BASIC PLAN BENEFITS
When, as the result of an Accident or a Sickness, the Insured incurs Loss within 52 weeks immediately following the date of the Accident or the date of first treatment for Sickness, the Company will pay the benefits for the following medical services up to the Basic Plan Maximum Benefit, subject to the limits for the specific medical services listed below, for each Accident or each Sickness, unless specified otherwise. Covered Charges will not exceed the Reasonable and Customary charges for services and supplies listed.
| Benefit Limits | ||
|---|---|---|
| Medical Services | Plan I | Plan II |
| Hospital Room & Board (per day) | $200 | $400 |
| All other Hospital Confinement Services | $600 | $1,000 |
| Hospital Out-Patient Services, Emergency Room, Urgent Care, After Hours Care or Free Standing Ambulatory Surgical Center Services (Accident and Out-Patient Surgery only) |
$300 | $600 |
| Surgery - 80% of Covered Charges (see Limitation #1) |
$1,000 | $2,000 |
| Anesthesiologist (25% of specific primary surgical benefit) |
$250 | $500 |
| Doctor's nonsurgical treatment Daily Benefit (see Limitation #4) The first visit for out-patient treatment of a Sickness is not covered. |
$300 $25 |
$750 $50 |
| Out-Patient laboratory tests, x-rays and preventive cancer screening procedures including Mammograms, Pap Smears and PSA Test (see Limitation #10) |
$150 | $300 |
| Consultant Doctor Services (See Definition of Consultant Doctor Services.) |
$50 | $100 |
| Ambulance | $100 | $250 |
| Dentist's treatment of injured Sound Natural Teeth (Accident only) |
$150 | $300 |
| Basic Plan Maximum Benefit | $3,000 | $5,000 |