid or device. “Loss of thumb and index finger of the same hand” means complete severance of each through or above the metacarpophalangeal joint of both digits of the same hand.  Severance means the complete separation and dismemberment of the part from the body.

  “Hemiplegia” means total Paralysis of the upper and lower limbs on one side of the body.

 “Paraplegia” means total Paralysis of both lower limbs or both upper limbs.

 “Quadriplegia” means total Paralysis of both upper and lower limbs.

 “Uniplegia” means total Paralysis of one lower limb or one upper limb.

AD&D Aggregate Limit of Liability

 The maximum amount we will pay for all covered AD&D losses resulting from the same Accident will not exceed $250,000.  If the total amount payable for all such losses exceeds $250,000, each Covered Person’s Covered Loss will be paid at the same ratio that the Aggregate Limit of Liability has to the total amount of all Covered Losses.  We shall not be liable for amounts in excess of the Aggregate Limit of Liability.

 II. ACCIDENT MEDICAL AND DENTAL EXPENSE BENEFIT

 Subject to the applicable Deductible, we will pay Accident Medical and Dental Expense Benefits for Covered Expenses that result directly, and from no other cause, from a Covered Accident up to the applicable benefit maximum provided the first expense is incurred within 30 days of the Covered Accident. 

 Accident Medical Expense Benefits are only payable:

1)      for Usual and Customary Charges incurred after the Deductible has been met;

2)      for those Medically Necessary Covered Expenses incurred by or on behalf of the Covered Person;

3)      for Covered Expenses incurred within 365 days after the date of the Covered Accident.

 No benefits will be paid for any expenses incurred that are in excess of Usual and Customary Charges.

 Covered Medical Expenses, from a Covered Accident, include:

1)      Hospital room and board expenses: the daily room rate when a Covered Person is Hospital Confined and general nursing care is provided and charged for by the Hospital.  In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge.

2)      Ancillary Hospital expenses: services and supplies including operating room, laboratory tests, anesthesia and medicines (excluding take home drugs) when Hospital Confined.

3)      Daily Intensive Care Unit/Cardiac Care Unit Expenses:  the daily room rate when a Covered Person is Hospital confined in a bed in the Intensive Care Unit/Cardiac Care Unit and nursing services other than private duty nursing services.

4)      Medical Emergency Care (room and supplies) expenses incurred within 72 hours of a Covered Accident and including the attending Physician’s charges, x-rays, laboratory procedures, use of the emergency room and supplies.

5)      Outpatient surgery expenses, including Ambulatory Surgical Center.

6)      Outpatient surgical room and supply expenses for use of the surgical facility.

7)      Outpatient diagnostic x-rays, laboratory procedures and test expenses.

8)      Physician non-surgical treatment/examination expenses (excluding medicines) including the Physician’s initial visit, each necessary follow-up visit and consultation visits when referred by the attending Physician.

9)      Second surgical opinion expenses.

10)  Physician surgical expenses. If an Injury requires multiple surgical procedures, we will pay 100% of the available benefit for the largest of the procedures performed, 50% of the available benefit for the second procedure and 25% of the available benefit for any additional eligible procedures.

11)  Assistant Surgeon expenses when Medically Necessary.

12)  Anesthesiologist expenses for pre-operative screening and administration of anesthesia during a surgical procedure whether on an inpatient or outpatient basis.

13)  Outpatient laboratory test expenses.

14)  Physiotherapy (physical medicine) expenses on an inpatient or outpatient basis limited to one visit per day; expenses include treatment and office visits connected with such treatment when prescribed by a Physician, including diathermy, ultrasonic, whirlpool, heat treatments, chiropractic, adjustments, manipulation, massage or any form of physical therapy.

15)  Post surgical physical medicine expenses and office visits connected with such treatment when prescribed by a Physician.

16)  Diagnostic imaging expenses including magnetic resonance imaging (MRI) and CAT scans.

17)  Dental expenses including dental x-rays for the repair or treatment of each injured tooth that is whole sound and a natural tooth at the time of the Covered Accident.

18)  Outpatient registered nurse services if ordered by a Physician.

19)  Ambulance expenses for transportation from the Accident site to the Hospital.

20)  Rehabilitative braces or appliances prescribed by a Physician.  It must be durable medical equipment that is primarily and customarily used to serve a medical purpose and can withstand repeated use and generally is not useful to a person in the absence of Injury.  No benefits will be paid for rental charges in excess of the purchase price.

21)  Prescription drug expenses prescribed by a Physician and administered on an outpatient basis.

22)  Medical equipment rental expenses for a wheelchair or other medical equipment that has therapeutic value for the Covered Person.  We will not cover computers, motor vehicles or modifications to a motor vehicle, ramps and installation costs.

23)  Medical services and supplies for blood and blood transfusions; oxygen and its administration.

24)  Artificial limbs, eyes and larynx for initial acquisition and fitting.  We will not pay for repair or replacement of artificial limbs, eyes or larynx.

 Terms of Payment for Accident Medical and Dental Expense Benefit - Full Excess:

 If a Covered Person incurs Covered Expenses, We will pay the applicable benefit, subject to any applicable Deductible, Coinsurance Factor and Benefit Period shown on the Schedule of Benefits that are in excess of expenses payable by any other Health Care Plan, regardless of any Coordination of Benefits provision contained in such Health Care Plan.  The first expense must be incurred within the Loss Period stated on the Schedule of Benefits.  The Total Benefit Maximum payable and sub-limits under the Policy are shown on the Schedule of Benefits.

 Failure by a Covered Person to follow the terms and conditions and/ or failure to utilize the network providers and facilities of His primary coverage will result in a benefit reduction of Covered Expense to 50% of the amount otherwise payable under the Policy.  This limitation will not apply to emergency treatment required within 24 hours after an Accident when the Accident occurs outside the geographic area served by His primary plan’s HMO, PPO or other similar arrangement for provision of benefits or services, if applicable.

 For the purposes of this provision, “Health Care Plan” means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under:

 Premium is fully earned and nonrefundable at inception of policy. No refunds will be made for any reason including, but not limited to, policy cancellation, change of venue, or cancellation of team, league, camp, tournament, or event. All premium is fully earned as of the coverage effective date except for accident insurance in NH, NY, NM and WA.

1)      group or blanket insurance, whether on an insured or self-funded basis;

2)      hospital or medical service organizations on a group basis;

3)      Health Maintenance Organizations on a group basis;

4)      group labor management plans;

5)      employee benefit organization plan;

6)      professional association plans on a group basis;

7)      any other group employee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974 as amended; or

8)      automobile no-fault coverage (unless prohibited by law).

III. Exclusions

The policy does not cover any loss resulting in whole or part from, or contributed to by, or as a natural or probable consequence of any of the following even if the immediate cause of the loss is an accidental bodily Injury:

 1)      Suicide, self-destruction, attempted self-destruction or intentional self-inflicted Injury while sane or insane.

2)      War or any act of war, declared or undeclared.

3)      Service or Active Duty in the armed forces, National Guard, military, naval or air service or organized reserve corps of any country or international organization.

4)      Sickness, disease or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances.

5)      Disease or disorder of the body or mind.

6)      Voluntarily taking any drug or narcotic unless the drug or narcotic is prescribed by a Physician.

7)      Intoxication or being under the influence of any drug or narcotic.

8)      Violation or in violation or attempt to violate any duly-enacted law or regulation, or commission or attempt to commit an assault or felony, or that occurs while engaged in an illegal occupation.

9)      Conditions that are not caused by a Covered Accident.

10)  Covered Expenses for which the Covered Person would not be responsible in the absence of this Policy.

11)  Injuries paid under Workers’ Compensation, Employer’s liability laws or similar occupational benefits or while engaging in activity for monetary gain from sources other than the Policyholder.

12)  Travel or activity outside the United States.

13)  Participation in any motorized race or speed contest.

14)  Any Injury requiring treatment which arises out of, or in the course of fighting, brawling assault or battery.

15)  Injury caused by, contributed to or resulting from the Covered Person’s use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person’s Physician.

16)  Services or treatment rendered by a Physician, Nurse or any other person who is employed or retained by the policyholder; or an Immediate Family member of the Covered Person.

17)  Treatment of Osgood-Schlatter’s disease, osteochondritis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, whether or not caused by a Covered Accident.

18)  Treatment of a detached retina unless caused by an Injury suffered from a Covered Accident.

19)  Mental or nervous disorders, except as specifically provided in this policy.

20)  Damage to or loss of dentures or bridges or damage to existing orthodontic equipment, except as specifically provided in this Policy.

21)  Expense incurred for treatment of temporomandibular or craniomandibular joint dysfunction and associated myofacial pain, except as specifically provided in this Policy.

22)  Practice or play in any sports activity, including travel to and from the activity and practice, unless specifically provided for in the Policy.

23)  Damage to or loss of dentures or bridges or damage to existing orthodontic equipment, except as specifically provided in this Policy.

24)  Loss resulting from participation in any activity not specifically covered by this Policy.

25)  Any treatment, service or supply not specifically covered by this Policy.

26)  Eyeglasses, contact lenses, hearing aids.

27)  Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from:

                                i.      While riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; or

                              ii.      While being used for any test or experimental purpose; or

                            iii.      While piloting, operating, learning to operate or serving as a member of the crew thereof.

28)  Aggravation or re-injury of a prior Injury that the Covered Person suffered prior to his or her coverage Effective Date, unless We receive a written medical release from the Covered Person’s Physician.

29)  Heart attack, stroke or other circulatory disease or disorder, whether or not known or diagnosed, unless the immediate cause of Loss is external trauma.

30)  Treatment of a hernia whether or not caused by a Covered Accident.

Participant Accident policies will be sent via email after the required OFAC screening has been completed.

This document is only a summary of the benefits and exclusions provided under insurance policy series AH51051.  Please refer to your policy for a complete description of the coverages. If there is a conflict between this brochure and the issued policy, the issued policy will prevail. Capitalized terms have the meaning found in the policy under the Definitions section unless otherwise defined herein.  This proposal does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from offering or providing insurance. 

The insurance described in this document provides limited benefits. Limited benefits plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans. This insurance is not an alternative to comprehensive coverage. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

By purchasing this insurance I also agree that my insurance policy and certificates of insurance will be available for download through this website and that I will not receive paper copies.