Athens_Clarke_County_Accident_Flyer.pdf

EN-1974 (1-20) FOR EMPLOYEES R0488478

Unified Government of Athens-Clarke County

Accident Insurance can pay you money for covered accidental injuries and their treatment.

How does it work?

Accident Insurance can pay a set benefit amount based on the type of injury you have and the type of treatment you need. It covers accidents that occur on and off the job. And it includes a range of incidents, from common injuries to more serious events.

Who can get coverage?

Why is this coverage so valuable?

• It can help you with out-of-pocket costs that your medical plan doesn’t cover, like co-pays and deductibles.

• You’re guaranteed base coverage, without answering health questions.

• The cost is conveniently deducted from your paycheck.

• You can keep your coverage if you change jobs or retire. You’ll be billed directly.

You If you’re actively at work*

Your spouse Ages 17 and up

Your children Dependent children from birth until their 26th birthday, regardless of marital or student status.

*Employees must be legally authorized to work in the United States and actively working at a U.S. location to receive coverage. Spouses and dependent children must reside in the United States to receive coverage.

What’s included?

Sickness Hospital Confinement Benefit This benefit pays a daily amount if you’re in the hospital for a covered illness. It’s available to each family member who has Accident coverage. You can receive $200 per day. Coverage for children is 75% of that amount.

How much does it cost?

Monthly Premium

You $13.03

You and your spouse $21.07

You and your child(ren) $24.33

You, your spouse and child(ren) $32.37

For illustrative purposes only. Actual cost may vary.

EN-1974 (1-20) FOR EMPLOYEES R0488478

Accident Insurance – Schedule of Benefits

Accident coverage is a limited policy.

Covered injuries Benefit amount Fractures

Open Reduction (dependent on location of injury) $150 to $7,500

Closed Reduction (dependent on location of injury) $75 to $3,750

Chips 25% of closed amount

Dislocations

Open Reduction (dependent on location of injury) $300 to $6,000

Closed Reduction (dependent on location of injury) $150 to $3,000

Burns

At least 10 square inches, but less than 20 square inches

2nd degree – $0 3rd degree – $2,500

At least 20 square inches, but less than 35 square inches

2nd degree – $0 3rd degree – $5,000

35 or more square inches of the body surface

2nd degree – $1,000 3rd degree – $10,000

Skin grafts for 2nd and 3rd degree burns 50% of burn benefit

Skin graft for any other accidental traumatic loss of skin

At least 10 square inches, but less than 20 square inches $150

At least 20 square inches, but less than 35 square inches $250

35 or more square inches of the body surface $500

Concussion $150

Coma $10,000

Ruptured disc $800

Knee cartilage

Torn with surgical repair $750

Exploratory surgery or cartilage shaved, only $150

Laceration $25–$600

Tendon/ligament and rotator cuff

Surgical repair of one $800

Surgical repair of two or more $1,200

Exploratory surgery without repair $150

Dental work, emergency

Extraction $100

Crown $300

Eye injury $300

Emergency and hospitalization benefits Benefit amount

Ambulance (ground, once per accident) $400

Air ambulance $1500

Emergency room treatment $150

Emergency treatment in physician office/urgent care facility $75

Hospital admission (admission or intensive care admission once per covered accident) $1,000

Intensive care admission (same as above) $1,500

Hospital confinement (per day up to 365 days) $200

Intensive care confinement (per day up to 15 days) $400

Medical imaging test (once per accident) $200

Outpatient surgery facility service (once per accident) $300

Pain management (epidural, once per accident) $100

Treatment and other services Benefit amount

Surgery benefit

Open abdominal, thoracic $1,500

Exploratory (without repair) $150

Hernia repair $150

Physician follow-up visit (2 visits per accident) $75

Chiropractic visit (up to 3 visits per calendar year) $25

Therapy services (up to 10 per accident)

Occupational therapy $25

Speech therapy $25

Physical therapy $25

Prosthetic device or artificial limb

One $750

More than one $1,500

Appliance (once per accident) $100

Blood, plasma and platelets $400

Travel due to accident Transportation of more than 50+ miles from residence; 3 trips per accident; max 1,200 miles per round trip $0.40 per mile

Lodging (per night up to 30 days per accident) $150

Rehabilitation unit confinement (per day up to 15 days; max 30 days per calendar year) $100

Level 2 with AD&D

Underwritten by:

Unum Life Insurance Company of America, Portland, Maine The information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to policy form GA-1 or contact your Unum representative.

© 2020 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

Accidental death and other covered losses Benefit amount

Accidental death*

Employee $50,000

Spouse $20,000

Child $10,000

*The accidental death benefit triples if the insured individual is injured as a fare-paying passenger on a common carrier:

Employee–$150,000; spouse–$60,000; child–$30,000

Initial accidental dismemberment — one benefit per accident, not payable with initial accidental loss

Loss of both hands or both feet; or $15,000

Loss of one hand and one foot; or $15,000

Loss of one hand or one foot; $7,500

Loss of two or more fingers, toes or any combination; or $1,500

Loss of one finger or toe $750

Catastrophic accidental dismemberment†

— once per lifetime, not payable with catastrophic loss

Loss of both hands or both feet; or loss of one hand and one foot

Employee (prior to age 65) $100,000

Spouse and child $50,000

Employee (ages 65–69) $50,000

Spouse and child $25,000

Employee (70+ years old) $25,000

Spouse and child $12,500

Accidental loss — paralysis, sight, hearing and speech

Initial accidental loss — one benefit per accident, not payable with initial dismemberment

Permanent paralysis; or $15,000

Loss of sight of both eyes; or $15,000

Loss of sight of one eye; or $7,500

Loss of the hearing of one ear $7,500

Catastrophic accidental loss† — once per lifetime, not payable with catastrophic dismemberment Permanent paralysis; or loss of hearing in both ears; or loss of the ability to speak; or loss of sight of both eyes

Employee (prior to age 65) $100,000

Spouse and child $50,000

Employee (ages 65–69) $50,000

Spouse and child $25,000

Employee (70+ years old) $25,000

Spouse and child $12,500

†Catastrophic accidental loss benefit — payable after fulfilling a 365 day elimination period.

EN-1974 (1-20) FOR EMPLOYEES R0488478

Accident Insurance

See Schedule of Benefits for a complete listing of what is covered.

THIS IS A LIMITED BENEFITS POLICY.

Effective date of coverage Coverage becomes effective on the first day of the month in which payroll deductions begin.

Exclusions and limitations Unum will not pay benefits for a claim that is caused by, contributed to by or occurs as a result of:

test;

• operating, learning to operate, serving as a crew member of or jumping, parachuting, or falling from any aircraft or hot air balloon, including those which are not motor-driven.

This does not include flying as a fare paying passenger;

• engaging in hang-gliding, bungee jumping, sailgliding, parasailing, parakiting;

• participating or attempting to participate in a felony, being engaged in an illegal occupation or being incarcerated in a penal institution;

• committing or trying to commit suicide or injuring oneself intentionally, whether sane or not;

• practicing for or participating in any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received;

• having any sickness or declining process caused by a sickness, including physical or mental infirmity including any treatment for allergic reactions. Unum also will not pay benefits to diagnose or treat the sickness. Sickness means any illness, infection, disease or any other abnormal physical condition which is not caused by an injury.

In addition to the exclusions listed above, Unum will also not pay the extended accidental dismemberment or extended accidental loss benefit for the following injuries that are caused by or are the result of:

• an insured’s being intoxicated or under the influence of any narcotic unless administered on the advice of a physician; or

• injuries to a dependent child received during the birth.

Sickness Hospital Confinement Benefit exclusions Unum will not pay benefits on any covered individual for a hospital confinement that is caused by contributed to by or occurs as a result of:

taken on the advice of a physician;

of trauma, infection or other diseases;

• hospital confinement caused by, contributed to by, or resulting from your mental illness.

However, dementia as a result of stroke, trauma, viral infection, Alzheimer’s disease or other conditions not listed which are not usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment are covered under this policy;

• any hospital confinement of a newborn following the birth unless the newborn is sick or injured.

Termination of employee coverage If you choose to cancel your coverage under the policy, your coverage ends on the first of the month following the date you provide notification to your employer. Otherwise, your coverage under the policy ends on the earliest of the:

in active employment. However, as long as premium is paid as required, coverage will continue in accordance with the layoff and leave of absence provisions of this policy.

Unum will provide coverage for a payable claim which occurs while you are covered under this policy.

THIS IS A LIMITED BENEFITS POLICY

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form GA-1 et al. or contact your Unum representative.

Unum complies with state civil union and domestic partner laws when applicable.

Underwritten by:

Unum Life Insurance Company of America, Portland, Maine © 2020 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.