Sight:  Total and permanent loss of sight OR loss of sight that has lasted at least 120 days

• For each eye

$50,000

Hearing:  Total and permanent loss of hearing

Speech:  Total and permanent loss of speech

$50,000

Quadriplegia:  complete paralysis of all four limbs

$100,000

Hemiplegia:  complete paralysis of the upper and lower limbs on one side of the body

$100,000

Paraplegia:  complete paralysis of both lower limbs

$100,000

Uniplegia:  complete paralysis of one limb*

* Note:  Payment for uniplegia of arm cannot be combined with loss 9, 10 or 14 for the same arm. Payment for uniplegia of leg cannot be combined with loss 11, 12, 13 or 15 for the same leg.

$50,000

Burns:  2nd degree or worse burns to at least 20% of the body including the face OR, at least 20% of the face

$100,000

Amputation of hand:  Amputation at or above the wrist

• For each hand*

* Note: Payment for loss 9 cannot be combined with payment for loss 10 for the same hand.

$50,000

Amputation of 4 fingers on 1 hand OR thumb alone:  Amputation at or above the metacarpophalangeal joint

• For each hand

$50,000

Amputation of foot:  Amputation at or above the ankle

• For each foot*

* Note: Payment for loss 11 cannot be combined with payments for losses 12 or 13 for the same foot.

$50,000

Amputation of all toes including the big toe on 1 foot:  Amputation at or above the metatarsophalangeal joint

• For each foot

* Note: Payment for loss 12 cannot be combined with payments for loss 13 for the same foot.

$50,000

Amputation of big toe only, OR other 4 toes on 1 foot:  Amputation at or above the metatarsophalangeal joint

• For each foot

$25,000

Limb salvage of arm:  Salvage of arm in place of amputation

• For each arm*

* Note: Payment for loss 14 cannot be combined with payments for losses 9 or 10 for the same arm.

$50,000

Limb salvage of leg:  Salvage of leg in place of amputation

• For each leg*

* Note: Payment for loss 15 cannot be combined with payments for losses 11, 12 or 13 for the same leg.

$50,000

Facial Reconstruction:  reconstructive surgery to correct traumatic avulsions of the face or jaw that cause discontinuity defects.

• Jaw – surgery to correct discontinuity loss of the upper or lower jaw

$75,000

• Nose – surgery to correct discontinuity loss of 50% or more of the cartilaginous nose

$50,000

• Lips – surgery to correct discontinuity loss of 50% or more of the upper or lower lip

• Eyes – surgery to correct discontinuity loss of 30% or more of the periorbita
  • For each eye

$25,000

• Facial Tissue – surgery to correct discontinuity loss of the tissue in 50% or more of any of the following facial subunits: forehead, temple, zygomatic, mandibular, infraorbital or chin.
  • For each facial subunit

$25,000

Note 1: Injuries listed under facial reconstruction may be combined with each other, but the maximum benefit for facial reconstruction may not exceed $75,000.

Note 2: Any injury or combination of injuries under facial reconstruction may also be combined with other injuries listed in Part I and treated as one loss, provided that all injuries are the result of a single traumatic event. However, the total payment amount may not exceed $100,000.

Coma from traumatic injury AND/OR Traumatic Brain Injury resulting in inability to perform at least 2 Activities of Daily Living (ADL)

Hospitalization due to traumatic brain injury

• at 15th consecutive day of hospitalization

Note 1: Payment for hospitalization replaces the first payment period in loss 17.

Note 2: Duration of hospitalization includes dates on which member is transported from the injury site to a facility described in § 9.20(e)(6)(xiii), admitted to the facility, transferred between facilities, and discharged from the facility.

$25,000

Genitourinary Losses

Anatomical loss of the penis

Anatomical loss of the penis is defined as amputation of the glans penis or any portion of the shaft of the penis above the glans penis (i.e. closer to the body) or damage to the glans penis or shaft of the penis that requires reconstructive surgery.

$50,000

Permanent loss of use of the penis

Permanent loss of use of the penis is defined as damage to the glans penis or shaft of the penis that results in complete loss of the ability to perform sexual intercourse that is reasonably certain to continue throughout the lifetime of the member.

$50,000

Anatomical loss of one testicle

Anatomical loss of the testicle(s) is defined as the amputation of, or damage to, one or both testicles that requires testicular salvage, reconstructive surgery, or both.

$25,000

Anatomical loss of both testicles

See above – Same definition as anatomical loss of one testicle.

$50,000

Permanent loss of use of both testicles

Permanent loss of use of both testicles is defined as damage to both testicles resulting in the need for hormonal replacement therapy that is medically required and reasonably certain to continue throughout the lifetime of the member.

$50,000

Anatomical loss of the vulva, uterus, or vaginal canal

Anatomical loss of the vulva, uterus, or vaginal canal is defined as the complete or partial amputation of the vulva, uterus, or vaginal canal or damage to the vulva, uterus, or vaginal canal that requires reconstructive surgery.

$50,000

Permanent loss of use of the vulva or vaginal canal

Permanent loss of use of the vulva or vaginal canal is defined as damage to the vulva or vaginal canal that results in complete loss of the ability to perform sexual intercourse that is reasonably certain to continue throughout the lifetime of the member.

$50,000

Anatomical loss of one ovary

Anatomical loss of the ovary(ies) is defined as the amputation of one or both ovaries or damage to one or both ovaries that requires ovarian salvage, reconstructive surgery, or both.

$25,000

Anatomical loss of both ovaries

See above – Same definition as anatomical loss of one ovary.

$50,000

Permanent loss of use of both ovaries

Permanent loss of use of both ovaries is defined as damage to both ovaries resulting in the need for hormonal replacement therapy that is medically required and reasonably certain to continue throughout the lifetime of the member.

$50,000

Total and permanent loss of urinary system function

Total and permanent loss of urinary system function is defined as damage to the urethra, ureter(s), both kidneys, bladder, or urethral sphincter muscle(s) that requires urinary diversion and/or hemodialysis, either of which is reasonably certain to continue throughout the lifetime of the member.

$50,000

Note 1: Losses due to genitourinary injuries may be combined with each other, but the maximum benefit for genitourinary losses may not exceed $50,000.

Note 2: Any genitourinary loss may be combined with other (TSGLI) injuries listed in § 9.20(f)(1) through (18) and treated as one loss, provided that all losses are the result of a single traumatic event. However, the total payment may not exceed $100,000.

Traumatic injury resulting in inability to perform at least 2 Activities of Daily Living (ADL)

Hospitalization due to traumatic injury

• at 15th consecutive day of hospitalization

Note 1: Payment for hospitalization replaces the first payment period in loss 20.

Note 2: Duration of hospitalization includes dates on which member is transported from the injury site to a facility described in § 9.20(e)(6)(xiii), admitted to the facility, transferred between facilities, and discharged from the facility.

$25,000