Benefit Examples Benefit Pays Ambulance $100 ground; $500 air Voluntary Accident Chiropractic Services $25 per session; 6 sessions Coma $5,000 Insurance Concussion $100 Diagnostic Exams $100 per CT/MRI scan Initial Hospital Admission $500 What is it? How Much Does it Cost? ICU Hospital Admission $1,000 Accident insurance provides Bi- Hospital Confinement $200 per day; 365-day max payment for treatments and Level of Monthly Coverage Weekly Cost ICU Confinement $400 per day; 30-day max services resulting from an Cost Lacerations Up to $400 accidental injury, such as Employee Only $4.74 $10.27 treatment for fractures, Employee + Sp $7.38 $15.99 Physical Therapy $25 per session; 6 session max dislocations, lacerations, as Physician Visit $50 initial; $50 follow-up well as emergency room, Employee + Ch $8.17 $17.70 Rehab Facility Confinement $50 per day; 30-day max ambulance, and Family $11.07 $23.99 hospitalizations related to X-rays $25 the accident. Wellness $50 health screening Please click here to view the coverage certificate for a complete list of covered services and benefit details. 21