AXIOM TELECOM L.L.C. POLICY NO
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1 SCHEDULE OF BENEFITS AXIOM TELECOM L.L.C. POLICY NO Subgroup Name Subgroup Plan Sub office No. No. No. AXIOM TELECOM L.L.C.-Dubai-C Plan 001 Sub office 003 AXIOM TELECOM L.L.C.-Dubai-C Overage Plan 001 Sub office 003 BODY REPATRIATION AMOUNT OF INSURANCE Each Eligible Insured Up to age 65 years: AED 50,000 Age between years: AED 25,000 CRITICAL ILLNESS Critical Illness (Option 1) Each Eligible Insured Lump sum payment of AED 18,360 upon the diagnosis of Cancer MEDICAL BENEFITS Subgroup No Overage Maximum Benefit per Insured per Policy AED 500,000 AED 250,000 year METLIFE ALICO s Medical Network Standard Geographical Scope UAE,GCC, ME, ISC & SE ASIA Emergency non-elective In-patient treatment Coverage outside the Geographical Scope Worldwide whilst Insured is on vacation/business trips for a maximum of 60 days (emergency cases) Daily Room and Board (Average Private Room) 100% inside MetLife Alico Network within UAE Up to AED 650 outside MetLife Alico Network within UAE Up to AED 650 for Government Hospitals within UAE Up to AED 650 outside UAE; in GCC, ME, ISC & SE ASIA Up to AED 1,300 outside UAE; Worldwide for emergency cases Page 1 of 7
2 Intensive Care Unit Co-Insurance In-Patient & Out-Patient Deductible Out-patient Consultation Maximum per visit limit Pre-existing conditions Chronic conditions (if not Pre-existing otherwise as per the pre-existing waiver) In-Hospital reimbursement cash benefit (Per night for free hospitalization up to 20 days) Companion Room Accommodation Physiotherapy Organ Transplant (Cost of surgery in respect of the insured person as recipient and the organ donor at the time of transplant surgery) 100% inside MetLife Alico Network within UAE Outside MetLife Alico Network & within geographical scope double the daily room and board limit per disability for 21 days, standard room and board limits to apply thereafter. 100% on direct billing basis inside MetLife Alico Network within UAE 100% on reimbursement basis inside UAE; outside MetLife Alico s Network & in Government Hospitals 100% R&C on reimbursement basis outside UAE in GCC, ME,ISC & SE ASIA 100% R&C on reimbursement outside UAE, Worldwide for emergency cases. In-Patient Nil Out-Patient AED 75 per doctor s visit Nil deductible for follow-up visits within 7 days 100% inside UAE within MetLife Alico Network Up to AED 300 & AED 400 inside UAE outside MetLife Alico s Network & in Government Hospitals for GP & Specialist respectively Up to AED 300 & AED 400 outside UAE, in GCC, ME,ISC & SE ASIA for GP & Specialist respectively Up to Policy Limit per Insured at policy inception Up to Policy Limit for new entrants after policy inception in full Maximum of AED 650 (For a Child under the age of 18 years) (Prior approval required) Page 2 of 7
3 Renal Dialysis Nursing at home Acts of Terrorism (Passive exposure) Maternity Alternative Medicine On cash reimbursement basis (Immediately after or instead of hospitalization) Not Available Limit: AED 1,600 Recommended by Doctor for respective branch of alternative medicine Co-insurance: 90% Inclusion: Ayurvedic treatment, Homeopathy treatment, Chriropathy /reflexology treatment, Herbal treatment including herbal medicines. Emergency Dental Treatment for accidental damage to natural teeth dental services for the treatment of accidental injuries to sound natural teeth through violent external means within six months of the accident Psychiatric Treatment Co-insurance: 80% In-Patient AED 8,500 for psychiatric treatment following an accident or hospitalization up to a maximum of 20 visits per insured per year Out-Patient Up to a maximum of 15 visits and up to overall maximum of AED 1,500 per insured per year Medical Evacuation 100% (including expenses for one accompanying family member) up to a maximum of AED 140,000 per insured per policy year Assistance Program Available Benefits Predetermination Review / Second Opinion Hospitalization Program Applicable Page 3 of 7
4 ELIGIBILITY Employees / Spouses Minimum 18 years; Maximum 65 years. Coverage shall be extended up to seventy (70) years of age at half the benefits and double the premium rates, without providing evidence of insurability to the Insurance Company Children Minimum 0 days; Maximum 19 th birthday. Coverage shall be extended up to age 25 years subject to full-time student in an accredited College or University. Unmarried dependent daughters coverage shall be extended up to age 30. Page 4 of 7
5 Travel and Medical Assistance How to contact when you need help Call SOS at any time at any of SOS Alarm Centres around the world. Simply provide SOS with: Your name Your company name Your member account number (as printed on your card) The telephone number from which you re calling For 24/7 assistance, please contact SOS on the number appearing on the front of your card. You can also call any Alarm Center on the numbers listed on next page. Medical assistance i. Telephone medical advice SOS will arrange for the provision of medical advice to the Insured over the telephone. ii. iii. iv. Medical Service Provider referral SOS shall provide to the insured, upon request, the name, address, telephone number and, if available, office hours of physicians, hospitals, clinics, dentists and dental clinics (collectively Medical Service Provider(s) ). SOS shall not be responsible for providing medical diagnosis or treatment. Although SOS may make such referrals, it cannot guarantee the quality of the Medical Service provided and the final selection of a Medical Service Provider shall be the decision of the Insured. Arrangement of hospital admission If the medical condition of the Insured necessitates hospitalisation, SOS will assist such Insured in the hospital admission. Evacuation and Repatriation SOS, will arrange for the air and/or surface transportation, medical care during transportation, communications and all usual and customary ancillary charges incurred in moving and transporting an Insured to the nearest hospital where appropriate medical care is available, which may be a location other than the Insured s Home Country or Country of Assignment. Page 5 of 7
6 i. SOS will arrange for the transport of the Insured to his/her Home Country or Country of Assignment following a medical evacuation for subsequent in-patient hospitalization or rehabilitative treatment. ii. SOS reserves the right, at its sole discretion, to determine the location to which the Insured will be evacuated and the means or method by which such evacuation or repatriation will be carried out. In making such arrangements, SOS may consider all relevant circumstances including, but not limited to the Insured s medical condition, the degree of urgency, the Insured s fitness to travel, airport availability, weather conditions and travel distance in determining whether transportation will be provided by private medically equipped aircraft, helicopter, regular scheduled flight, rail or land vehicle. Transportation shall be carried out under constant medical supervision, unless otherwise approved by the Company physician. v. Arrangement of transportation of mortal remains SOS will arrange for the transportation of the Insured s mortal remains to the Home Country or Usual Country of Residence, or arrange, as requested by the Insured s family or legal representative, for local burial at the place of death. Page 6 of 7
7 Alarm Centers contact details: AZERBAIJAN Baku Tel: +994 (0) AUSTRALIA Sydney Tel: +61 (0) CAMBODIA Phnom Penh Tel: +855 (0) CHAD N Djamena Tel: CHINA Beijing Tel: +86 (0) Guangzhou Tel: +86 (0) Nanjing Tel: +86 (0) Shekou Tel: +86 (0) Tianjin Tel: +86 (0) CZECH REPUBLIC Prague Tel: FRANCE Paris Tel: +33 (0) GERMANY Stuttgart Tel: +49 (0) INDIA New Delhi Tel: +91 (0) INDONESIA Jakarta Tel: +62 (0) Jakarta (2) Tel: +62 (0) Bali Tel: +62 (0) JAPAN Tokyo Tel: +81 (0) KAZAKHSTAN Almaty Tel: +7 (0) Atyrau Tel: +7 (0) MYANMAR Yangon Tel: +95 (0) MALAYSIA Kuala Lumpur Tel: +60 (0) MYANMAR Yangon Tel: +95 (0) NEW ZEALAND Auckland Tel: +64 (0) NIGERIA Lagos Tel: +234 (0) Port Harcourt Tel: +234 (0) Warri Tel: +234 (0) PHILIPPINES Manila Tel: +63 (0) RUSSIA Moscow Tel: +7 (095) SINGAPORE Tel: SOUTH AFRICA Johannesburg Tel: +27 (0) SOUTH KOREA Seoul Tel: +82 (0) SPAIN Madrid Tel: +34 (0) SWITZERLAND Geneva Tel: +41 (0) TAIWAN (ROC) Taipei Tel: +886 (0) THAILAND Bangkok Tel: +66 (0) UNITED KINGDOM London Tel: +44 (0) USA Philadelphia Tel: +1 (0) VIETNAM Ho Chi Minh City Tel: +84 (0) Hanoi Tel: +84 (0) 4 934
AXIOM TELECOM L.L.C. POLICY NO
SCHEDULE OF BENEFITS AXIOM TELECOM L.L.C. POLICY NO. 45440 Subgroup Name Subgroup No. Plan No. Sub office No. AXIOM TELECOM L.L.C.-Dubai-B 45440-10000 Plan 002 Sub office 002 AXIOM TELECOM L.L.C.-Dubai-B
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