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BENEFITSRATESEXCLUSIONS

Accidental Injury Benefits 2 Low Plan Benefits High Plan Benefits
Fracture Benefit 3 $100 – $8,000 depending on the fracture and type of repair $250 – $12,000 depending on the fracture and type of repair
Dislocation Benefit 3 $100 – $8,000 depending on the dislocation and type of repair $250 – $12,000 depending on the dislocation and type of repair
Second or Third Degree Burn Benefit $75 – $10,000 depending on the degree of the burn and the percentage of burnt skin $150 – $17,500 depending on the degree of the burn and the percentage of burnt skin
Concussion Benefit $250 $750
Coma Benefit $7,500 $15,000
Laceration Benefit $50 – $400 depending on the length of the cut and type of repair $100 – $800 depending on the length of the cut and type of repair
Broken Tooth Benefit Crown $200

Filling $25

Extraction $100

 Crown $400

Filling $75

Extraction $200
Eye Injury Benefit $300 $500
Accident – Medical Services & Treatment Benefits Low Plan Benefits High Plan Benefits
Ambulance Benefit Ground: $300 Air: $1,000  Ground: $500 Air: $1,500
Emergency Care Benefit $75 – $150 depending on location of care $125 – $250 depending on location of care
Non-Emergency Initial Care Benefit $75 $125
Physician Follow-Up Visit Benefit $75 $125
Therapy Services Benefit (including physical therapy) $35 $65
Medical Testing Benefit $150 $250
Medical Appliance Benefit $75 – $750 depending on the appliance $200 – $1,250 depending on the appliance
Transportation Benefit $300 $500
Pain Management Benefit (for epidural anesthesia) $75 $125
Prosthetic Device Benefit One device: $750
More than one device: $1,500		 One device: $1,250
More than one device: $2,500
Modification Benefit $1,000 $2,000
Blood/Plasma/Platelets Benefit $400 $600
Surgical Repair Benefit $150-$1,500 depending on the type of surgery $250-$2,500 depending on the type of surgery
Exploratory Surgery Benefit $150 $300
Other Outpatient Surgery Benefit $300 $500
Hospital Benefits 4 Low Plan Benefits High Plan Benefits
Admission Benefit7 $1,000 for the day of admission $2,000 for the day of admission
ICU Supplemental Admission Benefit $1,000 for the day of admission $2,000 for the day of admission
Confinement Benefit8
(paid for up to 15 days per accident)		 $200 per day $400 per day
ICU Supplemental Confinement Benefit
(paid for up to 15 days per accident)		 $200 per day $400 per day
Inpatient Rehabilitation Benefit10
(paid for up to 15 days per accident)		 $150 per day $300 per day
Paralysis Low Plan Benefits High Plan Benefits
Paralysis $10,000 – $20,000 depending on the number of limbs $30,000 – $60,000 depending on the number of limbs
Other Benefits Low Plan Benefits High Plan Benefits
Lodging Benefit – for a companion of a covered person who is hospitalized 5  $100 per day $300 per day

Benefits may vary by state Click Here to read your Outline of Coverage.

Plan is not available in Alaska, Colorado, Guam, Louisiana, Maine, New Hampshire, Oregon, Utah, Vermont, Washington.

MONTHLY RATES

LOW PLAN
Member Only $8.66
Member + Spouse/Domestic Partner 6 $17.33
Member + Children $19.75
Member & Spouse/Domestic Partner 6 + Child(ren) $24.43
HIGH PLAN
Member Only $16.23
Member + Spouse/Domestic Partner 6 $32.46
Member + Children $37.00
Member & Spouse/Domestic Partner 6 + Child(ren) $45.77

Termination Age

Coverage terminates at age 70.

Member Eligibility

  • Members must be under age 60 to enroll
  • Members must not be subject to any medical restrictions as set forth on the enrollment form and in the Certificate.
  • A member must be enrolled for coverage for their Spouse / Domestic Partner and / or Dependent Child(ren) to be eligible for coverage. Child(ren) are eligible for coverage from birth to age 26.
  • Spouses / domestic partners and dependent child(ren) must not be subject to any medical restrictions as set forth on the enrollment form and in the Certificate.

Exclusions may vary by state Click Here to see full policy details.

Exclusions and limitations:

The Certificate does not provide benefits for any loss for a covered person caused by the covered person’s

  • sickness, or the diagnosis or treatment of such sickness, except:
  • for the covered person’s use of:
  • any drug, medication or sedative that is taken or used as prescribed by a Physician; or
  • an “over the counter” drug, medication or sedative taken as directed.

The Certificate does not provide benefits for any loss for a covered person caused or contributed to by:

  • the covered person’s voluntary use, by any means, 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; or
    • poison, gas, or fumes;
  • the covered person’s suicide or attempted suicide (while sane or insane);
  • the covered person’s intentionally self-inflicted injury;
  • war, whether declared or undeclared; or act of war;
  • the covered person’s active participation in an insurrection, rebellion, riot, or terrorist act;
  • the covered person’s engagement in any activity that constitutes a felony under the laws of the jurisdiction in which the activity occurred;
  • the covered person’s infection, other than infection occurring in an external wound resulting from an Injury;
  • food poisoning;
  • the covered person’s operation, while intoxicated, of a motor vehicle involved in the incident. For purposes of this exclusion:
    • intoxicated means that the Insured’s blood alcohol level met or exceeded .08%; and
    • motor vehicle means any vehicle that is powered by a motor, including, but not limited to: an automobile; a boat; a motorcycle; a truck; an all-terrain vehicle; or a snow mobile;
  • dental or plastic surgery for cosmetic purposes, except when such surgery is performed to:
    • treat an injury;
    • correct a disorder of normal bodily function or structure that was caused by an injury for which coverage is not otherwise excluded under this Certificate; or
    • reconstruct a part of the body which was disfigured or removed as a result of an injury for which coverage is not otherwise excluded under this Certificate;
  • the covered person’s mental illness, or the diagnosis or treatment of such mental illness, except for the covered
    • any drug, medication or sedative that is taken or used as prescribed by a physician; or
    • an “over the counter” drug, medication or sedative taken as directed;

Person’s use of:

  • activities required by the covered person’s service in the armed forces or any auxiliary unit of the armed forces of any country or international authority;
  • the covered person’s travel or flight in any aircraft except as a fare-paying passenger on a regularly scheduled charter or commercial flight;
  • the covered person parachuting or otherwise exiting from a motorized or non-motorized aircraft while such aircraft is in flight, except for self-preservation;
  • the covered person riding in or driving any motor-driven vehicle in a race, stunt show or speed test;
  • the covered person participating in any semi-professional or professional competitive athletic activity for which any type of compensation or remuneration is received; or
  • the covered person bungee jumping, base jumping, hang gliding, para-kiting, sail-gliding, scuba diving deeper than 130 feet; spelunking; or mountaineering including rock climbing using ropes and any other climbing equipment. For the purposes of this exclusion the term mountaineering does not include backpacking, mountain biking, hiking or trail running.

In addition, the Certificate does not provide benefits for:

  • a covered person while incarcerated in any type of penal or detention facility; or
  • any of the following outside of the United States, Canada or Mexico:
    • any medical or healthcare treatment, services or transportation; or
    • any inpatient admission or stay in any medical or health care facility.

When your insurance ends:

Your insurance will end if: the Group Policy ends; you die; insurance ends for your class; your premium is not paid when due; you cease to be in an eligible class; or your membership ends.

Premiums:

Premiums for this insurance are shown in the enclosed materials. Premiums for this coverage are subject to change in accordance with the provisions of the Group Policy.

Questions?

How does the payment work?

We make payments directly to you. You receive a benefit for a covered event regardless of what other insurance you might have and you can spend it however you like. You might use it to help pay for medical plan deductibles and copays, out-of-network care, or even for your family’s everyday living expenses. Whatever you need while recovering from an accident or injury, accident insurance is there to make life a little easier.

Am I eligible to enroll for this coverage?

Yes, you can enroll both yourself and eligible family members. As a NFICA member all you need to do is enroll at nfica.org.

I have a good medical plan at work, so why do I need accident insurance?

Accidents can happen anytime, anywhere and always when you least expect them. What’s more they can be costly.

Can I enroll for this insurance without having a medical exam?

Yes. Your accident coverage is guaranteed1.  You must not be subject to any medical restrictions as set forth on the enrollment form and in the Certificate. There are no medical exams to take and no health questions to answer, so the whole process might be easier than you first thought.

How much will it cost?

 Accident insurance may be more affordable than you think. It’s designed to be an economical way to supplement your health care plan. Exact rates can be found in the enrollment materials above.

When does my coverage begin?

Right away — your coverage starts on day you enroll and premium is collected. There are no waiting periods for it to begin.

Are benefits paid directly to me or my health care provider?

Payments will be paid directly to you, not to the doctors, hospitals or any other health care providers. And to make things even easier, the check is made payable to you. There’s no need to work it around any other insurance you may have. Benefits are paid no matter what your other insurance plans may cover.

Can I use the benefit payment on anything I need?

Yes, you can use your payment as you see fit. Accident Insurance helps provide financial protection to absorb expenses such as copays and deductibles.

Is the claims process simple?

Yes. Once we receive all the information, claims are generally processed within 10 business days. You only need one claim form per accident and every claim is reviewed by a claims professional. If you have a claim once enrolled, please contact administrator or visit mybenefits.9 www.metlife.com/mybenefits

1. Coverage is guaranteed provided (1) you are a current member of NFICA and (2) dependents to be covered are not subject to medical restrictions as set forth on the enrollment form and in the Certificate. Some states require the insured to have major medical coverage. Additional restrictions apply to dependents serving in the armed forces or living overseas.
2. Covered services/treatments must be the result of an accident as defined in the group policy/certificate.  See your Disclosure Statement or Outline of Coverage/Disclosure Document for more details
3. Chip fractures are paid at 25% of Fracture Benefit and partial dislocations are paid at 25% of Dislocation Benefit.
4. Hospital does not include certain facilities such as nursing homes, convalescent care or extended care facilities. See MetLife’s Disclosure Statement or Outline of Coverage/Disclosure Document for full details.
5. The lodging benefit is not available in all states. It provides a benefit for a companion accompanying a covered insured while hospitalized, provided that lodging is at least 50 miles from the insured’s primary residence.
6. Coverage for Domestic Partners, civil union partners, and reciprocal beneficiaries varies by state. Please contact MetLife for more information.
7. When the plan pays an Admission Benefit, the Confinement Benefit may begin to pay on Day 2.
8. Hospital Confinement requires the assignment to a bed as a resident inpatient in a Hospital (including an Intensive Care Unit of a Hospital) on the advice of a Physician or confinement in an observation area within a Hospital for a period of no less than 20 continuous hours on the advice of a Physician. Please consult your certificate for details.
9. Applies only to “clean” claims. A clean claim is a claim submitted with all the required information necessary to process the claim; no missing information requiring additional follow up with the subscriber. It generally takes 10 business days to process “clean” claims.
10.The Admission Benefit is not payable for Emergency Room treatment or outpatient treatment. The payment of the admission benefit requires a Confinement. Hospital Confinement requires the assignment to a bed as a resident inpatient in a Hospital (including an Intensive Care Unit of a Hospital) on the advice of a Physician or confinement in an observation area within a Hospital for a period of no less than 20 continuous hours on the advice of a Physician. Please consult your certificate for details.

METLIFE’S ACCIDENT INSURANCE IS A LIMITED BENEFIT GROUP INSURANCE POLICY. The policy is not intended to be a substitute for medical coverage and certain states may require the insured to have medical coverage to enroll for the coverage. The policy or its provisions may vary or be unavailable in some states. There are benefit reductions that begin at age 65, if applicable. Like most group accident and health insurance policies, policies offered by MetLife may include waiting periods and contain certain exclusions, limitations and terms for keeping them in force. For complete details of coverage and availability, please refer to the group policy form GPNP12-AX or contact MetLife.

Benefits are underwritten by Metropolitan Life Insurance Company, New York, NY.  Hospital does not include certain facilities such as nursing homes, convalescent care or extended care facilities. See MetLife’s Disclosure Statement or Outline of Coverage/Disclosure Document for full details.

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