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Accident Insurance
Symetra Life Insurance Company
A scheduled benefit accident insurance plan for JPS Health Network team members that pays fixed dollar amounts for injuries and services resulting from a covered accident, including emergency care, hospitalization, surgery, common injuries, and catastrophic benefits.
Starting from
$5.27
/bi-wk
Team Member
$5.27
/bi-wk
Team Member + Spouse
$9.16
/bi-wk
Team Member + Child(ren)
$11.56
/bi-wk
Team Member/Family
$16.36
/bi-wk
Emergency Care & Diagnostics Benefits
| Benefit | Amount |
|---|---|
| Emergency Care & Diagnostics | |
|
Ambulance - Ground 1 trip per covered accident |
$400 pp/pa |
|
Ambulance - Air 1 trip per covered accident |
$2,000 pp/pa |
|
Emergency Room 1 trip per covered accident; services must be incurred within 30 days from the accident |
$300 pp/pa |
|
Major Diagnostic Testing (MRI, CT Scan, EEG) 1 exam per covered accident; must be administered within 365 days of the accident |
$300 pp/pa |
|
X-Ray 1 test per covered accident; must be performed within 365 days of the accident |
$60 pp/pa |
|
Pain Management/Epidural 1 visit per covered accident; services must be administered within 365 days of the accident |
$100 pp/pa |
|
Initial Doctor's Visit Once per person, per accident; must occur within 365 days of the accident |
$100 pp/pa |
Accident Hospitalization & Surgical Benefits
| Benefit | Amount |
|---|---|
| Accident Hospitalization & Surgical Benefits | |
|
Hospital Admission Once per person, per accident; must occur within 365 days of the accident; minimum 24 consecutive hours |
$1,500 pp/pa |
|
ICU Admission Once per person, per accident; must occur within 365 days of the accident; minimum 24 consecutive hours |
$3,000 pp/pa |
|
Hospital Confinement Up to 365 days per accident; must begin within 365 days of the accident |
$300 per day |
|
ICU Up to 30 days per accident; must begin within 365 days of the accident |
$600 per day |
|
Rehabilitation/Skilled Nursing Facility Up to 90 days per accident; must begin within 365 days of the accident |
$150 per day |
|
Blood/Plasma/Platelets Once per person, per accident |
$500 pp/pa |
|
Surgery - Open Abdominal, Thoracic Must be performed within 365 days of the accident |
$3,000 per surgery |
|
Surgery - Cranial Must be performed within 365 days of the accident |
$3,000 per surgery |
|
Surgery - Hernia Must be performed within 365 days of the accident |
$1,500 per surgery |
|
Surgery - Exploratory or Without Repair Must be performed within 365 days of the accident |
$400 per surgery |
|
Outpatient/Miscellaneous Surgery Once per person, per accident; must be performed within 365 days of the accident |
$400 per surgery |
|
Transportation Up to 3 trips per accident; travel must be more than 50 miles from primary residence; within 365 days of the accident |
$500 per trip |
|
Family Lodging Up to 30 nights; facility must be more than 50 miles from primary residence |
$125 per night |
|
Coma After 7 day duration; coma must occur within 365 days of injury |
$8,000 pp/pa |
Follow Up Care Benefits
| Benefit | Amount |
|---|---|
| Follow Up Care | |
|
Follow Up Doctor's Visit 1 visit per covered accident; must occur after initial treatment in a doctor's office or emergency room |
$100 pp/pa |
|
Physical Therapy Up to 10 visits per accident; must begin within 365 days after the accident |
$75 per visit |
|
Chiropractic Visit Up to 10 visits per accident; must begin within 365 days after the accident |
$75 per visit |
|
Medical Equipment 1 appliance per covered accident; must be prescribed by a doctor within 365 days after the injury |
$400 pp/pa |
|
Prosthetic Device 1 device per covered accident; must be prescribed by a doctor within 365 days after the injury |
$2,500 pp/pa |
Common Injuries Benefit Schedule
| Benefit | Amount |
|---|---|
| Burns - Second Degree | |
|
Second Degree: 20 - 100 square centimeters Once per person, per accident; highest eligible benefit paid if multiple burns |
$100 pp/pa |
|
Second Degree: 101 - 225 square centimeters Once per person, per accident; highest eligible benefit paid if multiple burns |
$200 pp/pa |
|
Second Degree: More than 225 square centimeters Once per person, per accident; highest eligible benefit paid if multiple burns |
$800 pp/pa |
| Burns - Third Degree | |
|
Third Degree: 20 - 100 square centimeters Once per person, per accident; highest eligible benefit paid if multiple burns |
$800 pp/pa |
|
Third Degree: 101 - 225 square centimeters Once per person, per accident; highest eligible benefit paid if multiple burns |
$6,000 pp/pa |
|
Third Degree: More than 225 square centimeters Once per person, per accident; highest eligible benefit paid if multiple burns |
$20,000 pp/pa |
| Skin Grafts | 25% of burn benefit |
| Paralysis | |
|
Quadriplegia Once per person, per accident; must be diagnosed within 365 days of the accident |
$20,000 pp/pa |
|
Paraplegia Once per person, per accident; must be diagnosed within 365 days of the accident |
$10,000 pp/pa |
|
Hemiplegia Once per person, per accident; must be diagnosed within 365 days of the accident |
$10,000 pp/pa |
|
Uniplegia Once per person, per accident; must be diagnosed within 365 days of the accident |
$5,000 pp/pa |
| Lacerations | |
|
Not requiring sutures Once per person, per accident; must be repaired within 96 hours after accident |
$50 pp/pa |
|
Under 3 inches, required sutures Once per person, per accident; must be repaired within 96 hours after accident |
$80 pp/pa |
|
3 to 6 inches, requires sutures Once per person, per accident; must be repaired within 96 hours after accident |
$150 pp/pa |
|
Over 6 inches, requires sutures Once per person, per accident; must be repaired within 96 hours after accident |
$400 pp/pa |
| Emergency Dental Work | |
|
Crown Repair Once per person, per accident; dental work must occur within 365 days after accident |
$200 pp/pa |
|
Extraction Once per person, per accident; dental work must occur within 365 days after accident |
$100 pp/pa |
| Eye Injuries | |
|
Removal of Foreign Object Once per person, per accident; must require treatment within 365 days after accident |
$60 pp/pa |
|
Surgical Repair Once per person, per accident; must require treatment within 365 days after accident |
$300 pp/pa |
| Specific Injuries | |
|
Ruptured Disc Once per person, per accident; must require surgery or medical treatment within 365 days |
$600 pp/pa |
|
Tendons/Ligaments - 1 tear with surgical repair Once per person, per accident |
$800 pp/pa |
|
Tendons/Ligaments - 2 or more tears with surgical repair Once per person, per accident |
$1,200 pp/pa |
|
Tendons/Ligaments - Arthroscopic surgery with no repair Once per person, per accident |
$300 pp/pa |
|
Torn Knee Cartilage - Exploratory surgery with no repair Once per person, per accident |
$300 pp/pa |
|
Torn Knee Cartilage - Surgical repair Once per person, per accident |
$800 pp/pa |
|
Concussion Once per person, per accident |
$300 pp/pa |
Dislocations & Fractures Benefit Schedule
| Benefit | Amount |
|---|---|
| Dislocations (Closed Reduction) | |
|
Hip 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$5,000 per dislocation |
|
Knee (except patella) 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per dislocation |
|
Shoulder 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per dislocation |
|
Foot/Ankle 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per dislocation |
|
Wrist 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per dislocation |
|
Lower Jaw 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per dislocation |
|
Elbow 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per dislocation |
|
Bones of the Hand (except fingers) 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$1,000 per dislocation |
|
Collarbone 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$1,000 per dislocation |
|
2 or more fingers 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$400 per dislocation |
|
2 or more toes 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$400 per dislocation |
|
1 finger or toe 3 dislocation benefits per person, per accident maximum; must be treated within 365 days |
$150 per dislocation |
| Open Reduction | 200% of dislocation benefit |
| Partial Dislocation | 25% of dislocation benefit |
| Fractures (Closed Reduction) | |
|
Skull 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$5,000 per fracture |
|
Hip/Thigh 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$5,000 per fracture |
|
Vertebral Body (excluding vertebral processes) 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$5,000 per fracture |
|
Pelvis 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$5,000 per fracture |
|
Arm (upper) 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$3,000 per fracture |
|
Shoulder Blade 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$3,000 per fracture |
|
Leg 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$3,000 per fracture |
|
Upper Jaw 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per fracture |
|
Vertebral Processes 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per fracture |
|
Knee Cap 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per fracture |
|
Collarbone 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per fracture |
|
Forearm 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per fracture |
|
Foot/Ankle 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$2,000 per fracture |
|
Hand/Wrist 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$1,500 per fracture |
|
Lower Jaw 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$1,500 per fracture |
|
Ribs (2 or more) 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$1,000 per fracture |
|
Facial Bones or Nose 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$1,000 per fracture |
|
1 rib, finger, or toe 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$400 per fracture |
|
Coccyx 3 fracture benefits per person, per accident maximum; must be treated within 365 days |
$400 per fracture |
| Open Reduction | 200% of fracture benefit |
| Bone Chip | 25% of fracture benefit |
Catastrophic Accident Benefits
| Benefit | Amount |
|---|---|
| Catastrophic Accident Benefits | |
|
Accidental Death Team Member 100%, Spouse 50%, Child 25%; loss must occur within 365 days of the accident |
$50,000 |
|
Common Carrier Accidental Death Team Member 100%, Spouse 50%, Child 25%; payable in lieu of Accidental Death benefit; loss must occur within 365 days |
$100,000 |
| AD&D Benefits — Double Dismemberment | |
|
Loss of both hands, both feet or sight in both eyes Team Member 100%, Spouse 50%, Child 25%; loss must occur within 365 days |
$50,000 |
|
Loss of Speech or Hearing in both ears Team Member 100%, Spouse 50%, Child 25%; loss must occur within 365 days |
$25,000 |
|
Loss of 1 hand and 1 foot Team Member 100%, Spouse 50%, Child 25%; loss must occur within 365 days |
$50,000 |
|
Loss of 1 eye Team Member 100%, Spouse 50%, Child 25%; loss must occur within 365 days |
$25,000 |
|
Loss of 1 hand or 1 foot Team Member 100%, Spouse 50%, Child 25%; loss must occur within 365 days |
$25,000 |
|
Loss of 2 or more fingers or toes Team Member 100%, Spouse 50%, Child 25%; loss must occur within 365 days |
$10,000 |
|
Loss of 1 finger or toe Team Member 100%, Spouse 50%, Child 25%; loss must occur within 365 days |
$2,500 |
Optional Benefits
| Benefit | Details |
|---|---|
| Optional Benefits | |
|
Wellness Screening Benefit Once per person per calendar year; $100 for Team Member, $100 for Spouse, $100 for Children |
$100 pp/pcy |
| Occupational Coverage | Not Included |
|
Portability Allows coverage to continue following termination of employment or loss of eligibility |
Included |
|
Child Organized Sports Additional 25% of accident benefits; $5,000 per person/per accident maximum; child must be insured by the Policy on the date of the accident |
Included |
Is This Right for You?
- Team Members seeking supplemental coverage to offset out-of-pocket accident costs
- Families with active children participating in organized sports
Main Advantages
- ✓Receive $100 wellness benefit per covered person per calendar year for completing an eligible wellness screening
- ✓Eligible screenings include: abdominal aortic aneurysm ultrasonography, baseline testing for concussion, blood test for lipids, bone density screening, bone marrow testing, breast MRI, breast ultrasound, CA 15-3 blood test for breast cancer, CA 125 blood test for ovarian cancer, carotid Doppler, CEA blood test for colon cancer, chest X-ray, child sports physicals, colonoscopy or virtual colonoscopy, COVID-19 (PCR, rapid, antibody), CT angiography, electrocardiogram, fasting blood glucose test, flexible sigmoidoscopy, mammograms, pap test, PSA test, serum cholesterol test, stress test on a bicycle or treadmill, testicular ultrasound, thermography, ThinPrep Pap test
- ✓Submit wellness claims by phone, email, mail, fax, or online through My Group Online (MyGO) at symetra.com/MyGO
- ✓To claim: provide (1) name of insured, (2) type of screening, and (3) date screening was completed
- ✓If you have multiple Symetra coverages, claims are automatically cross-checked for eligibility
- ✓Simple enrollment — no required medical questions or exams
- ✓Easy and flexible claims process
- ✓Responsive customer service representatives at a U.S.-based call center
Limitations
- ⚠Wellness benefit is payable once per insured per calendar year regardless of number of screenings completed
Ideal For
- 👤Families with multiple covered members who each qualify for the $100 annual wellness benefit
Plan Provisions & Legal Disclosures
Scheduled Benefit Accident insurance policies are for accident only insurance and do not provide coverage for sickness. Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory.
Coverage is provided under policy form number SBC-03510.
Benefit Amounts: Team Member 100%, Spouse 50%, Child 25%.
pp/pa = per person/per accident.
Policyholder: JPS Health Network. Policy Issue State: TX. Policy #: 12379000. Insured by Symetra Life Insurance Company.
This document is intended as a summary of information on exclusions and state-required plan variations. For complete details, please see the certificate of coverage that will be provided for those who enroll. If there is a discrepancy between this summary and the terms of the policy, the policy will govern.
Additional Benefits through Symetra
Your coverage through Symetra includes the following benefits at no additional cost to you:
Travel Assistance Program: 24/7 emergency medical assistance and other key services.
Identity Theft: Protect yourself from identity theft.
Estate Guidance: Create wills, healthcare and financial power of attorney, and/or final arrangement documents. Get more information at estateguidance.com.
For more information, call 1-833-808-0253, 1-978-651-9223 (international).
Provider
Symetra
1-877-377-6773
symetra.com