24 Hour Emergency Room Coverage

24 Hour Emergency Room
Coverage for Sickness & Accidental Injuries

THIS POLICY PROVIDES LIMITED FIRST DOLLAR BENEFITS - PAID DIRECTLY TO YOU

Benefit provides up to $1,000.00 per Hospital Emergency Room visit, up to $2,000 per Covered Person/Family per membership year (Benefits are subject to a $100 deductible)

Affordable monthly cost of $20 for Single or Family Membership

Issue Ages Through Age 69

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Value ER Plan - Benefits Details

EMERGENCY ROOM BENEFIT
Benefit Amount:	$1,000 per Injury or Sickness per Covered Person
Deductible Amount:	$100 per Injury or Sickness per Covered Person
Waiting Period:	30 Days After Policy Effective Date
Annual Maximum Benefit:	$2,000 per Covered Person/Family per Membership Year

DESCRIPTION OF BENEFITS EMERGENCY ROOM BENEFIT

Subject to the definitions, provisions, exclusions and limitations stated herein, We will pay the Emergency Room Benefit shown in the Schedule of Benefits if a Covered Person requires medically necessary treatment by a Physician in a Hospital emergency room for a medical emergency due to Injury or Sickness. We will pay a benefit not to exceed Usual and Customary charges for emergency room Covered Expenses.

Benefits are subject to deductible, limits and maximums shown in the Certificate Schedule.

Covered Expenses are the following charges:

1. charges of a licensed and legally accredited hospital;
2. physician charges;
3. charges of or licensed registered nurse (R.N.), who is not a member of the Insured Person's family;
4. charges for x-ray, laboratory tests, oxygen, casts, splints, crutches, braces (other than dental braces), blood, blood plasma, prescription drugs and medications;
5. charges for Injury or Sickness to sound, natural teeth; and
6. charges for rental of durable medical equipment of a medical or surgical nature, medically necessary for treatment of the Injury or Sickness and not used solely for comfort or convenience.

Definitions: As they relate to this benefit.

Hospital means a facility that: is licensed as a hospital and operated pursuant to law; is primarily engaged in providing or operating either on its premises or in facilities available to the hospital on a contractual prearranged basis and under the supervision of a staff of one or more duly licensed Physicians, medical diagnostic and major surgery facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made; provides 24-hour nursing service by or under the supervision of a registered nurse (R.N.); maintains and operates a minimum of five beds; has x-ray and laboratory facilities either on the premises or available on a contractual prearranged basis; maintains permanent medical history records; or a facility that is accredited by the Joint Commission on Accreditation of Health Care Organization.

Hospital does not mean convalescent, nursing, rest or extended care facilities or facilities operated exclusively for treatment of the aged, whether such facilities are operated as a separate institution or as a section of an institution operated as a hospital. Hospital does not mean a facility primarily providing custodial care or educational services.

Deductible means the amount of Covered Expenses an Insured Person must pay for each emergency room visit before benefits are available.

Medical Emergency means the sudden onset of a medical condition for which the Covered Person seeks immediate medical treatment at the nearest available facility. The condition must be one that manifests itself by acute symptoms that are sufficiently severe that, without immediate medical attention, could reasonably be expected to result in: placing the Insured Person's health in serious jeopardy; serious impairment of bodily functions; or serious dysfunction of any bodily organ or part.

Medically Necessary means services or supplies that are Covered Expenses, prescribed by Your Physician, to diagnose or treat an Injury or Sickness, that are known to be safe and effective by the majority of licensed Physicians who diagnose or treat that Injury or Sickness; provided such services are: provided at the appropriate facility and at the appropriate levels of care for the treatment of the Covered Person's medical condition; not provided primarily for the convenience of the Covered Person, the treating Physician or the Hospital providing the service; consistent with health care practice guidelines and standards that are issued by professionally recognized health care organizations or governmental agencies; not primarily educational, experimental or investigative; consistent with the Covered Person's symptoms, diagnosis or treatment; and no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency.

Physician means a licensed practitioner of the healing arts acting within the scope of his or her license. The attending Physician may not be: employed or retained by the Policyholder; the Covered Person, or a person who is related to the Covered Person.

Sickness means a sickness, illness or disease which occurs after the effective date of coverage under this certificate and while this certificate is in force.

Usual and Customary means the most common charge for similar professional services, drugs procedures, devices, supplies or treatment within the city or county in which the charge is incurred.

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