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ACCIDENT || CHAMPION
No one plans on getting injured . . .
but just in case, we’ve got you covered.
You do everything you can to stay active and healthy, Facts on the GO!
but accidents happen every day, including sports- About 39 million emergency room
1
related accidents. An injury that hurts an arm or a leg visits each year are due to injuries.
can hurt your finances, too. That’s where Accident 70% of injuries requiring medical
2
Champion can help. consultation are of adults ages 18-64.
Accident Champion pays cash benefits directly to you Sports and leisure injuries accounted
or anyone you choose regardless of any other for the majority of all injuries among
children.2
coverage you have. And Accident Champion pays up to
an extra $1,000 for injuries resulting from participating
in organized sports. Let Accident Champion help take
care of your bills so you can take care of yourself and
your family.
1
www.cdc.gov/nchs/fastats, as of Jan. 2019
2
National Safety Council, Injury Facts, 2017 Edition
Schedule of Benefits Non-occupational coverage
PLATINUM PLAN
Initial Care Injuries
Ambulance Burns
Ground $200 2nd/3rd Degree $1,000–$10,000
Air $2,000 Skin Graft 25% of the burn benefit
Emergency Room $150 Coma $10,000
Initial Doctor’s Office Visit $75 Dislocations
Urgent Care $75 Open reduction, up to ... $5,148
Closed reduction, up to ...
Emergency Dental $2,574
Crown $300 Eye $250
Extraction $75 Fractures
Hospital and Rehabilitation Open reduction, up to ... $7,020
Closed reduction, up to ...
$3,510
Hospital Admission $1,250 Herniated Disc $500
ICU Admission $2,500 Knee Cartilage – Torn $500
Rehabilitation Admission $1,250 Lacerations $30-$400
Hospital Confinement Loss of Hands, Feet or Sight $14,000
Per day, up to 365 days $200 Loss of Fingers or Toes $1,500
ICU Confinement
Per day, up to 30 days $400 Additional Benefits
Rehabilitation Confinement First Accident
Per day, up to 30 days $120 Once per policy $100
Recovery Accidental Death
Per day, up to seven days $75 Employee and/or Spouse $25,000
Common Carrier
Follow-up Care & Treatment (Employee & Spouse) $100,000
Child
Abdominal or Thoracic Surgery $1,500 $5,000
Appliances $100 Catastrophic Accident
Prior to Age 70
Blood, Plasma, Platelets $300 Employee and/or Spouse $25,000
Child
Chiropractic Care $12,500
Per visit, up to three visits On or after Age 70 50%
$35
Concussion $100 Paralysis
Follow-up Treatment Prior to Age 70
Per visit, up to three visits Employee and/or Spouse $25,000
$25 Child
$12,500
Lodging On or after Age 70 50%
For treatment 100 miles Family Care
or more away, per night, For each child in a child care
up to 30 nights
$125 center: Per day, up to 30 days $35
Major Diagnostic Exam
(CT, MRI, etc.) $150 Sports Package Benefits are 25% higher
Organ Loss $2,500 when accident is due to participating in organized sports.
Up to $1,000 per person per year, in addition to the other
Outpatient Surgery Facility $35 benefits of the policy,
Physical Therapy Wellness
Per visit, up 10 visits $25 Per person, once per year $50
Prosthetics $2,000 90 day waiting period
Tendon, Ligament, from application date
Rotator Cuff Surgery $500
Transportation
For treatment 100 miles or more
away, per trip up to three trips $500
X-ray $30
Benefits are paid once per accident unless otherwise noted.
READY > SET > GO! 2
ACCIDENT | CHAMPION
Features Initial Eligibility Exclusions & Limitations
Date of Application Coverage Employee This is Accident-Only Insurance.
Coverage becomes effective as soon Actively employed working at least No benefits will be paid for services
as your application is signed, you have 17.5 hours per week rendered by a member of the Immediate
authorized payment and the Initial Ages 18 and up Family of a Covered Person.
Eligibility requirements are met. No benefits will be payable for sickness
Spouse or infection including physical or mental
Guaranteed Issue Ages 18 and up condition that is not caused solely by or
No medical history is required for as a direct result of a Covered Accident.
coverage to be issued. Dependent children/grandchildren No benefits will be paid for an injury that
Ages 0 through age 26 is caused by, or occurs as a result of a
Guaranteed Renewable No student status required Covered Person’s:
Your coverage cannot be canceled as Coverage will continue for Being intoxicated, or under the
long as your premiums are paid as incapacitated dependent children influence of alcohol or any narcotic or
due. other prescription drug unless
regardless of age. administered on the advice of a
Fully Portable Physician and taken according to the
You can keep your coverage even if Physician’s instructions (the term
you change jobs or retire. “intoxicated” means the minimum blood
alcohol level required to be considered
operating an automobile under the
influence of alcohol in the jurisdiction in
which the accident occurred);
Accident Champion Semi-Monthly Premium Participating in an illegal occupation or
attempting to commit or actually
committing a felony (“felony” is as
PLATINUM defined by the law of the jurisdiction in
Employee $5.84 which the activity takes place);
Intentionally self-inflicted injury;
Employee + Spouse $10.70 Having dental treatment, except for
Employee + Child(ren) $12.26 such care or treatment due to injury to
sound natural teeth within twelve (12)
Family $17.12 months of the Covered Accident;
Being exposed to war or any act of war,
declared or undeclared, or serving in
any of the armed forces or units auxiliary
This is a supplement to health insurance and is not a substitute for Major thereto; or
Medical, or other minimal essential, coverage. Participation in any contest using any
This document is a brief description of Certificate Form No. C14059R. Benefits, type of motorized vehicle.
rates, exclusions and limitations may vary by state. Refer to your certificate of No benefits will be paid for an injury
insurance for specific details. incurred while working for pay or profit.
READY > SET > GO! 3
Convenient Claims Filing And Processing
Combined Insurance makes life easier when you need it most.
Convenient Claim Submission Claim FAQs
Q. What is needed to file a claim?
Accident & Critical Illness Claims A. Claims require basic information like your name,
address, telephone number, policy number and a brief
To meet policyholder needs, Combined Insurance provides description of your loss. Additional documents vary
three options for filing an insurance claim. according to policy coverage and the extent of your
Via the Web loss. If we need more information we’ll request it in
Our online self-service portal is a fast, convenient and writing.
secure way to file a claim at any time. The easy step-by- Q. What is the quickest way to get Combined Insurance
step process ensures your claim is properly completed and the information they need?
filed so it can be processed quickly. A. Use our online Policyholder Center or fax to 312-351-
https://my.combinedinsurance.com 6930. In some cases, we can process your claim with
Via Phone the initial information you provide.
If you would rather talk than type, just pick up your phone. Q. How do I know if something is (or isn’t) covered by my
A customer service specialist can help you file your claim policy?
and answer claims related questions you may have. A. Call 800-544-9382. Our representatives will assist you.
Phone: 800-544-9382
Via Paper Q. What if I don’t have information requested by the
After requesting forms be mailed to you or by online claim system or paper claim form?
downloading them from our web site, you can file a claim A. A complete claim submission is helpful. If you don’t
by mailing or faxing the completed paper claim forms to: have answers to all items online or on the form, submit
Combined Insurance, Claim Department your claim with information you do have. You can
P.O. Box 6700, Scranton, PA 18505-0700 provide additional documents online or by mail at a
later date.
Or fax: 312-351-6930
Q. What if I have multiple policies with Combined
Hospital Indemnity Claims Insurance?
Three ways to submit claims A. File a claim with the policy that relates to the primary
cause of loss. We will issue benefits under multiple
Via Phone (Telephonic, toll-free) policies, if applicable.
Please have an itemized hospital bill available (on average, Q. How long does it take to receive payment on my claim?
this process takes less than 7 minutes). A. We strive to process claims within 5 business days upon
Phone: 800-964-7096 receipt of complete proof of loss. If claims require
Via the Web (Online) additional information or further review we will provide
Online via the internet for prompt receipt and review: regular status updates throughout the process.
(on average, this process takes less than 7 minutes) Q. What happens if my claim is denied?
http://info.visit-aci.com/coc A. If, for any reason, your claim is denied, you will receive a
letter describing our decision. If you think you have
Via Paper additional information to verify that the loss was within
Send a completed claim form and itemized bills to our the policy requirements, we would be happy to review it
claims administrator. and reconsider the claim.
Administrative Concepts, Inc.
994 Old Eagle Road, Ste. 1005, Wayne, PA 19087-1802
Regardless of the way in which the Hospital Indemnity For more information please visit the Policyholder Center
at www.combinedinsurance.com.
claim is submitted, benefits will always be paid directly to
the insured/Employee. Each family is allowed two (2)
claims per year via Telephonic or Online, any additional
claims will need to be submitted via paper.
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