HOSPITAL CONFINEMENT SICKNESS INDEMNITY LIMITED BENEFIT POLICY SURGICAL BENEFIT AFLAC will pay benefits according to the Schedule of Operations when a covered person has a surgical operation performed for a covered sickness in a hospital or ambulatory surgical center. Only one benefit is payable per 24-hour period for surgery even though more than one surgical procedure may be performed. We will pay the highest eligible benefit. Benefits are not payable for cosmetic or elective surgery that is not due to sickness. Surgical Benefits are not payable for surgery performed in a doctor's or dentist's office, clinic, or other such location. Surgery performed but not listed in the Schedule of Operations will be paid according to the amount shown for the surgery most similar in severity and gravity. No lifetime maximum. SCHEDULE OF OPERATIONS BONE DIGESTIVE (cont.) Bone marrow biopsy Gastroscopy ................................... 100 or aspiration ............................. $100 Sigmoidoscopy ............................... 100 Arthroscopy.................................... 150 Appendectomy................................ 200 Removal of knee cartilage............. 150 Colostomy....................................... 300 Total knee replacement................. 500 ERCP .............................................. 300 Total hip replacement.................... 750 Vagotomy........................................ 300 Partial colectomy ............................ 400 BRAIN Colectomy....................................... 600 Burr holes not followed Colectomy with ileostomy .............. 600 by surgery ............................... 300 Cholecystectomy............................ 625 Ventriculoperitoneal shunt............. 500 Esophagectomy.............................. 750 Exploratory craniotomy.................. 700 Gastrectomy Excision brain tumor...................... 1,000 Partial......................................... 750 Hemispherectomy.......................... 2,000 Total........................................... 1,200 BREAST EAR/NOSE Incisional biopsy ............................ 100 Myringoscopy ................................. 100 Needle biopsy................................ 100 Tympanotomy................................. 100 Breast reduction............................. 300 Adenoidectomy............................... 150 Lumpectomy ................................. 300 Myringoplasty ................................. 150 Stereotactic biopsy ........................ 300 Mastoidectomy Axillary node dissection................. 475 Simple........................................ 150 Partial mastectomy ........................ 475 Radical....................................... 300 Breast reconstruction .................... 625 Tonsillectomy with or without Mastectomy adenoids.................................... 300 Simple ....................................... 625 Radical...................................... 925 EYE Cataract .......................................... 200 DIGESTIVE Enucleation..................................... 500 Colonoscopy .................................. 100 Corneal transplant.......................... 750 Esophagoscopy............................. 100 Exploratory laparotomy ................. 100 Form A-45075-SS RC(8/04) GYNECOLOGIC MISCELLANEOUS Dilation & curettage (D&C)............ 150 Foot surgery .................................. 150 Vaginal delivery ............................. 300 Repair of hernia.............................. 250 Cesarean delivery.......................... 400 Carpal tunnel release Hysterectomy (one hand or two)...................... 250 Partial........................................ 400 Cleft lip repair.................................. 250 Vaginal...................................... 450 Club foot repair............................... 250 Vulvectomy Partial mandibulectomy Partial........................................ 450 (for TMJ).................................... 250 Radical...................................... 900 Mandibulectomy ............................. 400 Abdominal hysterectomy with or Cleft palate repair........................... 400 without tubes and ovaries........ 775 Organ transplant............................. 2,000 HEART PANCREAS Insertion of pacemaker.................. 200 Jejunostomy ................................... 750 Angioplasty Pancreatectomy ............................. 1,000 One vessel .............................. 500 Whipple procedure......................... 2,000 Two vessels ............................ 750 Coronary artery with graft.............. 1,000 SPINE Replacement of aortic Cordotomy ...................................... 450 or mitral valve.......................... 1,000 Laminectomy .................................. 750 LARYNX THYROID Laryngoscopy with biopsy............. 100 Biopsy ............................................. 150 Tracheostomy................................ 200 Thyroidectomy Laryngectomy ............................... 500 One lobe.................................... 450 Laryngectomy with radical Two lobes.................................. 800 neck dissection ....................... 1,000 URINARY LIVER Biopsy prostate............................... 100 Needle biopsy................................ 125 Hydrocele........................................ 100 Wedge biopsy................................ 300 Cystoscopy..................................... 125 Resection of liver ........................... 750 Arteriovenous shunt/fistula ............ 200 Cystotomy....................................... 200 LUNGS Orchiectomy Needle biopsy................................ 200 (unilateral, bilateral) .................. 300 Bronchoscopy with biopsy ............ 250 Biopsy of kidney ............................. 400 Thoracostomy ................................ 300 TUR bladder ................................... 475 Thoracotomy.................................. 400 TUR prostate .................................. 475 Pneumonectomy............................ 750 Prostatectomy, radical.................... 750 Wedge resection of lung................ 1,200 Cystectomy Lobectomy...................................... 1,500 Partial......................................... 800 Complete ................................... 1,400 LYMPHATIC Nephrectomy .................................. 1,500 Biopsy lymph node ........................ 150 Splenectomy .................................. 300 Lymphadenectomy (bilateral)........ 800 Personal Sickness Indemnity Plan Hospital Confinement Sickness Indemnity Insurance Plan Benefits • Physician Visits • Initial Hospitalization • Hospital Confinement • Major Diagnostic Exams • Surgical • Plus ... more American Family Life Assurance Company of Columbus (Aflac) Form A45075B1TX IC(2/08) Personal Sickness Indemnity Plan Policies A-45100-TX, A-45200-TX, and A-45300-TX K Policy A-45100-TX (Level 1) Major Diagnostic Exams K Policy A-45200-TX (Level 2) Aflac will pay $150 when a covered person requires one of the K Policy A-45300-TX (Level 3) following exams for a covered sickness: • CT scan Physician Visits Benefit • MRI (magnetic resonance imaging) Aflac will pay the amount for the level chosen when a covered • EEG (electroencephalogram) person incurs a charge for a physician visit. Services must be • Thallium stress test under the supervision of a physician. This is a health • Myelogram maintenance benefit; the sickness of a covered person is not • Angiogram required for this benefit to be payable. No lifetime maximum. • Arteriogram Level 1 Level 2 Level 3 These exams must be performed in a hospital, doctor’s office, A-45100-TX A-45200-TX A-45300-TX or ambulatory surgical center, and a charge must be incurred. Benefit Amount $15 $20 $25 This benefit is limited to one payment per calendar year, per covered person. No lifetime maximum. Number of Visits per Year: Surgical Benefit Individual 344 Aflac will pay $100–$2,000 when a covered person has surgery Family* 688 performed for a covered sickness in a hospital or ambulatory surgical Covered physician visits include, but are not limited to, eye center based upon the Schedule of Operations in the policy.Only one exams, well-baby visits, immunizations, periodic health benefit is payable per 24-hour period for surgery even though more exams, and routine physicals. than one surgical procedure may be performed. Wewill pay the highest eligible benefit. Benefits are not payable for cosmetic or The following benefits are payable for a covered sickness that elective surgery that is not due to sickness. Surgical Benefits are not occurs while coverage is in force. Treatment or confinement in a payable for surgery performed in a doctor’sor dentist’soffice, clinic, U.S. government hospital does not require a charge for benefits to or other such location. Surgery performed but not listed in the be payable. All of the benefits listed below, except for the schedule will be paid according to the amount shown for the surgery Hospital Confinement Benefit, are the same for Levels 1, 2, and 3 most similar in severity and gravity. No lifetime maximum. (Policies A-45100-TX, A-45200-TX, and A-45300-TX). Hospital Confinement Benefit Ambulance Benefit Aflac will pay the amount per day for the level chosen when a Aflac will pay $100 for ground ambulance and $1,000 for air covered person requires hospital confinement for 14 or more ambulance if, because of a covered sickness, a covered person hours for a covered sickness or for rehabilitory care as a result