What does accident insurance actually cover?

Accident insurance is the most straightforward product we sell, and it is also the one people most often misunderstand — usually because they assume it works like the medical plan it sits next to. It does not, and the difference is in your favour.

It reimburses expenses. It does not pay a flat amount.

A fixed benefit medical plan pays a scheduled amount per service. An accident policy works the other way: it looks at the covered charges from your accident, applies a $250 calendar-year deductible, and reimburses the rest up to the annual benefit you selected.

So the payout tracks what actually happened to you. A small injury produces a small claim. A bad one produces a large claim, up to the ceiling you chose. How that differs from the scheduled-benefit design is explained in how a set benefit amount works.

It pays on top of whatever else you have

This is the part worth reading twice. There is no coordination of benefits on the accident side. The policy pays you whether or not your health plan paid, and whether or not you have any health plan at all.

In practice the claim uses the Explanation of Benefits from your other coverage to establish what the charges actually were after discounts. But that document is used to price the claim, not to reduce it. The benefit is yours either way, and it is paid directly to you rather than to the hospital.

What is covered

The policy splits covered services into two groups, by how quickly you are treated.

Treated within 48 hours of the accident:

• Emergency room visit
• Urgent care centre visit
• Burns or lacerations
• Diagnosed concussion

Treated within 30 days of the accident:

• Ambulance
• Hospital stay, including ICU
• Surgery and anaesthesia services
• Fractures
• Labs and X-rays; MRI and CT scans
• Doctor visits
• Prescriptions
• Prosthetics

Those deadlines are real and they are the most common reason a good claim fails. If you hurt yourself and decide to wait and see, then go in a week later for what turns out to be a fracture, you are inside the 30-day window for the fracture but outside the 48-hour window for the emergency room. Get seen, and keep the dates.

A worked example, from the carrier

A cyclist comes off his bike at the park and fractures his arm. An ambulance takes him to hospital and he has surgery to repair it. Total medical expenses: $7,006.

• Annual benefit selected: $10,000
• Less the calendar-year deductible: $250
• Paid to him: $6,756
• Still available for the rest of that year: $3,244 — and the full $10,000 resets in January

He can use that money for anything. The hospital bill, the deductible on another plan, the mortgage while he is off work. It is his.

There is more than accident cover in the policy

Two things come built in, which is why this single policy does more work than its name suggests.

• A critical illness benefit. The policy pays a lump sum on a covered diagnosis, with a lifetime maximum of three times the amount you choose. Detail is in what critical illness insurance pays for.
• Accidental death and dismemberment. The AD&D amount matches the accident benefit you selected and pays in addition to it. Loss of two or more limbs pays 100%, one limb 50%.

What it does not do

Stated plainly, because the exclusions decide claims:

• Illness is not covered on the accident side. This is injury cover. Sickness is what the medical plan and the critical illness benefit are for.
• Stroke is excluded from the accident benefit specifically — it is covered under the critical illness side instead.
• Work injuries are excluded where you were paid for the activity. That is workers' compensation territory.
• Hazardous activities are excluded — skydiving, hang gliding, bungee jumping, racing, rodeo, scuba below 60 feet, and semi-professional or intercollegiate sport among them.
• Mental disorders and substance abuse treatment, cosmetic treatment, experimental treatment, and care outside the United States are excluded.

If you ride motocross at weekends or play in a semi-pro league, say so on the call. It changes the recommendation, and we would rather find out now than at claim time.

What counts as an accident

Worth defining, because the word does more work here than anywhere else in the policy. An accident is a sudden, unforeseen event causing injury. It is not an illness that came on quickly, and it is not the gradual consequence of something you have been doing for years.

Most of what people claim on is ordinary: a fall on a step, a knee that goes on a hike, a burn in the kitchen, a car accident, a child coming off a bicycle. None of those are dramatic. All of them produce an emergency room visit and a bill, which is exactly the event this policy exists for.

Who buys it, and at what level

Issue ages run 18 through 64 and the policy is renewable to age 70. The version with a short set of medical questions offers higher benefit levels; a guaranteed-issue version with no health questions is available at slightly lower amounts — see what guaranteed issue means.

Households with children and self-employed people tend to buy this one first, and the reasoning is set out in is accident insurance worth it. If you are weighing it against the other cash policies, building a coverage package puts them side by side.

How The Jordan Insurance Agency helps

We are an independent agency in Charlotte, and our licensed agents have worked with North Carolina families since 2006. This policy is part of almost every package we build — because the emergency room is where most people's coverage gets tested, and this is the piece that answers it.

We will walk you through the covered list, the two treatment deadlines and the exclusions before you decide, and we will tell you which benefit level actually fits your household rather than selling you the biggest one.

Do you mind if we take a look together?

Benefit amounts, deductibles, treatment windows and the worked example shown are the carrier's own published figures for one accident plan design available in North Carolina. There are several benefit levels and the amounts differ between them. Examples are illustrative and the people in them are fictional. This product provides limited benefits. It is a supplement to health insurance and is not a substitute for the minimum essential coverage required by the Affordable Care Act.