Accident

Insurance
Explore Your Benefits & Costs

Group Name: Concentrix CVG

Group Number: 717517

Cleaning the gutters. Yoga class. Soccer practice. Life offers plenty of opportunities
for accidental injuries. When an injury happens, Accident Insurance can help. This document includes
expanded cost and benefit information for Accident Insurance. As you explore, keep in mind:

No medical questions or Employees get an annual Benefit payments go directly to

tests are required for Wellness Benefit of $50 for you. Use them how you’d like!
Accident coverage. completing an eligible
health screening test.

Accident Insurance doesn’t replace your medical coverage; instead, it complements it. The benefit payments
don’t go out to pay for medical bills or treatments you may need, instead they come in—directly to you—
to be used however you’d like. Choose this supplemental health insurance product for added protection if one
of the following covered conditions comes your way.
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.

ReliaStar Life Insurance Company

a member of the Voya ® family of companies
How much does it cost?
This table shows your rates for Accident Insurance. The cost provided below includes Accident Insurance
premium and a fee for Voya Travel Assistance.

Low Plan - Monthly Rates

Employee and
Employee Employee and Spouse Family
Children

$3.98 $6.66 $8.31 $10.99

High Plan - Monthly Rates

Employee and
Employee Employee and Spouse Family
Children

$7.80 $12.15 $13.99 $18.34

Your spouse will be covered for the same Accident benefits as you. “Spouse” may include domestic partners or
civil union partners as defined by your employer’s plan.

If you have coverage on yourself, your natural children, stepchildren, adopted children or children for whom you
are legal guardian can be covered up to age 26. Your children will be covered for the same benefit amounts as
you. One premium amount covers all of your eligible children.

What’s covered?
Accident Insurance provides a benefit payment after a covered accident that results in the specific injuries and
treatments listed in this document. Some of the most common treatments and conditions we pay benefits for
include:

ER treatment X-rays Physical therapy

Follow-up doctor
Stitches
treatment(s)
Sample payment amounts
If one of these events happens to you, and your claim is approved, you’d receive a benefit payment in the amount
listed below. Use it however you’d like:

Accident-related treatment Low High

Emergency room treatment $150 $200

X-ray $100 $200

Physical or occupational therapy (up to six per accident) $180 $270

Stitches (for lacerations, up to 2”) $40 $60

Follow-up doctor treatment $60 $100

Hospital admission $750 $1,250

Hospital confinement (per day, up to 365 days) $150 $275

This is only a small preview of the benefits available to you.

See the full Schedule of Benefits toward the end of this document.

What else is included?

The Accident Insurance available through your employer also features the following:

Wellness Benefit
Complete an eligible health screening test, and we’ll send you a benefit
Receive $50 to
payment to use however you’d like.
use however
you’d like  Employees receive an annual benefit of $50.
 Spouses receive an annual benefit of $50.
 Children receive 100% of your benefit amount.

Additional non-insurance service(s)

Voya Travel Assistance
Being in an unfamiliar place can cause stress, especially if something goes wrong.
Voya Travel Assistance offers you and your dependents services when traveling
Access extra
100 miles or more from home, including: medical assistance services, emergency
support next time
medical transport services, travel assistance services such as pre-trip and cultural
you travel
information, security services and accessible technology.
Voya Travel Assistance services are provided by International Medical Group, Inc.,
Indianapolis, IN.

For a list of standard exclusions and limitations, please refer to the end of this document. For a complete
description of your available benefits, exclusions and limitations, see your certificate of insurance and any riders.
Schedule of Benefits
The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care
for your injury within a set amount of time. Note that there may be some variations by state. For a list of standard
exclusions and limitations, go to the end of this document.

 Your coverage includes a Sport Accident Benefit. This means that if your accident occurs while
participating in an organized sporting activity (as defined in the certificate of coverage); the benefit amounts
in the accident hospital care, accident care or common injuries sections below will be increased by 25%; to a
maximum additional benefit of $1,000.

Event Low High

Accident hospital care
Surgery open abdominal, thoracic $1,000 $1,200
Surgery exploratory or without repair $125 $175
Blood, plasma, platelets $300 $600
Hospital admission $750 $1,250
Hospital confinement
per day, up to 365 days $150 $275
Critical care unit confinement
per day, up to 15 days $300 $500
Rehabilitation facility confinement
per day, up to 90 days $125 $200
Coma duration of 14 or more days $11,500 $17,000
Transportation
per trip, up to three per accident $300 $600
Lodging per day, up to 30 days $120 $200
Family care
per child per day, up to 45 days $15 $25
Accident care
Initial doctor visit $60 $100
Urgent care facility treatment $150 $200
Emergency room treatment $150 $200
Ground ambulance $240 $360
Air ambulance $1,000 $1,500
Follow-up doctor treatment $60 $100
Medical equipment $75 $200
Physical or occupational therapy up
to six per accident $30 $45
Speech therapy up to 6 per accident $30 $45
Prosthetic device (one) $500 $750
Prosthetic device (two or more) $800 $1,200
Major diagnostic exam $125 $275
Outpatient surgery
(one per accident) $150 $225
X-ray $100 $200
Common injuries
Burns second degree, at least 36% of
the body $1,000 $1,250
Burns third degree, at least nine but
less than 35 square inches of the body $4,500 $7,500
Burns third degree, 35 or more square
inches of the body $10,000 $15,000
Skin grafts 50% of the burn benefit 50% of the burn benefit
Emergency dental work: crown $250 $350
Extraction $60 $90
Eye injury removal of foreign object $60 $100
Eye injury surgery $225 $350
Torn knee cartilage surgery with no
repair or if cartilage is shaved $150 $225
Torn knee cartilage surgical repair $500 $800
Laceration1 treated no sutures $20 $30
Laceration1 sutures up to 2” $40 $60
Laceration1 sutures 2” – 6” $160 $240
Laceration1 sutures over 6” $320 $480
Ruptured disk surgical repair $500 $800
Tendon/ligament/rotator cuff
exploratory arthroscopic surgery with no $275 $425
repair
Tendon/ligament/rotator cuff
$550 $825
one, surgical repair
Tendon/ligament/rotator cuff
$800 $1,225
two or more, surgical repair
Concussion $150 $225
Paralysis - paraplegia $10,750 $16,000
Paralysis – quadriplegia $16,000 $24,000
Dislocations Closed/open Closed/open
reduction2 reduction2
Hip joint $2,550/$5,100 $3,850/$7,700
Knee $1,600/$3,200 $2,400/$4,800
Ankle or foot bone(s) $1,000/$2,000 $1,500/$3,000
other than toes
Shoulder $1,000/$2,000 $1,600/$3,200
Elbow $750/$1,500 $1,100/$2,200
Wrist $750/$1,500 $1,100/$2,200
Finger/toe $175/$350 $275/$550
Hand bone(s) other than fingers $750/$1,500 $1,100/$2,200
Lower jaw $750/$1,500 $1,100/$2,200
Collarbone $750/$1,500 $1,100/$2,200
Partial dislocations 25% of the closed 25% of the closed
reduction amount reduction amount
 Fractures Closed/open Closed/open
reduction3 reduction3
Hip $2,000/$4,000 $3,000/$6,000
Leg $1,500/$3,000 $2,500/$5,000
Ankle $1,200/$2,400 $1,800/$3,600
Kneecap $1,200/$2,400 $1,800/$3,600
Foot excluding toes, heel $1,200/$2,400 $1,800/$3,600
Upper arm $1,400/$2,800 $2,100/$4,200
Forearm, hand, wrist except fingers $1,200/$2,400 $1,800/$3,600
Finger, toe $160/$320 $240/$480
Vertebral body $2,240/$4,480 $3,360/$6,720
Vertebral processes $960/$1,920 $1,440/$2,880
Pelvis except coccyx $2,250/$4,500 $3,200/$6,400
Coccyx $200/$400 $400/$800
Bones of face except nose $800/$1,600 $1,200/$2,400
Nose $400/$800 $600/$1,200
Upper jaw $1,000/$2,000 $1,500/$3,000
Lower jaw $960/$1,920 $1,440/$2,880
Collarbone $960/$1,920 $1,440/$2,880
Rib or ribs $300/$600 $400/$800
Skull – simple except bones of face $1,000/$2,000 $1,400/$2,800
Skull – depressed $2,000/$4,000 $3,000/$6,000
except bones of face
Sternum $240/$480 $360/$720
Shoulder blade $1,200/$2,400 $1,800/$3,600
Chip fractures 25% of the closed 25% of the closed
reduction amount reduction amount

1
Laceration benefits are a total of all lacerations per accident.
2
Non-surgical repair of a completely separated joint may be referred to in your policy documentation as a “closed reduction.”
Surgical repair of a completely separated joint may be referred to in your policy documentation as an “open reduction.”
3
Non-surgical repair of a fracture may be referred to in your policy documentation as a “closed reduction.” Surgical repair of a
fracture may be referred to in your policy documentation as an “open reduction.”
212680-09162020
 Exclusions and limitations
Standard exclusions for the Certificate, Spouse Accident Insurance, and Children’s Accident Insurance and AD&D
are listed below. (These may vary by state.) For a complete description of your available benefits, exclusions and
limitations, see your certificate of insurance and any riders.
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 sustained while on 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 semi-professional or professional competitive athletic contests for which
any type of compensation or remuneration is received.
test
 Any sickness or declining process caused by a sickness.

*Definition and limitations/exclusions may vary by state.

Ready to Enroll?
Enrollment instructions will be provided by your employer. If you have additional questions before you enroll,
please call:
 Voya Employee Benefits Customer Service at (877) 236-7564 or go to
https://presents.voya.com/EBRC/concentrix

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 (Minneapolis, MN), a member of the Voya® family of companies. Policy Form #RL-ACC3-POL-16; Certificate Form #RL-ACC3-CERT-16; and Rider
Forms: Spouse Accident Rider Form #RL-ACC3-SPR-16, Children's Accident Rider Form #RL-ACC3-CHR-16, Wellness Benefit Rider Form #RL-ACC3-WELL-16, Accidental
Death & Dismemberment (AD&D) Rider Form #RL-ACC3-ADR-16, Catastrophic Accident Rider Form #RL-ACC3-CAR-16, Off Job Accident Disability Income Rider form
#RL-ACC3-DIR-16, Sickness Hospital Confinement Rider Form #RL-ACC3-HCR-16, Waiver of Premium Rider form #RL-ACC3-WOP-16, Continuation of Insurance Rider
form #RL-ACC3-CNT-16. Form numbers, provisions and availability may vary by state and employer’s plan.

1222304
ACC2 Only
Date Prepared: 10/15/24
212309-08152020