Accidental Injury (AME)
Accident-only coverage is designed to provide, to persons insured, coverage for certain losses resulting from a covered accident ONLY, subject to limitations contained in the policy. Coverage is not provided for basic hospital, basic medical-surgical, or major medical expenses.
38 Million Injuries : U.S. emergency rooms logged nearly 38 million injury-related visits. CDC, “National Hospital Ambulatory Medical Care Survey: 2013 Emergency Department Summary Tables”, Rui P, Kang K, Albert M.
52% occur at home : The single most common place of injury is in or around the home. Adams, P.F, Kirzinger W.K, & Martinez, M.E. (2013, December). “Summary of health statistics for the U.S. population: National Health Interview Survey, 2012.” National Center for Health Statistics. Vital and Health Statistics, Series 10 (No. 259).
$200 billion spent :More than $200 billion was spent on medical costs related to unintentional injuries. National Safety Council, “Injury Facts 2015 Edition”
Full reimbursement amounts : Get reimbursed for billed charges, less any applicable adjustments or discounts
Payments sent directly to the policyholder : Benefits are payable directly to the policyholder for covered accidents, regardless of payment by other insurance.
No lifetime limit : Receive up to the maximum benefit amount selected each year no matter how many accidents occur.
Choice of benefit amount : Choose a benefit level amount — from $5,000 to $25,000.
No doctor or hospital restrictions : Receive care from any hospital, medical facility, or physician’s office — there’s no network to worry about.
Guaranteed issue : All applicants who apply for coverage receive it — no medical underwriting is required.
No payment coordination required : Benefits are payable directly to the insured for covered accidents regardless of payment by other coverage.
Guaranteed renewable policy : Policy will not be cancelled regardless of claims history. As long as premium is paid on time.
|Issues Age||18 to 64|
|Renewability||Guaranteed renewable to age 70|
|Coverage Options||Individual / Individual & Spouse / Individual & Child(ren) / Family|
(per calendar year per covered person)
|$100 / $300 / $500 – Choices for Individual, Individual & Spouse, and Individual & Child(ren) coverage options
With a family plan, the maximum deductible is two times the policy deductible chosen in a calendar year.
|Benefit Amount||$5,000 to $25,000, in $5,000 increments
This is the maximum amount that can be paid in a calendar year for each covered person. All children, ages 0 to 26, are combined under one maximum benefit amount choosen
|Rate Structure||Unisex, Age Banded Rates
• 18-24 • 25-54 • 55-64 • Children
|Payment Methods||Credit card or deductions from a designated checking or savings account|
- Emergency Room
- Urgent Care Center
- Physician charge
- Prosthetic device
- Physical therapy
- Major diagnostic exam – exams limited to CT scan, MRI, and EEG
- Drugs administered in an emergency room, hospital, or urgent care center (no payment for drugs prescribed for use after discharge)
Limitations may apply. See policy for complete details.
For any benefit to be payable under the benefits described in this section, the following conditions apply:
- The Accidental Injury, including any subsequent care received for the Accidental Injury, must occur while the Covered Person’s coverage is in force and is not excluded from coverage under the Exclusions and Limitations or the Pre-Existing Conditions Limitation provisions;
- Initial care for the Accidental Injury must begin within seven days of the Injury; and
- Benefits will be eligible for expenses that are incurred within 45 days of the Accidental Injury, unless otherwise specified in the policy.
Medico will pay benefits less any adjustments or discounts, if applicable, up to the Calendar Year Maximum Benefit Amount for each Covered Person. If Your policy provides coverage for more than one Dependent child, the benefit amount is the maximum amount payable for all covered children combined. Benefits will not exceed the Reasonable and Customary Charge, which may not be the same as the billed charge. You are responsible for Your Calendar Year Deductible and any amount over the Calendar Year Maximum Benefit Amount, as well as any amount a Physician may balance bill.
Accidental Emergency Care Benefit
Medico will provide benefits for Emergency Care a Covered Person receives from a Physician in a Hospital including an Emergency Room or Urgent Care Center due to an Accidental Injury. Such Emergency Care can include Surgical operations or procedures.
Accident Follow Up Care Visit
When a Covered Person requires follow-up care after receiving Emergency Care in a Hospital including an Emergency Room or Urgent Care Center for an Accidental Injury, Medico will provide benefits for up to three follow-up Physician visits per Covered Person for each Accidental Injury. This benefit is limited to one Physician visit per day. The follow-up care must be provided in a Physician’s office or in a Hospital on an outpatient basis. This benefit includes follow-up visits for a Surgical operation or procedure. Coverage under this benefit will not be provided for Physical Therapy visits.
Medico will provide benefits for Ambulance transportation services from the scene of an Accident to a Hospital for a Covered Person who has sustained an Accidental Injury for which the Accident Emergency Care Benefit is payable.
Medico will provide benefits for drugs that are prescribed by a Physician and administered to a Covered Person while being treated in an Emergency Room, Hospital or Urgent Care Center for an Accidental Injury. Coverage under this benefit will not be provided for drugs prescribed by a Physician to be taken or used after discharge.
Major Diagnostic Examinations Benefit
Medico will provide benefits for the following major diagnostic exams performed on a Covered Person to Diagnose an Injury:
- Computer tomography scan (CT);
- Magnetic resonance imaging (MRI);
- Electroencephalogram (EEG).
This benefit is limited to one major diagnostic exam per Covered Person per Accidental Injury and such exam must be performed within 14 days of the Accidental Injury.
Physical Therapy Benefit
Medico will provide benefits for Physical Therapy a Covered Person receives as a result of an Accidental Injury. Physical Therapy must be received from a licensed Physical Therapist in an office or Hospital, on an inpatient or outpatient basis, and such treatment must begin within 45 days of the Accidental Injury or the Hospital discharge date. Such treatment must be completed within six months after the Accidental Injury. This benefit is limited to one Physical Therapy visit per day, up to a maximum of 10 visits for each Accidental Injury.
Medico will provide benefits for a Prosthetic Device prescribed by a Physician for functional purposes when a Covered Person suffers the Dismemberment of a hand, foot, arm, leg, or Loss of Sight due to an Accidental Injury. This benefit is limited to one Prosthetic Device received within one year of the Accidental Injury and must occur while the Covered Person’s coverage is in force.
Medico will provide benefits for one x-ray or an x-ray image set a Covered Person undergoes to Diagnose an Injury. Such x-ray(s) must be ordered by a Physician and performed in a Hospital, Physician’s office, or an Urgent Care Facility within 14 days of the Accidental Injury. No benefits are payable for a CT scan or MRI under the X-Ray Benefit; benefits for these exams are only payable under the Major Diagnostic Exams Benefit.
Exclusions and Limitations
No benefits will be paid for any expense not identified and included as a covered loss under the policy. You will be fully responsible for payment of any expense that is not a covered loss.
Medico will not pay benefits for:
- Any Injury that occurs while this policy is not in force.
- Any Injury sustained prior to the Policy Date that is aggravated or reinjured by any event that occurs after the Policy Date.
- Amounts not reimbursed because of applicable Calendar Year Deductible, benefit maximums, or frequency limitations.
- Items, treatments or services:
- Not covered under this policy, including any complications arising therefrom;
- That are not prescribed by or performed by or under the direct supervision of a Physician in accordance with generally accepted medical standards, to include services not rendered or that are not rendered within the scope of their license;
- Not Medically Necessary as determined by Us;
- Deemed to be Experimental or Investigational as determined by Us;
- That would not routinely be paid in the absence of insurance; or
- Performed by an Immediate Family member.
- Any cosmetic items, treatments or services provided primarily for the purpose of improving appearance, self-esteem or body image, including characterizing and personalizing prosthetic devices, and correction of congenital malformation.
- Repairing or replacing a lost, stolen or missing Prosthetic Device.
- Treatment or Diagnosis received while outside the territorial United States.
- Work-related Injury for which the Covered Person is eligible for any workers’ compensation, employers’ liability or similar laws, whether or not benefits are claimed.
- Services furnished by, or payable under, any public program (except Medicaid), or paid for or sponsored by any government body.
- Any loss caused by or resulting in whole or in part from:
- War, declared or undeclared, or actively serving in the armed forces or their auxiliary units, including any country’s National Guard or Army Reserve or their equivalent;
- Committing, attempting to commit, or participation in a felony or engaging in an illegal occupation;
- Participation in a riot, rebellion, or insurrection;
- Alcoholism or drug addiction; or
- An intentionally self-inflicted Injury while sane or insane.
- Any loss resulting, either directly or indirectly, from participation in high risk activity for pay, profit or other commercial purposes, including, but not limited to:
- A sporting event;
- Hang gliding;
- Piloting experimental or ultralight aircraft;
- Riding in any aircraft not licensed to carry passengers or not operated by a duly licensed pilot;
- Any device for aerial navigation, except as a fare-paying passenger;
- Riding in a hot air balloon;
- Bungee jumping;
- Professional mountain and/or rock climbing;
- Rodeo participation;
- Organized contests including, but not limited to, organized contests of speed, go cart racing, dirt bike racing, demolition derbies, and mountain bike racing. This exclusion also includes the practice, qualification, and/or testing for such activities.
- Injuries received or caused directly or indirectly while under the influence of a controlled substance, unless prescribed by a Physician, or by intoxication as defined by the laws and jurisdiction of the geographic area in which the loss or cause of loss was incurred.
- Injuries received or caused directly or indirectly while under the influence of poison, fumes, a noxious chemical substance, or gas that was deliberately ingested.
- Amounts in excess of the Reasonable and Customary Charge.
Pre-Existing Condition Limitation:
Medico will not pay benefits for an Accidental Injury that is caused by a Pre-Existing Condition during the first two years after the Policy Date. If a Dependent is added as a Covered Person after the Policy Date, Medico will not pay benefits for an Accidental Injury that is caused by a Pre-Existing Condition during the first two years after the date the Covered Dependent’s coverage is effective.
Renewability and Premium Changes
Renewability – Guaranteed Renewable to Age 70:
This policy is renewable until the policy anniversary on or following the Covered Person’s 70th birthday except as provided in the Termination section of this policy. Medico retain the right to change Your premium, pursuant to the Premium Change provision of this policy.
Terms Under Which Medico May Change Premiums:
Medico may change Your premium only if they do the same to all policies of this form, which are issued to persons of Your rate class. Your premium is based on Your age and the age of any Covered Dependents when the policy was issued. Your premium may also change due to:
- A change in Your premium payment method;
- A new rate table being applied;
- A rating classification change;
- A misstatement on the application that results in the proper amount due not being charged.
If Medico makes a change, it will not be based on any physical impairment a Covered Person might have or any claims a Covered Person has incurred under this policy. If it is necessary to change the premium for Your policy Medico will send You written notice in advance of the change in premium.
Premiums are subject to change on a limited basis, as stated above. You have a 31-day grace period in which to pay your premium. Your policy stays in force during your grace period. This is a product summary and state variations may apply. See policy for complete details.
$100 Deductible $25,000 Benefit
$100 Deductible $25,000 Benefit
$100 Deductible $25,000 Benefit
$100 Deductible $25,000 Benefit
Phone: 541-382-8949 – EXT. 115
Phone: 541-382-8949 – EXT. 113