Prudential accident insurance pays you a fixed cash benefit when you or a covered family member is hurt in an accident, with set dollar amounts for specific injuries, emergency and hospital care, dismemberment, and accidental death. It is a supplemental “excepted benefits” policy issued through employers and associations by The Prudential Insurance Company of America. It is not health insurance, it does not meet the Affordable Care Act’s minimum essential coverage requirement, and it does not pay for illness or disease. Accidents only.
Because the benefit is a flat amount tied to the injury or service, the payment goes to you rather than to a hospital or doctor. If you break a leg, the policy pays the set fracture benefit regardless of what the hospital charges or what your health plan already covered, and you can spend the money however you want.
Injuries the Policy Pays For
Benefit amounts vary by employer plan and by tier (many employers offer a High Plan and a Low Plan), but the categories of covered injuries are consistent. The figures below come from sample employer plan documents and show the typical range.
Fractures and Dislocations
Fracture benefits depend on which bone is broken and whether the break is open (through the skin) or closed. Open fractures pay roughly double what closed fractures pay. One high-plan example pays up to $3,000 for a closed fracture and up to $6,000 for an open one. A sample schedule lists open-fracture benefits of $3,000 for the skull, $1,000 for a leg, $750 for the pelvis, and $300 for a hand, with lower amounts for closed breaks.
Dislocations work the same way. Under one employer’s high plan, closed dislocations pay up to $2,000 and open dislocations up to $4,000. Specific examples include $4,500 for an open hip dislocation, $2,250 for the spine, and about $900 for a shoulder or collarbone.
Burns
Burn benefits are tiered by degree and by the percentage of body surface burned. One detailed plan pays $100 for a second-degree burn covering less than 10 percent of the body and $2,500 for one covering 35 percent or more. Third-degree burns range from $1,000 for less than 10 percent of the body up to $15,000 for 35 percent or more. A separate skin graft benefit pays 50 percent of the applicable burn benefit. Across employer plans, maximum burn benefits run from $6,000 to $10,000.
Lacerations
Cuts are paid by severity and whether stitches are needed. One plan pays $50 for a laceration repaired without stitches, $100 for a sutured cut under two inches, $200 for two to six inches, and $700 for cuts longer than six inches. Across tiers, laceration benefits run from $100 to $1,000.
Concussions, Coma, and Other Injuries
Concussion benefits vary widely, from $150 or $200 in some plans up to $4,000 in others, and plans generally do not distinguish by severity. Coma benefits run $5,000 to $10,000.
Other covered injuries and typical benefit ranges include:
- Torn knee cartilage with surgical repair: $500 to $750
- Rotator cuff repair: $500 to $1,400
- Puncture wound: up to $50
- Broken tooth: up to $300, with separate benefits for a crown ($150), extraction ($75), or filling ($50)
- Eye surgery: $150, with $75 for removal of a foreign object
Dismemberment and Loss of Function
The largest injury-related payouts cover the loss of limbs, sight, hearing, and speech. One high plan pays $20,000 for the loss of both hands, both feet, or one of each; $15,000 for a single arm, leg, hand, or foot; and $5,000 for individual fingers or toes. Catastrophic sensory losses pay more: $50,000 to $100,000 for loss of sight in both eyes or hearing in both ears, up to $200,000 for loss of both speech and hearing, and $25,000 to $50,000 for loss of sight in one eye or hearing in one ear.
Paralysis
Paralysis benefits scale with the number of limbs affected. In a high-plan example, paralysis of all four limbs pays $20,000 to $40,000, three limbs $30,000, two limbs $20,000, and one limb $1,000 to $5,000.
Emergency, Hospital, and Follow-Up Care
Beyond injury-specific amounts, the policy pays for medical services that follow an accident.
Emergency room visits typically pay $150 to $200, and urgent care visits around $100. One plan pays $350 for an ER visit with an X-ray and $150 without. A non-emergency initial care benefit for seeing a doctor more than 96 hours but less than 90 days after the accident pays about $50 to $75.
Hospital admission pays $1,000 to $1,500 per admission, usually capped at one per accident and three per calendar year, with an added benefit for ICU admission. Daily hospital confinement pays $200 to $300 for a standard room and $400 to $600 for ICU, for up to 365 days per accident.
Ground ambulance benefits run from $200 up to $5,000 depending on the plan. One plan pays $2,500 for air ambulance under its enhanced tier. X-rays typically pay $100, and advanced imaging like MRI or CT pays $150 to $300. Therapy visits pay about $25 each, and pain management about $100. Other service benefits include prosthetic devices ($250 to $1,000), medical appliances such as crutches or braces ($50 to $250), and inpatient surgery ($100 to $1,000).
Follow-up treatment pays about $75 per visit, with care required to begin within 90 days of the accident and be delivered within 180 days. Some plans also pay for transportation and lodging to receive treatment, with amounts that vary by plan.
Accidental Death and Travel Benefits
Most Prudential group accident plans include an accidental death benefit. One employer plan pays $50,000 under its high tier and $25,000 under its low tier. If the death occurs while the insured is a passenger on a common carrier such as a commercial airplane, the benefit can triple, reaching $150,000 in one high-plan example. Some plans add $10,000 for a seat belt benefit and $10,000 for an air bag benefit when those apply.
Wellness Benefit
Plans typically pay a wellness or health screening benefit once per calendar year for a covered preventive screening, commonly $50 to $100 per covered person. Eligible screenings can include routine physicals, mammograms, colonoscopies, cholesterol panels, Pap smears, prostate-specific antigen tests, immunizations, and dental and eye exams.
Child Organized Sports Benefit
Many plans add 25 percent to the standard benefit when a covered child is injured during an organized sports activity. The bonus applies to accidental injury, medical treatment, and hospital benefits, and is usually capped at two payouts per child per year.
What the Policy Will Not Cover
Prudential accident insurance will not pay benefits for losses caused by:
- Self-inflicted injury or suicide
- Illness or disease, including bacterial infections not resulting from an accidental wound
- Intoxication at or above the legal limit in the state where the accident occurred
- Illegal drug use or intentional misuse of prescription or over-the-counter medications
- Commission of a crime
- Armed conflict involving any government, whether war is declared or not
- Full-time active military duty exceeding 30 days (Reserve or National Guard training is not excluded)
- Certain aviation activities, including acting as a pilot or crew member or traveling in an aircraft not licensed for passenger transport
- Hazardous sports, which in some plans specifically include skydiving, bungee jumping, base jumping, hang gliding, paragliding, scuba diving, and ballooning
Some group contracts also include a pre-existing condition limitation. Where it applies, the policy will not pay for an accident-related condition if you received treatment for that condition, or had symptoms warranting treatment, during the 12 months before coverage began and symptoms recur within the first 12 months of coverage. Not every plan includes this restriction.
Enrolling and Filing a Claim
The coverage is almost always employee-paid and voluntary: the employer offers it and you pay the full premium through payroll deduction. Tiers typically include employee-only, employee and spouse or domestic partner, employee and children, and family. Enrollment usually happens during open enrollment or when you first become eligible. Children are typically eligible up to age 26, and spouses or domestic partners up to age 100 in some plans.
Claims are filed through Prudential’s MyBenefits online portal, where you can submit documentation and track status. Prudential’s claims line is 1-877-507-4778, Monday through Friday, 8:00 a.m. to 8:00 p.m. Eastern time. The policy instructs that claims be made without delay, and the exact filing deadline depends on the terms of your group contract. A separate wellness benefit claim form is used to submit proof of an eligible preventive screening.