Accident Medical Plan
ACCIDENT MEDICAL
IN-HOSPITAL ACCIDENT ONLY
ACCIDENTAL DEATH & DISMEMBERMENT
***THIS COVERAGE IS INCLUDED IN ALL ATA MEDICAL BENEFIT PLANS***
SCOPE OF COVERAGE
We will provide the benefits described in this policy to all covered persons who suffer a covered loss, which is within the scope of the Description of Benefits Provisions and results, directly and independently of all other causes, from bodily injury, which is suffered in an accident, and occurs while the person is a covered person under this policy and is within the scope of the risks set forth in the Description of Hazards provisions.
INSURED PERSONS include all members and their lawful spouses under age 70.
ACCIDENT means a sudden, unforeseeable external event which causes injury to one or more covered persons and occurs while coverage is in force and such injury directly and independently causes a loss covered by the policy.
THIS IS A LIMITED, ACCIDENT ONLY INSURANCE. IT IS AN ACCIDENT ONLY POLICY AND DOES NOT COVER LOSS OR EXPENSE RESULTING FROM SICKNESS, DISEASE, OR BODILY INFIRMITY. In order to receive benefits, an insured person must sustain an injury while the policy is in force and such injury directly and independently causes a loss covered by the policy.
Benefits are payable for eligible expenses for non-work related injuries on the following basis:
DESCRIPTION OF BENEFITS
BENEFIT AMOUNT: $25,000 DEDUCTIBLE: $1,000 Per injury
If, as a result of injury, an insured incurs covered expenses starting within 90 days from the date of the Accident causing the injury, we will pay, less the deductible as shown above, and not to exceed the maximum benefit amount shown therein, all covered expenses incurred within one year from such date.
Covered expenses mean the usual, reasonable and customary charges for local professional ambulance service to or from a hospital and/or surgical center as well as the following usual, reasonable and customary charges for treatment, services and supplies provided or prescribed by a doctor:
(1) Hospital room & board, or Surgical Center care and treatment; (2) Outpatient hospital emergency room; (3) Surgical Benefits;
(4) Doctor’s visits in-hospital; (5) Doctor’s visits out-patient; (6) X-ray and laboratory; (7) Nursing care; (8) Physiotherapy;
(9) Ambulance; (10) Medical equipment rental charges; (11) Medical services and supplies (blood, blood transfusions, oxygen);
(12) Prescription drugs; (13) Dental treatment as a result of injury to natural teeth
ACCIDENTAL DEATH & DISMEMBERMENT
Principal Sum: $50,000
If within one year from the date of an Accident covered under this policy, injury from such Accident results in Loss listed below, we will pay the percentage of the Principal Sum set opposite the loss in the table. The amount will not exceed the Principal Sum which applies to the Covered Person.
ACCIDENTAL DEATH, DISMEMBERMENT, OR LOSS OF SIGHT
LOSS PERCENTAGE OF PRINCIPLE SUM
| Loss of life | 100% |
| Loss of both hands | 100% |
| Loss of both feet | 100% |
| Loss of entire sight of both eyes | 100% |
| Loss of one hand and one foot | 100% |
| Loss of one hand and entire sight of eye | 100% |
| Loss of one foot and entire sight of eye | 100% |
| Loss of one hand | 50% |
| Loss of one foot | 50% |
| Loss of entire sight of one eye | 50% |
| Loss of thumb and index finger of the same hand | 25% |
DESCRIPTION OF HAZARDS
24 Hour Coverage. We will pay the benefits describe in this policy for any Accident which happens to a covered person while he is covered by this policy. This includes travel or flight in an aircraft with some restrictions. SEE EXCLUSIONS.
GENERAL POLICY PROVISIONS
WORKER’S COMPENSATION INSURANCE: This policy is not in lieu of, and does not affect, any requirement for coverage under any Worker’s Compensation Insurance.
EXCLUSIONS
Benefits will not be paid for a Covered Person’s loss which:
1) Is caused by or results from the Covered Person’s own:
(a) Intentionally self-inflicted injury, suicide or any attempt thereat. (In Missouri this applies only while sane);
(b) Voluntary self administration of any drugs or chemical substance not prescribed by, and taken according to the directions of
a doctor (Accidental ingestion of a poisonous substance is not excluded);
(c) Commission or attempt to commit a felony;
(d) Participation in a riot or insurrection;
(e) Driving under the influence of a controlled substance unless administered on the advice of a doctor;
(f) Driving while intoxicated. “Intoxicated” will have the meaning determined by the laws in the jurisdiction of the geographical
area where the loss occurs;
(2) is caused by or results from:
(a) Declared or undeclared war or act of war
(b) An Accident which occurs while the Covered Person is on active duty service in any armed forces. (Reserve or National
Guard active duty for training is not excluded unless it extends beyond 31 days);
(c) Aviation, except as specifically provided in this policy;
(d) Sickness, disease, bodily or mental infirmity or medical or surgical treatment, bacterial or viral infection, regardless of how
contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily
injury or accidental food poisoning.
(e) Nuclear reaction or the release of nuclear energy. However, this exclusion will not apply if the loss is sustained within 180
of the initial incident and:
i) The loss was caused by fire, heat, explosion or other physical trauma which was the result of the release of nuclear
energy, and
ii) The Covered Person was within a 25 mile radius of the site of the release either:
1) At the time of the release; or
2) Within 24 hours of the start of the release
CLAIMS PROVISIONS
Written notice of claim must be given within 30 days after a covered loss occurs or as soon as reasonably possible. We will send
forms to authorized members who ask for them.
Notice must be sent to the address below or call 1-800-591-6764
ATA Administrator
4676 Highway41 North
Springfield, TN. 37172
