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| Benefits | Plan Pays |
|---|---|
| Hospital Confinement Benefit Pays the amount shown per Plan Year for hospital confinement for covered injury or sickness | $1,000 per day for days 1-5 $500 per day for days 6-15 |
| Intensive Care Unit Maximum 10 days per Plan Year. Pays in addition to the Hospital Confinement Benefit | $500 per day |
| Inpatient Surgery Benefit Maximum 1 day per Plan Year. Pays the amount shown per Plan Year for medically necessary inpatient surgery for a covered injury or sickness. | $3,000 per day a surgery is performed limited to one benefit per 24 hour period |
| Anesthesia Maximum 1 day per Plan Year. Pays the amount shown per Plan Year for anesthesia administered during a surgical procedure on an inpatient basis. | 25% of the Surgery Benefit per day, limited to one benefit per 24 hour period |
| Emergency Room Benefit Pays the amount shown for 1 day for sickness and 2 days for injury per Plan Year. Limited to 1 visit per day | $250 per day |
| Maternity | Includes surgical and hospital benefits as above schedule |