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Scheduled Benefit Accident — Plan 1

Symetra Life Insurance Company

A scheduled benefit accident insurance plan insured by Symetra Life Insurance Company for JPS Health Network employees. Pays fixed dollar amounts for covered accidental injuries and related services including emergency care, hospitalization, surgery, fractures, dislocations, burns, and catastrophic benefits.

Starting from $12.28 /mo

👤 Single $12.28 /mo

👫 Employee + Spouse $21.34 /mo

👨‍👧 Employee + Child(ren) $26.94 /mo

👨‍👩‍👧‍👦 Family $38.12 /mo

Emergency Care & Diagnostics

Benefit	Amount
Emergency Care & Diagnostics
Ambulance - Ground 1 trip per covered accident	$400 pp/pa
Ambulance - Air 1 trip per covered accident; must be within 96 hours of 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 accident; only one benefit paid if multiple tests performed	$300 pp/pa
X-Ray 1 test per covered accident; must be performed within 365 days of accident	$60 pp/pa
Pain Management/Epidural 1 visit per covered accident; services must be within 365 days of accident	$100 pp/pa
Initial Doctor's Visit Once per person per accident; must occur within 365 days of accident	$100 pp/pa

Accident Hospitalization & Surgical Benefits

Benefit	Amount
Accident Hospitalization & Surgical Benefits
Hospital Admission Once per person per accident; admission must occur within 365 days of accident; minimum 24 consecutive hours	$1,500 pp/pa
ICU Admission Once per person per accident; admission must occur within 365 days of accident; minimum 24 consecutive hours	$3,000 pp/pa
Hospital Confinement Up to 365 days per accident; must begin within 365 days of accident	$300 per day
ICU Confinement Up to 30 days per accident; must begin within 365 days of accident	$600 per day
Rehabilitation/Skilled Nursing Facility Up to 90 days per accident; must begin within 365 days of accident; minimum 24 hours	$150 per day
Blood/Plasma/Platelets Once per person per accident; for surgical procedure transfusions	$500 pp/pa
Surgery - Open Abdominal, Thoracic Surgery must be performed within 365 days of accident; if multiple procedures same day, largest benefit paid	$3,000 per surgery
Surgery - Cranial Surgery must be performed within 365 days of accident	$3,000 per surgery
Surgery - Hernia Surgery must be performed within 365 days of accident	$1,500 per surgery
Surgery - Exploratory or Without Repair Surgery must be performed within 365 days of accident	$400 per surgery
Outpatient/Miscellaneous Surgery Once per person per accident; surgery must be performed within 365 days of accident	$400 per surgery
Transportation Up to 3 trips per accident; travel to/from health care facility more than 50 miles from primary residence; within 365 days of accident	$500 per trip
Family Lodging Up to 30 nights; for adult family member/companion when insured is confined 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

Benefit	Amount
Follow Up Care
Follow Up Doctor's Visit 1 visit per covered accident; must occur after initial treatment in doctor's office or ER	$100 pp/pa
Physical Therapy Up to 10 visits per accident; must begin within 365 days after accident	$75 per visit
Chiropractic Visit Up to 10 visits per accident; must begin within 365 days after accident	$75 per visit
Medical Equipment 1 appliance per covered accident; must be prescribed by doctor within 365 days after injury	$400 pp/pa
Prosthetic Device 1 device per covered accident; must be prescribed by doctor within 365 days after injury	$2,500 pp/pa

Common Injuries — Burns

Benefit	Amount
Burns — Second Degree
Second Degree: 20–100 square centimeters Once per person per accident; if multiple burns, highest eligible benefit paid	$100 pp/pa
Second Degree: 101–225 square centimeters Once per person per accident; if multiple burns, highest eligible benefit paid	$200 pp/pa
Second Degree: More than 225 square centimeters Once per person per accident; if multiple burns, highest eligible benefit paid	$800 pp/pa
Burns — Third Degree
Third Degree: 20–100 square centimeters Once per person per accident; if multiple burns, highest eligible benefit paid	$800 pp/pa
Third Degree: 101–225 square centimeters Once per person per accident; if multiple burns, highest eligible benefit paid	$6,000 pp/pa
Third Degree: More than 225 square centimeters Once per person per accident; if multiple burns, highest eligible benefit paid	$20,000 pp/pa
Skin Grafts	25% of burn benefit

Common Injuries — Paralysis, Lacerations, Dental, Eye & Specific Injuries

Benefit	Amount
Paralysis
Quadriplegia Once per person per accident; must be diagnosed within 365 days of accident	$20,000 pp/pa
Paraplegia Once per person per accident; must be diagnosed within 365 days of accident	$10,000 pp/pa
Hemiplegia Once per person per accident; must be diagnosed within 365 days of accident	$10,000 pp/pa
Uniplegia Once per person per accident; must be diagnosed within 365 days of accident	$5,000 pp/pa
Lacerations
Not requiring sutures Once per person per accident; lacerations must be repaired within 96 hours after accident; if multiple lacerations, total length used	$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 regardless of number of teeth; 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 be done by doctor within 365 days after accident	$60 pp/pa
Surgical Repair Once per person per accident; must be done by doctor within 365 days after accident	$300 pp/pa
Specific Injuries
Ruptured Disc Once per person per accident; injury must require surgery or medical treatment within 365 days after accident	$600 pp/pa
Tendons/Ligaments — 1 tear with surgical repair Once per person per accident; injury must require surgery within 365 days after accident	$800 pp/pa
Tendons/Ligaments — 2 or more tears with surgical repair Once per person per accident; injury must require surgery within 365 days after 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

Common Injuries — Dislocations (Closed Reduction)

Benefit	Amount
Dislocations (Closed Reduction)
Hip Up to 3 dislocation benefits per person per accident; must be treated by doctor within 365 days after accident	$5,000 per dislocation
Knee (except patella) Up to 3 dislocation benefits per person per accident; must be treated by doctor within 365 days after accident	$2,000 per dislocation
Shoulder Up to 3 dislocation benefits per person per accident	$2,000 per dislocation
Foot/Ankle Up to 3 dislocation benefits per person per accident	$2,000 per dislocation
Wrist Up to 3 dislocation benefits per person per accident	$2,000 per dislocation
Lower Jaw Up to 3 dislocation benefits per person per accident	$2,000 per dislocation
Elbow Up to 3 dislocation benefits per person per accident	$2,000 per dislocation
Bones of the Hand (except fingers) Up to 3 dislocation benefits per person per accident	$1,000 per dislocation
Collarbone Up to 3 dislocation benefits per person per accident	$1,000 per dislocation
2 or more fingers Up to 3 dislocation benefits per person per accident	$400 per dislocation
2 or more toes Up to 3 dislocation benefits per person per accident	$400 per dislocation
1 finger or toe Up to 3 dislocation benefits per person per accident	$150 per dislocation
Open Reduction	200% of dislocation benefit
Partial Dislocation	25% of dislocation benefit

Common Injuries — Fractures (Closed Reduction)

Benefit	Amount
Fractures (Closed Reduction)
Skull Up to 3 fracture benefits per person per accident; must be treated by doctor within 365 days after accident	$5,000 per fracture
Hip/Thigh Up to 3 fracture benefits per person per accident	$5,000 per fracture
Vertebral Body (excluding vertebral processes) Up to 3 fracture benefits per person per accident	$5,000 per fracture
Pelvis Up to 3 fracture benefits per person per accident	$5,000 per fracture
Arm (upper) Up to 3 fracture benefits per person per accident	$3,000 per fracture
Shoulder Blade Up to 3 fracture benefits per person per accident	$3,000 per fracture
Leg Up to 3 fracture benefits per person per accident	$3,000 per fracture
Upper Jaw Up to 3 fracture benefits per person per accident	$2,000 per fracture
Vertebral Processes Up to 3 fracture benefits per person per accident	$2,000 per fracture
Knee Cap Up to 3 fracture benefits per person per accident	$2,000 per fracture
Collarbone Up to 3 fracture benefits per person per accident	$2,000 per fracture
Forearm Up to 3 fracture benefits per person per accident	$2,000 per fracture
Foot/Ankle Up to 3 fracture benefits per person per accident	$2,000 per fracture
Hand/Wrist Up to 3 fracture benefits per person per accident	$1,500 per fracture
Lower Jaw Up to 3 fracture benefits per person per accident	$1,500 per fracture
Ribs (2 or more) Up to 3 fracture benefits per person per accident	$1,000 per fracture
Facial Bones or Nose Up to 3 fracture benefits per person per accident	$1,000 per fracture
1 rib, finger, or toe Up to 3 fracture benefits per person per accident	$400 per fracture
Coccyx Up to 3 fracture benefits per person per accident	$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 Loss must occur within 365 days of accident; Employee 100%, Spouse 50%, Child 25%	$50,000
Common Carrier Accidental Death Payable in lieu of Accidental Death benefit; loss must occur within 365 days of accident; Employee 100%, Spouse 50%, Child 25%	$100,000
AD&D Benefits — Double Dismemberment
Loss of both hands, both feet or sight in both eyes Employee 100%, Spouse 50%, Child 25%; loss must occur within 365 days of accident	$50,000
Loss of Speech or Hearing in both ears Employee 100%, Spouse 50%, Child 25%; loss must occur within 365 days of accident	$25,000
Loss of 1 hand and 1 foot Employee 100%, Spouse 50%, Child 25%; loss must occur within 365 days of accident	$50,000
Loss of 1 eye Employee 100%, Spouse 50%, Child 25%; loss must occur within 365 days of accident	$25,000
Loss of 1 hand or 1 foot Employee 100%, Spouse 50%, Child 25%; loss must occur within 365 days of accident	$25,000
Loss of 2 or more fingers or toes Employee 100%, Spouse 50%, Child 25%; loss must occur within 365 days of accident	$10,000
Loss of 1 finger or toe Employee 100%, Spouse 50%, Child 25%; loss must occur within 365 days of accident	$2,500

Optional Benefits

Benefit	Details
Optional Benefits
Wellness Screening Benefit Once per person per calendar year; $100 for Employee, $100 for Spouse, $100 for Children; paid regardless of number of screenings in the year	$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; applies when insured dependent child is participating in an organized sport	Included

Ambulance Transportation Benefit

This benefit pays for ground or air ambulance transportation as shown in the Schedule of Benefits. It will be paid for transportation by a licensed ground or air ambulance transportation service from the place of injury to the nearest accredited hospital where adequate treatment facilities are available. Air ambulance transportation must be within 96 hours of the accident. Ground transportation must be within 90 days of the accident.

Emergency Room Benefit

The benefit amount shown in the Schedule of Benefits will be paid for treatment in an emergency room for an injury. Emergency room services must be incurred within 30 days from the Accident.

Major Diagnostic Testing Benefit

The benefit amount shown in the Schedule of Benefits will be paid if for any of the following major diagnostic tests as the result of the injury. Tests must be administered by a provider within 365 days of the accident. If multiple tests are performed, only one benefit will be paid. The following tests are covered: magnetic resonance imaging (MRI), computed tomography (CT, Cat Scan), electrocardiogram (EKG) and electroencephalogram.

Hospital Admission Benefit

This benefit will pay the amount shown in the Schedule of Benefits for the first calendar day of confinement and admission to a hospital as the result of an injury for a minimum of 24 consecutive hours or if a charge is made for room and board. Hospital admission must occur within 365 days from the date of the accident. The benefit is payable once per person, per accident. This benefit is payable regardless of other hospital benefits available.

Coma Benefit

This benefit will pay the amount shown in the Schedule of Benefits if an insured lapses into a coma as the result of an injury. The coma must occur within 365 days of injury and last for a minimum of 7 days.

Wellness Screening Benefit

This benefit will pay the amount shown in the Schedule of Benefits for any of the wellness screening tests listed. The benefit will be paid once per person during a calendar year regardless of the number of screening tests administered during that year. To claim, contact Symetra with: (1) name of the insured, (2) type of screening, and (3) date screening was completed. Claims can also be submitted through My Group Online (MyGO) at symetra.com/MyGO.

Child Organized Sports Benefit

Provides an additional 25% benefit (up to a specified cap of $5,000 per person/per accident), for benefits payable under the Policy, if the Accident occurred while an Insured Dependent child is participating in an organized sport. The child must be insured by the Policy on the date the Accident occurred.

Portability / Extension of Coverage

Allows coverage to continue following termination of employment or loss of eligibility. Review the certificate of coverage to understand the full details of this provision. N/A for policies issued in CO, KY, LA, MN, NH, NV, OR, UT, VT, WA, or WV, or for residents of LA, MN, NH, VT or WV.

HSA Compatibility Notice

These benefits are designed to be offered to those covered under a High-Deductible Health Plan (HDHP) without the effect of disqualifying a participant from electing an HSA. Please consult with your Benefits Advisor to assist with determination that electing this limited benefit coverage is in fact permitted coverage under the rules applicable to an HSA.

Main Advantages

✓Abdominal aortic aneurysm ultrasonography
✓Baseline testing for concussion
✓Blood test for lipids, including total cholesterol, LDL, HDL and triglycerides
✓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 / ThinPrep Pap test
✓Prostate-specific antigen (PSA) test
✓Serum cholesterol test to determine level of HDL and LDL
✓Stress test on a bicycle or treadmill
✓Testicular ultrasound
✓Thermography

Is This Right for You?

Employees enrolled in a High-Deductible Health Plan (HDHP) seeking supplemental accident coverage
Active individuals and families with dependent children in organized sports
Employees wanting help covering deductibles, copays, and out-of-pocket costs from accidental injuries

Who Can Enroll

👨‍👩‍👧‍👦Dependents covered up to age 26
✅Guarantee Issue — no medical exam required

Contact Information

Symetra Life Insurance Company
777 108th Avenue NE, Suite 1200
Bellevue, WA 98004-5135

Phone: 1-800-497-3699 (Monday–Friday, 8 a.m. to 8 p.m. ET)
Email: sbclaims@symetra.com
Online Claims: symetra.com/MyGO
Mailing Address: P.O. Box 674419, Houston, TX 77267-4419
Fax: 715-682-5919

Policy #: 12379000
Policyholder: The Tarrant County Hospital dba JPS Health Network
Policy Form: SBC-03510
Coverage Issue State: TX