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Student Accident Medical Expense Insurance Table
Student Accident Medical Expense Insurance

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Paramount
Deluxe
Choice
Basic
Compulsory, including All Sports Up to $1,000,000 Up to $1,000,000 Up to $1,000,000 Up to $1,000,000
Mandatory All Sports or Football Only Up to $1,000,000 Up to $1,000,000 Up to $1,000,000 Up to $1,000,000
Voluntary (All Students) Excluding Senior High School Interscholastic Sports or Football Only Up to $25,000 Up to $25,000 Up to $25,000 Up to $25,000
Voluntary Football Not Available Up to $25,000 Up to $25,000 Up to $25,000
Hospital Services        
1. Daily Room and Board—Semi-Private Usual and reasonable Average semi-private up to $200/day Average semi-private up to $125/day Average semi-private up to $75/day
2. Intensive Care Room and Board Usual and reasonable not to exceed 7 days Usual and reasonable not to exceed $300/day for 7 days Usual and reasonable not to exceed $175/day for 7 days Usual and reasonable not to exceed $125/day for 7 days
3. Miscellaneous Services-when hospital confined or when surgery is performed Usual and reasonable not to exceed $10,000 Usual and reasonable not to exceed $2,000 Usual and reasonable not to exceed $1,500 Usual and reasonable not to exceed $1,000
4. Emergency Room (out patient)   Usual and reasonable not exceed $150 Usual and reasonable not exceed $100 Usual and reasonable not exceed $75
Physician Services        
1. Surgery, including pre- and post-operative care Usual and reasonable up to the Unit Value listed in the Medical Data Research File Multiplied by $150 Usual and reasonable up to the Unit Value listed in the Medical Data Research File Multiplied by $120 Usual and reasonable up to the Unit Value listed in the Medical Data Research File Multiplied by $100 Usual and reasonable up to the Unit Value listed in the Medical Data Research File Multiplied by $75
2. Anesthetic (including administration) and Assistant Surgeon 40% of Surgery benefit 25% of Surgery benefit 20% of Surgery benefit 15% of Surgery benefit
3. Physician visits other than for physiotheraphy and similar treatment, when no surgery benefit is paid. $60.00-First Visit
$30.00-Thereafter		 $40.00-First Visit
$20.00-Thereafter		 $30.00-First Visit
$15.00--Thereafter		 $25.00-First Visit
$10.00-Thereafter
4. Consultants (when required by attending physician for confirming or determining a diagnosis but not for treatment) and second opinions. Usual and reasonable Usual and reasonable not to exceed $100 Usual and reasonable not to exceed $75 Usual and reasonable not to exceed $50
Laboratory and X-ray services        
Includes reading and interpretation dental services benefits shown below. Usual and reasonable to a maximum of $500 X-Ray--Maximum of $200 Laboratory-$200 X-Ray-Maximum of $150 Laboratory-$150 X-Ray--Maximum of $75 Laboratory-$75
Additional services        
1. Physiotherapy or similar treatment        
  —In Hospital $50.00/Visit—one per day Included in hospital miscellaneous Included in hospital miscellaneous Included in hospital miscellaneous
  —Out of Hospital $50.00/Visit-Max of 10 visits $30.00/Visit-Maximum of 5 visits $25.OO/Visit-Maximum of 5 visits $20.OO/Visit-Maximum of 5 visits
2. Registered or licensed nurse Usual and reasonable Usual and reasonable Usual and reasonable Usual and reasonable
3. Ambulance to initial treatment facility Usual and reasonable Usual and reasonable Usual and reasonable Usual and reasonable
4. Orthopedic appliances (includes rental of crutches or wheelchair)        
  —In Hospital Usual and reasonable Included in hospital miscellaneous. Included in hospital miscellaneous. Included in hospital miscellaneous.
  —Out of Hospital $600 $200 $75 $50
5. Prescribed Drugs or Medicines Usual and reasonable $100 $50 $25
6. Eyeglasses, contact lenses, hearing aids replacement, when damaged in conjunction with a covered injury requiring medical treatment Usual and reasonable Usual and reasonable not to exceed $100 Usual and reasonable not to exceed $50 Usual and reasonable not to exceed $25
Dental services        
Treatment, repair or replacement of injured natural teeth. Includes initial braces when required for treatment of a covered injury, as well as examination, x-rays, restorative treatment, endodontics, oral surgery, and treatment for gingivitis resulting from trauma. Usual and reasonable up to policy maximum Usual and reasonable not to exceed $200 per tooth Usual and reasonable not to exceed $150 per tooth Usual and reasonable not to exceed $100 pr tooth
Additional extended dental services        
1. Replacement of caps, crowns, dentures and orthodontic appliances (including braces), when damaged in a covered accident. Usual and reasonable up to policy maximum

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2. When a dentist certifies that treatment will continue beyond the expense incurral period, an additional amount will be paid.

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**Available only on voluntary plans under optional extended dental benefit.
Note  Other tailor-made plans, including various deductible amounts are available upon request. Please note that not all plans are available in all states

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Last Update 2005 August 2
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