Proprietary 8-23 BENEFIT PAYMENT EXAMPLE: A covered person fell, was knocked unconscious and taken by ambulance to the emergency room . She was diagnosed with a concussion and broken tooth. She was treated and released to her primary care physician for follow-up care and her dentist repaired the broken tooth with a crown. Covered Event Benefit Amount Ambulance (ground) $400 Emergency care $300 Physician follow-up ($150 x 2) $300 Medical testing $400 Concussion $500 Crown for broken tooth $400 TOTAL paid by MetLife $2,300 Plan benefits are paid directly to you from MetLife. 22 ACCIDENT PLAN The MetLife Accident Plan provides payments in addition to any other insurance payments you may receive. Covered events/services include: n Accidental Injury Benefits: Examples include fractures, dislocation, second or third degree burn, concussion, laceration, broken tooth, eye injury. n Accident Medical Services and Treatment Benefits: Examples include ambulance, emergency care, non-emergency initial care, physician follow-up, therapy services (including physical therapy), medical testing, medical appliances, surgical repair benefit, exploratory surgery benefit, other outpatient surgery benefit. n Accidental Dismemberment: Dismemberment, loss and paralysis. Benefits are based on a schedule of benefits, which can be found at www.farmersagentsbenefits.com. Enrollment Enrollment is guaranteed provided you are actively at work. There is no waiting period required for this coverage. To elect the Accident Plan for yourself and your dependents, log on to www.farmersagentsbenefits.com. Plan exclusions and limitations Exclusions and limitations in any policy and certificate issued will be based on the policyholder’s situs state, plan design and states where employees reside. If the policyholder has employees residing in the following states, that state’s Exclusions and Limitations will apply: Alaska, Arkansas, Connecticut, Louisiana, Minnesota, Mississippi, Montana, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, South Carolina, Texas, Utah, Vermont, Washington, West Virginia, and Wisconsin.
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