Health Summary Plan Description

Accidental Death And Dismemberment (AD&D) Benefits

Eligibility

AD&D benefits are provided in addition to life insurance. To qualify for AD&D benefits, you must be covered under Plan I Earned Eligibility at the time of your loss. Your AD&D insurance coverage ends when you lose Plan I Earned Eligibility. AD&D benefits are not available if you have Plan II Earned Eligibility or are covered under the Senior Performers Health Plan or the Self-Pay Program, nor are they available to dependents.

AD&D Benefits

Benefits are payable if you are involved in an accident and if you suffer any of the losses indicated below as a result of the accident. Generally the loss must occur within 90 days of the accidental injury. Exceptions are for coma and brain damage, which must occur or manifest within 30 days of the accidental injury. The maximum benefit that will be paid for all losses resulting from one accident is $10,000.

Accident Resulting in: The Benefit Paid is:
Loss of life $10,000
Loss of one arm at or above elbow $7,500
Loss of one leg at or above knee $7,500
Loss of one hand $5,000
Loss of one foot $5,000
Loss of thumb and index finger on same hand $2,500
Loss of sight of one eye $5,000
Loss of hearing in both ears – must continue for six consecutive months $5,000
Loss of speech – must continue for six consecutive months $5,000
Paralysis of one arm $2,500
Paralysis of one leg $2,500
Coma – benefit becomes payable on the 7th day of a coma $100 per month for up to a maximum of 60 months
Brain damage – requires a five day hospitalization and brain damage that has persisted for 12 consecutive months $10,000
More than one of the above resulting from one accident $10,000 or the sum of the benefits payable for each loss (whichever is less)

Paralysis means loss of use of a limb, without severance. A physician must determine the paralysis to be permanent, complete and irreversible.

Coma means a state of deep and total unconsciousness from which the comatose person cannot be aroused.

Brain damage means permanent and irreversible physical damage to the brain causing the complete inability to perform all the substantial and material functions and activities normal to everyday life.


If you die in the accident, the benefit will be paid to your beneficiary. Otherwise, the benefit will be paid to you.

Seat Belt and Air Bag Benefits

Additional benefits may be available if you die in a car accident and you were wearing a seat belt and sitting in a seat protected by an air bag. These benefits are available if you were driving or riding as a passenger in a passenger car. Passenger car means any validly registered four-wheel private passenger car, fourwheel drive vehicle, sports-utility vehicle, pick-up truck or mini-van. It does not include any commercially licensed car, any private car being used for commercial purposes or any vehicle used for recreational or professional racing.

If you were wearing a seat belt which was properly fastened at the time of the accident an additional $1,000 benefit will be paid. Seat belt also includes any child restraint device that meets the requirements of state law.

If you were wearing a seat belt and sitting in a seat protected by an airbag an additional $500 benefit will be paid. This benefit is in addition to the seat belt benefit.

A police officer investigating the accident must certify that the seat belt was properly fastened. If applicable, the police officer must also certify that the passenger car in which you were traveling was equipped with airbags. A copy of such certification must be submitted with the claim for benefits.

Exclusions

AD&D benefits are not payable for losses due to:

  • Diagnosis of or treatment for physical or mental illness or infirmity.
  • Committing or trying to commit a felony.
  • Infection, unless it occurs in an external accidental wound.
  • Intentional or reckless self-inflicted injury.
  • Intoxication, if you were the operator of a vehicle or other device involved in the accident.
  • Service in the armed forces of any country or international authority, except the United States National Guard.
  • Suicide or attempted suicide.
  • Voluntary use of:
    • Any drug, medication or sedative unless it is:
      – Taken or used as prescribed by a physician;
      or
      – An over- the-counter drug, medication or sedative taken as directed.
    • Alcohol in combination with any drug, medication or sedative.
    • Poison, gas or fumes.
  • War, whether declared or undeclared; or act of war, insurrection, rebellion or riot.