Group Health Plans of  La.
4323 Division St # 104
Metairie, LA 70002
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MED CHOICE PLUS HOSPITAL INDEMNITY PLAN
   

 BRONZE PLAN

 SILVER PLAN

GOLD PLAN

PLATINUM PLAN

Insured Only      $25.05

Insured Only     $46.60

Insured Only       $61.80

Insured Only      $93.00

Plus Spouse      $49.10

Plus Spouse     $91.20

Plus Spouse      $122.00

Plus Spouse     $184.80

Plus Children     $43.00

Plus Children    $78.80

Plus Children     $106.10

Plus Children    $168.75

Full  Family        $64.60

Full Family      $118.50

Full Family         $161.90

Full  Family       $258.85

Scheduled Medical Benefits
   
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BENEFIT TYPE

DESCRIPTION

BRONZE

SILVER

GOLD

PLATINUM

Hospital Expense
Benefit

Pays a daily benefit for hospitalization due to sickness or accident beginning on the first day of hospitalization. Payable  up to 365 days of confinement per insured.

$50

  $100

$150

$250

Annual First
   Occurrence Hospital
Confinement Rider

This benefit is payable when a covered per­son is admitted and confined in a hospital for at least twenty-four (24) consecutive hours. Payable once per covered person in a calendar year.

$250

  $500

$750

$1,000


   Emergency Accident
Rider

Pays the actual cost, up to the benefit amount, for emergency care by a physician in a hos­pital or physicians office when incurred within 30 days of an accident. Benefits are payable for up to four covered accidents for the employee, four for the spouse, and four For all covered children.

   $300

  $300

$300

$300


   Outpatient Sickness
Rider

This benefit pays actual charges not to exceed amount listed per treatment for a covered sickness by a physician or surgeon in their office, clinic, or other out-of-hospital facility. Payment will be limited to the listed maximum, for all insureds combined in a calendar year.

$25

$150
 Max

$50

$300
 Max

$50

$450
 
Max

$50

$600
Max

Intensive Care
Coronary Care
Benefit Rider

Pays a daily intensive care benefit for each day an insured person is confined in a hospital's intensive care or coronary care unit due to an injury or sickness. Benefits begin on the 1st day of confinement, not to ex­ceed 20 days per period of confinement,


$200


$300


$400


$400


     Surgical & Anesthesia
Benefit Rider*

Pays actual charges, up to the amount shown in the schedule of operations, for surgery performed by a physician. Pays an additional 25% of the surgical benefit for anesthesia administered by a physician in connection with surgery.


$1,000


$2,500


$3,000


$5,000

Accidental Death & Dismemberment

Pays benefit amount shown.

$5000

$7,500

$10,000

$50,000

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*Refer to the policy for benefits and schedules.
Form #Hi 2000 Bro-rev-(12-01)