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<br />SCHEDULE OF BEREFrrS <br /> <br />MEDICAL EXPENSE BENEFITS <br /> <br />Maximums <br />Lifetime--all disabilities.......................................$1,000,000 <br />mental & emotional conditions.............................$15,OOO <br />(included in lifetime maximum) <br />chemical dependency benefits..............................$15,OOO <br />(included in lifetime maximum) <br /> <br />chiropractic care.........................................$10,000 <br />(included in lif~time maximum) <br /> <br />-DEDUCTIBLE <br />Per Calendar Year for Accident or Illness <br /> <br />Per Person........................................................... $200 <br /> <br />Per FamilY...".......".'.".'..........................3 Family Members <br />Accumulation Period...."'.'................................Calendar Year <br /> <br />DAILY ROOM ALLOWANCES <br />Maximum Hospital Daily Room Allowance..................Average Semi-Private <br />Room Rate <br /> <br />Maximum Intensive Care Unit Daily Allowance (ICU)...............Three Times <br />Hospi tal Daily <br />Room Allowance <br /> <br />Maximum Convalescent Facility Daily Allowance ......................$40/Day <br /> <br />BENEFIT PERCENTAGES <br /> <br />Mental and Emotional Conditions <br />When hospital confined (as any other illness).........................80% <br /> <br />When not confined..................................................... 80% <br /> <br />Calendar year maximum is $1,000 <br /> <br />Chemical Dependency Benefits <br />When hospital confined............................................... .80% <br />30 days per calendar year. <br />Calendar year maximum if $4,000 <br />When not confined...............................50% to annual max. $1,000 <br /> <br />Physician Charges.......................................................80% <br /> <br />Surgical Charges are paid at 60% if Second Surgical Opinion .not obtained <br />for specified procedures. <br /> <br />Inpatient Surgery Charges <br /> <br />Facili ty Charges...................................................... 80% <br /> <br />Surgeon, Asst. Surgeon, and Anethesiologist Charges Second Opinion NOT <br />Required or Required & Obtained.......................................80~ <br />Second Opinion Required and NOT Obtained..............................60% <br /> <br />2 <br />