DESCRIPTION:

What is Included (Emergency Care)

• Outpatient Emergency Care: Coverage for accidents treated in the ER without being admitted.

• Doctor's Services: Professional fees for the medical staff providing your emergency treatment.

• Emergency Room Fees: The standard charges for using the hospital's ER facilities.

• Emergency Medicines: Medications given for immediate relief and treatment while you are in the ER (take-home medications are not included).

• Medical Fluids and Blood: Oxygen, IV fluids, whole blood, and human blood products needed for your stabilization.

• Wound Care: Dressings, casts, and sutures (stitches) for accidental injuries.

• Diagnostic Testing: X-rays, laboratory tests, and other diagnostic exams ordered by the doctor to assess your injuries.

What is Excluded

This specific accident plan does not cover the following:

• Hospital Admission or Confinement: If the doctor decides you need to be admitted to a hospital room for a longer stay, those costs are outside of this specific plan's coverage.

• Ambulance Services: The cost of transporting you to the hospital via ambulance is not included.

• Exclusions and Limitations

• Non-Emergency Services

  • Services obtained for non-emergency conditions from physicians and providers

• Non-accident related emergencies

  • Non-accident related emergencies, illnesses, diseases, and medical conditions

• Hospital and Medical Care Limitations

  • Non-medical furnishings, appliances, personal items, food, and toiletries

  • Private or special nurse services

  • Custodial, domiciliary, convalescent, and intermediate care

  • Long-term rehabilitation

• Mental Health and Developmental Disorders

  • Psychiatric care and long-term rehabilitation

  • Developmental disorders (e.g., ADD/ADHD, Autism, Bipolar Disorders)

• Self-Inflicted Injuries and Risky Behaviors

  • Injuries from tattoos, body piercing, attempted suicide

  • Injuries resulting from negligence, drug/alcohol use, crime, law violations

  • Injuries from professional sports or hazardous activities

• Cosmetic and Elective Procedures

  • Aesthetic, cosmetic, and reconstructive surgery

  • Weight reduction programs and related procedures

• Dental and Oral Health

  • Dental treatments and oral surgery (except for accidental injury)

• Reproductive Health

  • Maternity care and pregnancy-related conditions

  • Fertility/infertility treatments, sterilization, sex transformation

• Experimental and Alternative Treatments

  • Experimental medical procedures

  • Alternative medicine (e.g., acupuncture, chirotherapy)

• Organ Donation

  • Expenses for the member as an organ donor

• Routine and Preventive Care

  • Routine physical examinations for employment, school, insurance, travel, etc.

  • Vaccines and immunizations (including administration)

• Medical Equipment and Supplies

  • Purchase or lease of medical equipment, prosthetics, and orthotics

  • Take-home and outpatient medicines (with some exceptions)

• Pre-Existing Conditions
  • Dreaded and non-dreaded conditions

• Specific Treatments and Procedures

  • Speech therapy for developmental and congenital diseases

  • Intravenous Immunoglobulin (IVIG)

  • Gallbladder stones and related illnesses

• External Circumstances

  • Treatment for injuries from riots, strikes, civil disturbances, or war

• Financial Limitations

  • Costs exceeding the Annual Benefit Limit (ABL)

  • Medico-legal case costs