|Emergency care at an urgent care facility||$500||$500|
|Emergency care at a hospital or emergency room||$1,000||$1,000|
|Hospital confinement, up to 10 days||$1000/day||$10,000|
|Physical therapy up to 10 visits||$75/visit||$750|
|Ambulance (air or ground)||Up to $5,000 for air ambulance or up to $250 for ground ambulance if an insured person requires ambulance transportation to a hospital or emergency center for injuries sustained in an accident. A licensed professional ambulance company must provide the transportation within 72 hours of the accident. If the provider of service does not receive payment for services from any other source, and provided the benefit under the policy has not been paid, we will directly reimburse the provider of the service.||$5,000|
|Additional Benefit A||Open reduction fractures of - leg, vertebrae (body of), pelvis (including coccyx), or sternum, vertebral processes, rib, skull (depressed).|
Open reduction dislocation of knee or shoulder, collar bone.
Surgical repair of tendons and/or ligaments, torn rotator cuffs, ruptured discs, torn knee cartilages, open abdominal (including exploratory laparotomy).
Any 2nd degree burn covering more than 65 square centimeters.
|$5,000 in total for Benefit A**|
|Additional Benefit B||Open reduction fractures of hip.|
Open reduction dislocation of hip.
Any 3rd degree burn covering more than 65 square centimeters.
|$10,000 in total for Benefit B***|
|A covered accident that results in death, the loss of both hands or both feet, the loss of sight of both eyes, the loss of speech and loss of hearing in both ears, paralysis, quadriplegia, hemiplegia, paraplegia, or severe traumatic brain injury||$50,000||$50,000|
|A covered accident that results in the loss of one hand or one foot or sight of one eye, loss of speech, loss of hearing in both ears, uniplegia, or moderate traumatic brain injury||$25,000||$25,000|
|A covered accident that results in the loss of hearing in one ear, or the loss of the thumb and index finger of the same hand||$12,500||$12,500|