Offered to employees of NextEra Energy, Inc.

Transcription

1 Accident Insurance A limited benefit policy Benefits at a Glance Affordable insurance that can help you pay for the out-of-pocket costs you may experience after an accident. Offered to employees of NextEra Energy, Inc. What is Accident Insurance? Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident while not at work. The amount paid depends on the type of injury and care received. You have the option to elect Accident Insurance to meet your needs. Accident Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. You may qualify to receive benefits for items listed below, as long as they are the result of a covered accident. Accident hospital care Follow-up care Common Injuries Emergency care benefits Other features of Accident Insurance include: Guaranteed Issue: No medical questions or tests required for coverage. Flexible: You can use the benefit money for any purpose you like. Payroll deductions: Premiums are paid through convenient payroll deductions. Portable: Should you leave your current employer or retire, you can take your coverage with you.

2 How can Accident Insurance help? Below are a few examples of how your Accident Insurance benefits could be used: Medical expenses, such as deductibles and copays Lost income due to lost time at work Everyday expenses like utilities and groceries Who is eligible for Accident Insurance? You as a NextEra Energy, Inc. employee. Your spouse* under age 70. o You must be enrolled to enroll your spouse. o If both you and your spouse are employees of NextEra Energy, Inc., you cannot cover yourself and also be covered as a dependent by your spouse in the Accident plan. o Elected Spouse coverage will equal Employee coverage. Your children** up to age 26. Coverage ends at the end of the month in which the child reaches 26 years of age. You must be enrolled to enroll your child(ren) o Your child(ren) s coverage will equal Employee coverage. o o One premium amount covers all of your eligible children If both you and your spouse are covered under the policy as an employee, then only one, but not both, may cover the same child(ren) under this benefit. If the parent who is covering the child(ren) stops being insured as an employee then the other parent may apply for children s coverage. *Spouse means a person to whom you are legally married. **Children means your natural child(ren), stepchild(ren), adopted child(ren) or child(ren) for whom you are a legal guardian Please contact your employer for more information. What accident benefits are available? The following list includes the benefits provided by Accident Insurance. The benefit amounts paid depend on the type of injury and care received. You may be required to seek care for your injury within a set amount of time. For a list of standard exclusions and limitations, go to the end of this document. Event Benefit Accident hospital care Surgery open abdominal, thoracic $1,000 Surgery exploratory or without repair $250 Blood, plasma, platelets $100 Hospital admission $1,000 Hospital confinement per day up to 365 $200 Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement $75 per day for 30 days Coma duration of 14 or more days $10,000 Transportation per trip, up to 3 per accident $300 Lodging per day, up to 30 days $100 Follow-up care Medical equipment Crutches, wheel chair, braces and walkers Physical therapy per treatment, up to 6 $100 $30 Prosthetic device (one) $500 Prosthetic device (two or more) $1,000 Major diagnostic exams CT, CAT scan, MRI, EEG $200 Medical fees x-rays and doctor services $125 Common injuries Burns second degree, at least 36% of the body $900 Burns 3rd degree, at least 9 but less than 35 sq. inches of the body $1,800 Burns 3rd degree, 35 or more sq. inches of the body $12,000 Skin Grafts 25% of the burn benefit $150 crown, Emergency dental work $50 while hospital confined extraction Eye Injury removal of foreign object $50 Eye Injury surgery $250 Torn Knee Cartilage (within 6 months) surgery with no repair or if cartilage is shaved $100

3 Event Benefit Torn Knee Cartilage/Ruptured Disk surgical repair treated no sutures $25 sutures up to 2 $50 sutures 2 6 $200 sutures over 6 Tendon/Ligament/Rotator Cuff One, surgical repair Tendon/Ligament/Rotator Cuff Two or more, surgical repair $600 Tendon/Ligament/Rotator Cuff Exploratory Arthroscopic Surgery with $120 no repair Concussion $200 Closed/open Dislocations reduction 2 Hip joint $3,000/$6,000 Knee $1,950/$3,900 Ankle or foot bone(s) Other than toes $1,200/$2,400 Shoulder $1,500/$3,000 Elbow $600/$1,200 Wrist $750/$1,500 Finger/toe $240/$480 Hand bone(s) Other than fingers $1,050/$2,100 Lower jaw $900/$1,800 Collarbone $1,600/$3,200 25% of the Partial dislocations closed reduction amount Closed/open Fractures reduction 3 Hip $4,000/$8,000 Leg $2,400/$4,800 Ankle $2,000/$4,000 Kneecap $2,000/$4,000 Foot Excluding toes, heel $2,000/$4,000 Upper arm $1,400/$2,800 Forearm, Hand, Wrist Except fingers $2,000/$4,000 Finger, Toe $320/$640 Vertebral processes $800/$1,600 Vertebral body $3,600/$7,200 Pelvis Except coccyx $3,200/$6,400 Coccyx $320/$640 Bones of face Except nose and teeth $1,200/$2,400 Upper jaw $1,400/$2,800 Lower jaw $1,600/$3,200 Collarbone $1,600/$3,200 Rib or more than one rib $320/$640 Skull simple Except bones of face $1,400/$2,800 Skull depressed Except bones of face $3,000/$6,000 Shoulder blade $1,600/$3,200 25% of the Chip fractures closed reduction amount Emergency care benefits Ground ambulance $200 Air ambulance $1,000 Emergency room treatment $200 Emergency room observation $100 Follow-up doctor visit $30 Initial doctor visit $60 1 Laceration benefits are a total of all lacerations per accident. 2 Closed Reduction of Dislocation = Non-surgical reduction of a completely separated joint. Open Reduction of Dislocation = Surgical reduction of a completely separated joint. 3 Closed Reduction of Fracture = Non-surgical. Open Reduction of Fracture = Surgical.

4 Meet Patty Patty wasn t sure she d be able to cover her medical expenses after she broke her leg in a car accident while out of town with friends. Thanks to her Accident Insurance coverage with emergency care benefits, Patty was able to use the benefits to help pay for her medical out of pocket costs. Benefits paid by Patty s Accident Insurance Out-of-Pocket Costs* Accident Insurance Benefit Payable to YOU Ground ambulance $ 500 $ 200 Emergency room treatment $1,300 $ 200 MEDICAL PLAN DEDUCTIBLE MET $1,800 Leg fracture treatment $ 480 ($2,400 X 20% coinsurance) $2,400 Crutches $ 24 ($120 cost X 20% coinsurance) $ 100 Follow up visit $ 30 ($150 cost X 20% coinsurance $ 30 Total $2,334 $2,930 *This is an example of how coverage could work. The amounts shown are an example only for someone still needing to satisfy their $1,800 individual deductible in the Health Investment medical plan prior to the accident. Actual costs/results may vary. How much does Accident Insurance cost? All employees pay the same rate, no matter their age. See the chart below for the premium amounts. Rates shown are guaranteed until January 1, Accident and Elected Riders Bi-weekly Rate Employee $2.26 Employee + Spouse $4.26 Employee + Child $5.25 Family $7.25

5 Exclusions and Limitations Exclusions in the Certificate, Spouse Accident Insurance and Children s Accident Insurance Benefit are listed below. (These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*: Participation or attempt to participate in a felony or illegal activity. An accident while the covered person is operating a motorized vehicle while intoxicated. Intoxication means the covered person s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred. Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane. War or any act of war, whether declared or undeclared, other than acts of terrorism. Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion. Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor. Riding in or driving any motor-driven vehicle in a race, stunt show or speed test. Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded. Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities. Practicing for, or participating in, any semiprofessional or professional competitive athletic contests for which any type of compensation or remuneration is received. Any sickness or declining process caused by a sickness. Work for pay, profit or gain Timing Requirements Blood, Plasma, Platelets: Transfusion, administration, cross matching, typing and processing of blood, plasma, platelets administered within 90 days after a Covered Accident. This benefit is payable once per Covered Accident. Coma means a state of unconsciousness for fourteen (14) consecutive days due to a Covered Accident with: no reaction to external stimuli, no reaction to internal needs, and the use of life support systems. Hospital Admission: Admission to a Hospital as a result of a Covered Accident. The admission must begin within six months after a Covered Accident. This benefit is payable once per Covered Accident. No benefit is payable for any of the following: Emergency Room treatment; Outpatient Surgery; A stay of less than 20 hours in an observation unit. Hospital Confinement: Confinement in a Hospital for at least 20 consecutive hours on an inpatient basis as the result of a Covered Accident. The Hospital Confinement must begin within six months after a Covered Accident. Benefits are payable daily for up to 365 days for a Covered Accident. Benefits are payable for only one Hospital Confinement at a time even if the Confinement is caused by more than one Covered Accident. Only one type of Confinement benefit is payable for each period of eligible Confinement. If You are discharged from the Hospital and then re-confined within 30 days due to the same Covered Accident or due to a related condition, the reconfinement will be considered part of the previous Hospital Confinement(s). Critical Care Unit Confinement: Confinement in Critical Care Unit for at least 20 consecutive hours on an inpatient basis as the result of a Covered Accident. The Confinement must begin within 30 days after a Covered Accident. Benefits are payable daily for up to 15 days for a Covered Accident. Benefits are payable for only one Critical Care Unit Confinement at a time even if the Confinement is caused by more than one Covered Accident. Only one type of Confinement benefit is payable for each period of eligible Confinement. If You are discharged from the Critical Care Unit and then re-confined within 30 days due to the same Covered Accident or due to a related condition, the re-confinement will be considered part of the previous Critical Care Unit Confinement(s). Lodging: Hotel/motel stay by Your companion while You are Confined in a Hospital or a Rehabilitation Facility. The Hospital/Facility must be more than 100 miles from Your home. This benefit is payable for up to 30 days per Covered Accident. Rehabilitation Facility Confinement: Confinement in a Rehabilitation Facility for 20 consecutive hours on an inpatient basis as the result of a Covered Accident. Benefits are payable daily for each subsequent and continuous day (or portion thereof) of inpatient Rehabilitation Facility Confinement, for up to 90 days per Covered

6 Accident. Benefits are payable for only one Rehabilitation Facility Confinement at a time even if the Confinement is caused by more than one Covered Accident. Only one type of Confinement benefit is payable for each period of eligible Confinement. If You are released and readmitted to a Rehabilitation Facility within 30 days due to the same Covered Accident or due to a related condition, the re-confinement will be considered part of the previous Rehabilitation Facility Confinement(s). Surgery: The surgery must take place within 72 hours after a Covered Accident. The benefit amount varies based on the type of services received (refer to the SCHEDULE OF BENEFITS). This benefit is payable once per Covered Accident. No benefit is payable for hernia repair. Transportation: Transportation for You for special treatment and Confinement in a Hospital or a Rehabilitation Facility. The special treatment must be prescribed by a Doctor and not available locally. The transportation must be more than 100 miles one-way. This benefit is payable for up to 3 trips per Covered Accident. No benefit is payable for transportation by ground ambulance or air ambulance. Major Diagnostic Exams: A major diagnostic exam must be prescribed by a Doctor and must occur within 6 months after the Covered Accident. This benefit is payable once per Covered Accident. Medical Equipment: The medical equipment must be prescribed by a Doctor and use must begin within 90 days after the Covered Accident. This benefit is payable once per Covered Accident. The types of eligible equipment are: Crutches, Wheelchair, Back Brace, Leg Brace, Walker. Medical Fees: X-rays and/or Doctor services received due to an injury from a Covered Accident and for each Covered Accident up to one year after the accident date. You must be injured and receive initial treatment within 72 hours of the Covered Accident. We will not pay the Medical Fee benefit and Emergency Room Treatment Benefit for the same Covered Accident. The higher eligible benefit amount will be paid. Physical Therapy: Physical therapy must be prescribed by a Doctor and provided by a Physical Therapist in an office or Hospital or a Rehabilitation Facility on an inpatient or outpatient basis. The therapy must begin within 60 days after a Covered Accident and be completed within six months after the Covered Accident. This benefit is payable up to 6 times per Covered Accident. Prosthetic Device: You receive a prosthetic device prescribed by a Doctor for use following the loss of use of a hand, a foot or the sight of an eye. The prosthetic device must be received within one year of a Covered Accident. The benefit amount varies based on the number of prosthetic devices received (refer to the SCHEDULE OF BENEFITS). This benefit is payable once per Covered Accident. Prosthetic devices do not include any of the following: Hearing aids, Dental aids including false teeth, Eye-glasses, Artificial joints, Cosmetic prostheses such as hair wigs. Ambulance, Air: Transport by a licensed professional air ambulance company to or from a Hospital or between medical facilities, for treatment of Injuries received as the result of a Covered Accident. The transport must be within 48 hours after the Covered Accident. This benefit is payable once per Covered Accident. Ambulance, Ground: Transport by a licensed professional ambulance company to or from a Hospital or between medical facilities, for treatment of Injuries received as the result of a Covered Accident. The transport must be within 90 days after the Covered Accident. This benefit is payable once per Covered Accident. Emergency Room Treatment: Examination and treatment by a Doctor in an Emergency Room within 72 hours after a Covered Accident. This benefit is payable once per Covered Accident. Exception: If You are also eligible for an Initial Doctor Visit benefit, the Initial Doctor Visit benefit amount will be subtracted from the Emergency Room treatment benefit. Emergency Room Observation: Observation by a Doctor in an Emergency Room for at least 24 consecutive hours on an inpatient basis as the result of a Covered Accident. The Emergency Room Observation must begin within 72 hours of a Covered Accident. Benefits are payable for only one Emergency Room Observation at a time even if the Observation is caused by more than one Covered Accident. This benefit is paid in additional to the Emergency Room Treatment Benefit or Medical Fees Benefit. Initial Doctor Visit: Examination and treatment by a Doctor within 72 hours after a Covered Accident. This benefit is payable once per Covered Accident. Exception: If You are also eligible for an Emergency Room treatment benefit, the Initial Doctor Visit benefit will be subtracted from the Emergency Room treatment benefit. Follow-Up Doctor Treatment: Follow-up treatment by a Doctor within 30 days after a Covered Accident. This benefit is only available if You are eligible for the Initial Doctor Visit benefit or the Emergency Room treatment benefit. This benefit is payable once per Covered Accident. Burns: The burn must be treated by a Doctor within 72 hours after a Covered Accident. The benefit amount varies based on the burn classification (refer to the SCHEDULE OF BENEFITS). If Your burns meet more than

7 one of the burn classifications, the higher amount will be payable. This benefit is payable once per Covered Accident. Concussion: The concussion must be diagnosed by a Doctor within 72 hours after a Covered Accident. The diagnosis must be confirmed by the use of some type of medical imaging procedure; i.e. x-ray, CAT scan or MRI. Dislocations: The Dislocation must be diagnosed by a Doctor within 90 days after a Covered Accident. The Dislocation must require Open or Closed Reduction by a Doctor. The benefit amount will vary based on the type of services received. Eye Injury: The eye Injury must be treated by a Doctor within 90 days after a Covered Accident. The Injury must require surgery or the removal of a foreign object by a Doctor. The benefit amount varies based on the type of services received (refer to the SCHEDULE OF BENEFITS). This benefit is payable once per Covered Accident. No benefit is payable for examination with anesthesia or for an Injury to the Eyelid. Fractures: The Fracture must be diagnosed by a Doctor within 90 days after a Covered Accident. The Fracture must require Open or Closed Reduction by a Doctor. If the Doctor diagnoses the Fracture as a Chip Fracture, the benefit will be reduced to 25% of what would have been paid for a Closed Reduction of the same bone. The benefit amount varies based on the type of services received (refer to the SCHEDULE OF BENEFITS). Laceration: A laceration is a cut. The laceration must be treated by a Doctor within 72 hours after a Covered Accident. The benefit amount will be based on the total length of all lacerations requiring repair that are received in any one Covered Accident. If the laceration is severe enough to require stitches but the Doctor chooses to repair it another way, the benefit will be determined as if the laceration was stitched. This benefit is payable once per Covered Accident. Ruptured Disk: You must receive surgical repair of a ruptured disk. The ruptured disk must be treated by a Doctor within 60 days after a Covered Accident. Surgical Repair by a Doctor is required within 1 year after the Covered Accident. This benefit is payable once per Covered Accident. Tendon/Ligament/Rotator Cuff: The tendon, ligament or rotator cuff must be torn, ruptured or severed and repaired through surgery within 90 days after a Covered Accident. The benefit amount varies based on the number of repairs required and the services received (refer to the SCHEDULE OF BENEFITS). This benefit is payable once per Covered Accident. Torn Knee Cartilage: You must receive surgical repair of torn knee cartilage. The Injury must be treated by a Doctor within 60 days after a Covered Accident. Surgical repair of the tear must occur within 6 months after the Covered Accident. The benefit amount varies based on the type of service received (refer to the SCHEDULE OF BENEFITS). This benefit is payable once per Covered Accident. *See the certificate of insurance and riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations. This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Accident Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya family of companies. Policy Form #RL-ACC2-POL-12; Certificate Form #RL-ACC2-CERT-12; and Rider Forms: Spouse Accident Rider Form #RL-ACC2-SPR-12 and Children's Accident Rider Form #RL-ACC2-CHR-12. Form numbers, provisions and availability may vary by state. CN NextEra Energy, Inc., Group # , Acct #001 Date Prepared: 04/07/ /08/2016