Student Accident Protection For Your School Children (For loss due to accidental bodily injury while the policy is in force) If injuries covered by this policy shall require the services of a licensed physician (physician : means any duly licensed practitioner of the healing arts) or dentist, the Company will reimburse up to the amount specified in the Schedule of Benefits subject to the following limitations: Medical and/or hospital treatment must begin within 30 days. in each section will be allowed for each injury. In multiple injuries on the same day, maximum payable shall be limited to 100% benefit for the most serious and 50% of the next most serious. Benefits for non-scheduled treatments will be paid on the basis of an equally serious scheduled treatment. SECTION I - HOSPITALIZATION If hospitilization as an in-patient is required as a direct result of injuries covered by this policy, reimbursement will be made in accordance with the following benefits: (1) The expense for charges made by the hospital for room and board, but not to exceed $15.00 for each day of hospital confinement, not to exceed 30 days. Maximum benefit $450.00. (2) The expense incurred for anesthetics, operating room, drugs and dressing, and laboratory tests up to a maximum of $75.00 (3) The expense for charges made for an ambulance up to a maximum of $15.00 for any one injury. EMERGENCY ROOM AND/OR OUT-PATIENT CHARGES ARE NOT COVERED. SECTION II - MEDICAL TREATMENTS Fractures and Dislocations requiring open reduction—benefits are increased 50%. Linear, green stick, avulsion or chip fractures or any fracture with no displacement or when reduction is not required, will be one-half of the scheduled amount. (Redislocation of a joint within 90 days will not be covered). FRACTURES AND DISLOCATIONS Payment is based on the 1964 California Relative Value Schedule of $3.00 per unit.(28-71) CUTTING OPERATIONS (4) Incision and draining of abscess (except cutaneous) (5) Excision of Calcification (6) Tendon repair (7) Nerve repair - - - - $15.00 . (8) Submucous resection-hospitalization not payable in addition to this benefit—one-half the total medical and hospital expense up to a maximum of (9) eeiigemaaieee maximum (15) (144) Treatment of concussion, cellu- Only treatments rendered within 120 days shall be covered. Only one treatment (13) Treatment of sprains, strains, bruises, abrasions or puncture wounds-Maximum for each such injury Cast for sprain (additional) (10) Chest, cutting into thoracic cavity for treatment of injured organs therein (11) Stomach cutting into abdominal cavity for treatment of injured organs therein MISCELLANEOUS MEDICAL TREATMENTS (12) Suture of Laceration litus, first and second degree burns, nail avulsion, orbit or ear, except auricle, aspiration of joints: $5.00 first treat- (16) ment; $3.00 each subsequent treatment; Maximum - - - $15.00 Treatment of spine, abdominal or thoracic viscerea; cerebral hemorrhage, concussion; septicemia; third degree burns; $5.00 first treatment; $3.00 each subsequent treatment; Maximum - $25.00 Bronchoscopy or Esophago- | SECTION III - DIAGNOSTIC X-RAYS One payment for each injury regardless of number of views. Film must be furnished on request: (17) Finger, Toes (18) Ankle, Arm, Elbow, Foot, Hand, Wrist, Leg, Nose, (19) Ribs, Spine, Pelvis, Hip, Skull, Shoulder SECTION IV - DENTAL TREATMENT Limited to injury of sound, natural, unfilled, permanent teeth. Maximum payable $75.00 per accident if bridgework is not required. $150.00 if bridgework is required. One benefit payable per tooth, plus scheduled dental X-rays. (20) Nerve removal and (23) Dental x-rays—each film treatment of canal (21) Restoration (by crown or facing) of broken Tooth (22) Bridgework, for each tooth replaced $1.00 up to maximum (24) of ---- $5.00 Treatment of tooth or teeth not covered under (20) through (22) inclusive SECTION V — ACCIDENTAL DEATH & DISMEMBERMENT If bodily injuries covered by this policy shall result directly and independently of all other causes, within 120 days from the date of such injury, in any of the specific losses enumerated in this Section, the Company will pay principal sum benefit in the amount set opposite such loss, but only one of the amounts, the largest so specified, which is applicable to a loss sustained, will be paid for injuries to any one insured. Loss of hand or foot means loss by severance at or above the wrist or ankle joint. Loss of sight must be entire and irrecoverable. Indemnity for loss of life is payable to the estate of the decedent. Any indemnity payable under this Section shall be in lieu of any indemnity otherwise payable under this policy. (25) Loss of Life (26) Loss of Both Hands, Both Feet, or Sight of Both Eyes (27) Loss of One Hand, One Foot, or Sight of One Eye EXCLUSIONS No payment shall be made for treatment of: boils, athlete’s foot, impetigo (or similar skin infection), warts, cysts, blisters, allergies, ingrown nails, hernia, appendicitis, cardiac disease, diabetes, heat prostration, overexertion, detached retina, pathological fractures, osteiomylitis, malignancy or Osgood-Schlatter’s disease, subluxation shall not be considered as a dislocation, eye glasses, physical therapy, diathermy and thermatic treatments; braces (including Dental Braces), crutches; for aggravation of a pre-existing condition; for injuries, provoked or unprovoked, connected with fighting or brawling; or for an athletic injury incurred while still receiving medical treatment for a previous injury.