| Carrier |
|
OneBeacon
Insurance |
|
|
Rated
A (Excellent) by AM Best |
| Coverage |
|
Full
Excess |
| Maximum
Benefit |
|
$25,000 |
| Deductible |
|
$0 |
| Accidental
Death & Dismemberment |
|
$10,000 |
| Incurral
Period |
|
60
days |
| Benefit
Period |
|
52
weeks |
| Covered
Expenses |
|
|
| In-Patient
Hospital Services |
|
|
| Daily
In-Hospital Benefit |
|
100%
of the average semi-private room rate |
| Outpatient
Hospital Services |
|
100%
of Covered Expenses |
| Physicians
Services |
|
|
| Surgery
Benefit |
|
100%
per procedure |
| Physician's
Surgical Facilities |
|
100%
per procedure |
| Second
Opinion or Consultation |
|
100% |
| Anesthesia
Benefit |
|
20% of
the Surgical Benefit |
| Inpatient
Visits |
|
100%
per visit |
| Office
Visits |
|
100% |
| Outpatient
X-ray |
|
100% |
| Outpatient
Physiotherapy |
|
100% |
| Ambulance
Services |
|
100% |
| Medical
Services & Supplies |
|
100% |
| Dental
Services |
|
100% |
| Prescription
Drugs |
|
100% |
 |
suicide
or any attempt at suicide; intentionally self-inflicted Injury or any
attempt at intentionally self-inflicted Injury, including, but not limited to, any attempt to restrict the
flow of oxygen to the brain for purposes of autoeroticism or auto-erotic
asphyxiation; |
 |
illness,
disease, or infections of any kind, regardless of how contracted; medical or
surgical treatment of illness, disease or infections; or complications
following the surgical treatment of illness, disease or infection except for
Accidental ingestion of contaminated foods; |
 |
cosmetic
surgery, except for reconstructive surgery that is Medically Necessary
due to a Covered Injury; |
 |
hernia
of any kind; hemorrhoids of any kind; Osgood-Schlatter’s Disease;
osteochondritis; appendicitis; osteomyelitis; cardiac disease or conditions;
pathological fractures; congenital weakness; detached retina unless caused
by a Covered Injury;
or mental disorder or psychological or psychiatric care or treatment whether
or not caused by a Covered Accident; |
 |
war,
or any act of war, whether declared or undeclared; |
 |
involvement
in any type of active military service; |
 |
treatment
provided in a governmental Hospital unless
the Insured Person is
legally obligated to pay such damages; |
 |
any
Injury for which the Insured Person is entitled to benefits
pursuant to any Workers' Compensation Law or other similar legislation; |
 |
any
Injury for which the Insured Person is entitled to recover
benefits from a third party; |
 |
the
Insured Person being
under the influence of intoxicants or drugs, unless taken under the advice
and in accordance with the directions of a Physician
operating within the scope of his or her authority. The Insured
Person is conclusively deemed to be under the influence of
intoxicants if the level of alcohol in
his or her blood exceeds the amount at which a person is presumed, under the
law of the locale in which the Accident occurred, to be under the
influence of alcohol if operating a motor vehicle, regardless of whether he
or she is in fact operating a motor vehicle when the Injury occurs. An
autopsy report from a licensed medical examiner, law enforcement officer
reports, or similar items will be considered proof of the Insured
Person’s intoxication.; |
 |
participation
in the commission or attempted commission of a crime, any felony, an
assault, insurrection or riot; or any Injury
resulting from a provoked attack; |
 |
a
cardiovascular event or stroke caused by exertion prior to or at the same
time as an Accident; |
 |
air
travel, except as a fare paying passenger on a scheduled commercial flight; |
 |
participation
in any of the following activities:
| skydiving |
|
hang gliding |
|
parasailing |
|
parachuting |
| automobile
racing or stunts |
|
bungee-jumping |
|
scuba
diving |
|
heli-skiing |
| motorcycle
racing or stunts |
|
endurance tests |
|
fire fighting |
|
racing |
| acrobatic
or stunt flying |
|
extreme sport stunts |
|
hunting |
|
|
| flight
on a rocket-propelled or rocket launched aircraft |
|
 |
riding
in or on, entering into or alighting from, or being struck by a two (2) or
three (3)-wheeled motor vehicle or a motor vehicle not designed primarily
for use on public streets and highways. |