23 NOV 05
|
USASA Insurance Limits 23 NOV 05 |
Contact HWSA Vice President, Sarah
Kerrigan
with questions.
| Named Insured: | United States Adult Soccer Association and its affiliated member leagues and teams |
| Coverage: | Accident/Excess medical coverage |
| Carrier: | Hartford Insurance Company |
| Policy Term: | 9/01/02 to 9/01/03 |
| Benefit Period: | 52 Weeks |
| Eligibility: | All registered participants |
| Benefits: |
$5,000.00 Maximum medical benefit per
claim $400.00 Deductible per claim |
| SCHEDULE OF BENEFITS: | |
| Hospital room & board expense (inpatient) | $150.00 maximum per day |
| Hospital miscellaneous (inpatient) | $1,000.00 maximum per admission |
| Hospital emergency care | $350.00 maximum per injury |
| Physician expense (non-surgical) | $35.00 maximum per visit, limit 6 visits per injury |
| Surgeon expense (in- or outpatient) | 50% of UCR amount |
| Anesthesiologist | 25% of surgeon's UCR |
| Physiotherapy (outpatient) | $25.00 maximum per visit, 20 visits maximum |
| X-Rays (in- or outpatient) including MRI, cat scans, diagnostic imaging, or similar procedure | $150.00 maximum per injury |
| Dental expense (sound, natural teeth only) | $500.00 maximum per injury |
| Ambulance expense | $100.00 maximum per injury |
| Orthopedic appliances or braces as a result of covered injury, not for prevention of injury | $400.00 maximum per injury |