Benefits Table effective 1/1/2018

Transcription

1 Your Health First Southeast Asia Plans Exclusively for residents of Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand & Vietnam Benefits Table effective 1/1/2018 Administrators A Plus International Services Limited Room 4, 17th Floor, Westlands Centre, 20 Westlands Road, Quarry Bay, Hong Kong China S.A.R. Tel: Fax: cs@aplusii.com Concepts and trademarks are licensed from A Plus International Insurance Development AG CH-8032 Zurich, Switzerland

2 Benefits Table - effective 1/1/2018 Note: The General Conditions can be provided upon request or downloaded from Important notice: 1) Only expenses which are reasonable & customary can qualify for reimbursement. (for all plans and options) 2) Unless indicated otherwise, all ceilings mentioned in this table are applicable per Insured and per Insurance Year. 3) For definitions of the terms used in this table, reference is explicitly made to article 1.2. ( Definitions ) of Chapter I of the General Conditions. 4) Pre-existing conditions are covered subject to acceptance by the medical consultant at the time of enrolment. Level of cover is according to the limits of the plan chosen. Essential Essential Plus Serene Serene Plus BENEFITS a) Hospitalisation a) Hospitalisation a) Hospitalisation b) Outpatient c) Other Benefits a) Hospitalisation b) Outpatient c) Other Benefits Maximum total reimbursement per Insured and per insurance year Premiums and claims shall be payable in US$, which is the same as the policy currency. $ 500,000 $ 1,000,000 $ 1,000,000 $ 1,350,000 Essential Essential Plus Serene Serene Plus 1. Inpatient Care (with overnight stay in hospital) Important : Precertification is always required except in case of emergency (see article precertification in General Conditions). Failure to comply with the precertification requirement could lead to a reduction of the reimbursement. Hospital accommodation - Room & board (standard private room) - Intensive Care Unit (ICU) - One accompanying parent for child under age 16 having to stay overnight in hospital up to 14 days up to 14 days Doctors' fees (including surgeon's & anaesthetist's fees) Other medical expenses, including: - use of operating room and recovery room - lab exams / - medical imaging (X-ray, CT, MRI, etc.) - prescription drugs and dressings - physiotherapy - logopaedic treatment, speech therapy, occupational therapy and ergo therapy Cancer treatment (e.g. radiotherapy, chemotherapy) and diabetes, kidney dialysis, excluding all experimental treatments Psychiatric inpatient hospital care up to $ 13,500 up to $ 13,500 Accidental Damage to teeth (treatment received in an emergency ward of a hospital within 5 days of incurring an accidental damage to sound and natural teeth) Reconstructive Surgery following an accident

3 Hospital Cash Benefit: daily allowance, only when room, board & treatment costs are not claimed to the policy $ per night up to 60 nights $ 135 per night up to 60 nights Organ transplant We cover doctors fees, hospital accommodation (standard private room) and other related medical expenses during hospital stay. Excluded from cover: costs related to the search for a donor, costs for acquisition of the organ, costs incurred for removal of organ from the donor Rehabilitation and convalescence rest / care (when the admission immediately follows hospitalisation) (Prior approval from the Insurer s Medical Consultant) up to 30 days (Prior approval from the Insurer s Medical Consultant) up to 30 days (Prior approval from the Insurer s Medical Consultant) up to 30 days (Prior approval from the Insurer s Medical Consultant) up to 60 days 2. Outpatient Care Essential Essential Plus Serene Serene Plus GP Fees of a GP (General Practitioner, Family Doctor) Specialist Fees of a Specialist Doctor Consultations, diagnostic tests,lab tests, medical imaging (cf. X-Ray, CT, MRI, etc.) by GP and Specialist, Prescribed Drugs, Treatments by Physiotherapists related to inpatient treatments within 15 days prior to admission and up to 30 days following hospital release. Outpatient psychiatric care, ergotherapy, logopaedics and / or speech therapy, occupational therapy Only care prescribed by or performed by a Doctor can qualify for reimbursement. The covered amount includes fees of Doctor and / or (treatment fees of) Medical Practitioner, but does not include prescription drugs which are covered according to the provisions of paragraph below. Prescription drugs Only drugs that are prescribed by a Doctor and that are not available without prescription can be reimbursed. Diagnostic tests, lab tests, medical imaging (cf. X-ray, CT, MRI, etc.) Cancer treatment (e.g. radiotherapy, chemotherapy) and diabetes, kidney dialysis, excluding all experimental treatments up to $ 2,000 if related to Inpatient treatment 50% up to $1,350 Physiotherapy prescribed by a Doctor Medical aids (including hearing aids, orthopaedic appliances & stockings, artificial limbs, wheelchair) up to $ 1,500 up to up to up to

4 Treatments performed by Complementary Medical Practitioners: Chiropractor / Osteopath / Acupuncturist / Homeopath These treatments must be prescribed by a registered medical Doctor. up to $ 1,500 up to Day surgery (outpatient surgery) (precertification required) (precertification required) (precertification required) (precertification required) Essential Essential Plus Serene Serene Plus 3. Other Benefits Local ambulance to nearest hospital up to $ 2,025 up to $ 2,025 up to $ 2,025 up to $ 2,025 Dental treatment following an accident (surgical reconstruction covered under hospitalisation benefits) Covered under Accidental Damage to teeth Covered under Accidental Damage to teeth Covered under Accidental Damage to teeth Covered under Accidental Damage to teeth Nursing at home 80%. Annual max. reimbursement of up to 60 days 80%. Annual max. reimbursement of up to 60 days Chronic Conditions (not pre-existing): Covered Covered Covered Covered Complication of Pregnancy Covered Covered Covered Covered Congenital Conditions Covered Covered Covered Covered AIDS / HIV Treatment $60,000 Lifetime, 2 years waiting period Covered $60,000 Lifetime, 2 years waiting period Covered Hormone Replacement therapy Covered Covered Covered Covered Hospice and palliative care in case of Terminal Illness $ 50,000 per insured and per lifetime $ 50,000 per insured and per lifetime $ 50,000 per insured and per lifetime $ 50,000 per insured and per lifetime 4. Medical Evacuation and Repatriation Services ^ (Included for Individuals, Optional for Companies*). Prior Approval from Insurer compulsory Evacuation / Repatriation Emergency medical evacuation to the nearest hospital or emergency medical repatriation Transportation of mortal remains or burial at the place of death Compassionate Visit by a relative of the Insured (Applicable when hospitalisation in excess of 5 consecutive days) One economy class return airfare Accommodation for compassionate visit by a relative accompanying the insured Return of minor children (<19, unmarried and at school) if left alone when Insured is hospitalised. One-way economy class airfare per eligible child Early Return One economy class return airfare Temporary replacement colleague (transport costs) $ 125 per day (Max 7 days) For complete terms and conditions and explanation of benefits, refer to Chapter III of the General Conditions ^ Covered by AXA Assistance * Conditions apply Note: Covered means treatment is reimbursed according to the limits of the plan chosen.

5 Additional Options 5. Dental Eligibility The optional dental cover is only open to persons a) who are accepted into the medical insurance plan and b) who are contracting into the Serene or Serene Plus medical plans. The choice for taking out the dental cover has to be made on per family level in the sense that all members of the same family, i.e. the Insured and his / her dependants who are accepted into the medical insurance, have to a) take out the dental insurance or not (i.e. all family members or none); b) opt for the same Dental plan (Dental Standard or Dental Plus). Benefits Deductibles do not apply to Dental benefits. Only expenses that are reasonable and customary can qualify for reimbursement, subject to the limits and ceilings as mentioned in following benefit table. Dental Standard Dental Plus Max. reimbursement per insured per year $1,500 $3,000 Basic dental care Includes up to 2 periodic check-ups per year, prophylactic treatments, fillings, root canal treatment, extraction, paradental treatment, treatment of paradontosis, treatment of gums, etc. A waiting period of 6 months applies. Major dentistry Bridges, implants, orthodontic treatment and dental prostheses (dentures, crowns, inlays). The amount covered includes the fees of the Dentist (or Dental Surgeon). Orthodontic treatment is only covered if started before age 17 (seventeen). A waiting period of 12 months applies. 80% up to $900 80% up to $600 up to $2,000 80% up to $1, Wellness (Only for Companies of 5 or more employees) Eligibility The optional wellness cover is only open to employees and dependants a) who are accepted into the medical insurance plan; b) who are contracting into the Serene or Serene Plus medical plans and c) with plans without deductible. The choice for taking out the wellness cover has to be made on per company level in the sense that all members of the same company, i.e. the Insured and his / her dependants who are accepted into the medical insurance, have to a) take out the wellness insurance or not (i.e. all members or none); b) opt for the same Wellness plan (Wellness Standard or Wellness Plus). Benefits Only expenses that are reasonable and customary can qualify for reimbursement, subject to the limits and ceilings as mentioned in following benefit table. Wellness Standard Wellness Plus Max. reimbursement per insured per year Preventive care & wellness benefits A waiting period of 12 months applies - well baby care - medically required vaccinations (adults & children) - one routine eye test per insurance year - one adult physical examination every 2 years including: - one (bilateral) mammogram and one pap-smear test every 2 years (females as of age 35) - one PSA-test every 2 years (males as of age 50) $300 $600

6 7. Routine Maternity (Only for Companies of 5 or more employees) Eligibility The optional routine maternity cover is only open to employees and dependants a) who are accepted into the medical insurance plan; b) who are contracting into the Serene or Serene Plus medical plans and c) with plans without deductible. The choice for taking out the routine maternity cover has to be made on per company level in the sense that all members of the same company, i.e. the Insured and his / her dependants who are accepted into the medical insurance, have to a) take out the routine maternity insurance or not (i.e. all members or none); b) opt for the same Routine Maternity plan (Routine Maternity Standard or Routine Maternity Plus). A waiting period of 12 months applies. Benefit limits on a per pregnancy basis. Benefits Only expenses that are reasonable and customary can qualify for reimbursement, subject to the limits and ceilings as mentioned in following benefit table. Elective caesarean surgery is excluded from cover. Routine Maternity Standard Routine Maternity Plus Pregnancy (pre & post natal fees) Childbirth The covered amount includes doctors fees, hospital accommodation and other related medical expenses during hospital stay. up to $3,000 up to $5,000 Prescribed caesarean (in addition to the above benefits) up to $1,000 up to $2, Currency Plans are to be subscribed in US dollars. Zone A: Worldwide 9. Zone of treatment Zone B: Worldwide excluding USA / Canada Zone C: Restricted in Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand & Vietnam 10. Deductible US$ Essential Plans Serene Plans ,350 1,350 per insured and per insurance year 11. Accidental death and dismemberment (AD&D) This cover will guarantee the payment of a lump sum in case you die in an accident or you incur a permanent disability of at least 20% caused by an accident. Lump Sum after accidental death - up to a maximum of $ 675,000 with a minimum of $ 67,500 - cover is available for you and your adult dependants Lump Sum after permanent disability - from at least a permanent disability degree of 20% - cash benefit = sum insured x degree of disability

7 12. Loss of income (TI / PD) Temporary incapacity (TI) With the temporary incapacity plan option, you will feel more secure knowing your family will be protected financially if you are totally unable to perform your professional occupation due to illness or accident. You can choose the level of income benefit that is appropriate to you and your family: - up to 80% of pre-disability gross monthly salary; - subject to a maximum of $ 13,500 per month and a minimum of $ 1,350. Income protection during 24 months We will pay you a regular income for as long as you are unable to return to work. After a waiting period of 90 days, the income will start up to a maximum of 24 months. If you are still unable to resume work after 24 months then you will receive a lump sum through the Permanent Disability plan if the PD option below has been contracted. Permanent disability (PD) (can be taken out only as supplement option to Temporary Incapacity) With this option, you receive a lump sum in case you are affected by a permanent disability of at least 33.33% caused by illness or accident. You can choose the level of sum insured that is appropriate to you: - up to 80% of pre-disability gross monthly salary multiplied by 48 months; - subject to a maximum of $ 648,000 and a minimum of $ 64,800; - when disability is between 33.33% and 66.67%, then cash benefit = sum insured x ((3 x n) - 1), n = degree of disability (%); - when disability is above 66.67%, then cash benefit = sum insured. Additional payment of $ 33,750 If from the start of the disability you need the assistance of a third person to perform the basic activities of daily living (such as feeding, washing yourself) and your degree of disability exceed 66.67%, then an additional sum of $ 33,750 will be paid.

8 Premiums (US$) Evacuation and repatriation included Essential Zone of Treatment A Worldwide Zone of Treatment B Worldwide excluding USA and Canada Zone of Treatment C Restricted in Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand & Vietnam Deductible ,350 Deductible ,350 Deductible ,350 <18 2,148 1,711 1,674 1,625 < < ,258 2,691 2,611 2, ,508 1,263 1, , ,800 3,177 3,109 2, ,760 1,495 1,451 1, , ,698 3,985 3,923 3, ,175 1,883 1,826 1, ,704 1,445 1,340 1, ,307 4,525 4,482 4, ,457 2,158 2,115 1, ,924 1,649 1,542 1, ,605 4,808 4,756 4, ,595 2,291 2,251 1, ,029 1,749 1,637 1, ,935 5,121 5,059 4, ,748 2,438 2,402 1, ,146 1,859 1,744 1, ,298 5,463 5,388 5, ,916 2,601 2,569 2, ,274 1,981 1,863 1, ,696 5,836 5,744 5, ,100 2,778 2,749 2, ,414 2,115 1,994 1, ,129 6,239 6,128 5, ,301 2,970 2,945 2, ,567 2,261 2,137 1, ,598 6,672 6,539 6, ,518 3,181 3,157 2, ,733 2,419 2,293 1, ,105 7,137 6,979 6, ,752 3,406 3,384 2, ,911 2,590 2,462 2, ,648 7,634 7,445 7, ,004 3,649 3,626 3, ,102 2,775 2,645 2, ,230 8,161 7,940 7, ,272 3,909 3,884 3, ,306 2,973 2,841 2, (*) 9,849 8,719 8,463 8, (*) 4,560 4,186 4,158 3, (*) 3,524 3,183 3,050 2, (*) 10,506 9,309 9,013 8, (*) 4,863 4,480 4,447 3, (*) 3,754 3,406 3,272 2, (*) 11,199 9,930 9,592 9, (*) 5,185 4,793 4,751 4, (*) 3,997 3,643 3,507 2, (*) 11,929 10,584 10,200 9, (*) 5,522 5,122 5,071 4, (*) 4,252 3,891 3,756 3, (*) 12,694 11,268 10,837 10, (*) 5,876 5,468 5,403 4, (*) 4,520 4,152 4,016 3, (*) 13,492 11,984 11,503 11, (*) 6,246 5,830 5,750 5, (*) 4,799 4,424 4,288 3, (*) 14,323 12,734 12,202 11, (*) 6,631 6,209 6,110 5, (*) 5,089 4,708 4,572 3, (*) 15,183 13,518 12,932 12, (*) 7,029 6,603 6,483 6, (*) 5,388 5,002 4,865 4, (*) 16,070 14,338 13,698 13, (*) 7,440 7,012 6,868 6, (*) 5,698 5,306 5,168 4, (*) 16,984 15,195 14,500 14, (*) 7,863 7,436 7,264 6, (*) 6,015 5,617 5,478 4, (*) 17,919 16,089 15,342 14, (*) 8,295 7,872 7,672 7, (*) 6,341 5,937 5,796 5, (*) 18,872 17,027 16,227 15, (*) 8,737 8,320 8,087 7, (*) 6,672 6,264 6,118 5, (*) 19,839 18,008 17,160 16, (*) 9,185 8,779 8,514 8, (*) 7,009 6,594 6,443 5, (*) 20,818 19,039 18,143 17, (*) 9,638 9,246 8,948 8, (*) 7,348 6,929 6,770 6, (*) 21,800 20,122 19,185 18, (*) 10,094 9,721 9,388 9, (*) 7,691 7,265 7,097 6, (*) 22,785 21,263 20,292 19, (*) 10,549 10,202 9,836 9, (*) 8,033 7,601 7,418 6, (*) 23,763 22,469 21,469 21, (*) 11,003 10,686 10,290 9, (*) 8,374 7,937 7,736 7, (*) 24,730 23,747 22,726 22, (*) 11,451 11,172 10,749 10, (*) 8,711 8,267 8,045 7, (*) 25,681 25,102 24,072 23, (*) 11,889 11,656 11,211 10, (*) 9,043 8,591 8,340 7, (*) 26,605 26,547 25,518 25, (*) 12,317 12,138 11,677 11, (*) 9,366 8,907 8,622 8,215 Essential Plus <18 2,251 1,799 1,752 1,708 < < ,432 2,848 2,750 2, ,588 1,338 1, , ,013 3,367 3,282 3, ,858 1,586 1,530 1, ,466 1, ,967 4,230 4,146 3, ,299 2,003 1,931 1, ,799 1,533 1,413 1, ,615 4,629 4,571 4, ,600 2,289 2,231 1, ,032 1,750 1,627 1, ,931 4,934 4,869 4, ,747 2,431 2,377 1, ,143 1,856 1,729 1, ,281 5,286 5,209 4, ,908 2,589 2,538 2, ,267 1,973 1,842 1, ,666 5,684 5,591 5, ,088 2,762 2,715 2, ,404 2,104 1,967 1, ,089 6,129 6,018 5, ,283 2,952 2,908 2, ,552 2,247 2,107 1, ,550 6,621 6,487 6, ,497 3,160 3,119 2, ,715 2,402 2,259 1, ,049 7,159 6,999 6, ,727 3,385 3,345 2, ,891 2,571 2,424 2, ,588 7,744 7,552 7, ,977 3,627 3,588 3, ,080 2,754 2,603 2, ,166 8,373 8,144 7, ,244 3,887 3,847 3, ,283 2,950 2,798 2, ,785 9,043 8,774 8, ,531 4,165 4,124 3, ,500 3,160 3,006 2, (*) 10,445 9,752 9,441 9, (*) 4,836 4,463 4,416 3, (*) 3,732 3,385 3,228 2, (*) 11,144 10,499 10,140 9, (*) 5,160 4,776 4,724 4, (*) 3,977 3,623 3,464 2, (*) 11,883 11,280 10,871 10, (*) 5,501 5,109 5,048 4, (*) 4,236 3,874 3,715 3, (*) 12,660 12,092 11,630 11, (*) 5,861 5,459 5,388 4, (*) 4,508 4,139 3,980 3, (*) 13,475 12,932 12,414 12, (*) 6,239 5,828 5,742 5, (*) 4,792 4,417 4,258 3, (*) 14,326 13,799 13,222 12, (*) 6,632 6,214 6,110 5, (*) 5,089 4,708 4,548 3, (*) 15,211 14,687 14,050 13, (*) 7,042 6,615 6,492 6, (*) 5,398 5,011 4,850 4, (*) 16,128 15,595 14,899 14, (*) 7,467 7,034 6,887 6, (*) 5,717 5,324 5,162 4, (*) 17,075 16,521 15,763 15, (*) 7,906 7,467 7,295 6, (*) 6,047 5,648 5,485 4, (*) 18,048 17,462 16,644 16, (*) 8,356 7,915 7,714 7, (*) 6,386 5,981 5,816 5, (*) 19,045 18,417 17,541 17, (*) 8,817 8,377 8,144 7, (*) 6,733 6,322 6,154 5, (*) 20,062 19,386 18,455 18, (*) 9,289 8,854 8,586 8, (*) 7,087 6,670 6,498 5, (*) 21,095 20,369 19,387 18, (*) 9,766 9,341 9,039 8, (*) 7,446 7,023 6,845 6, (*) 22,138 21,368 20,341 19, (*) 10,250 9,839 9,501 9, (*) 7,808 7,380 7,193 6, (*) 23,186 22,386 21,319 20, (*) 10,734 10,347 9,973 9, (*) 8,173 7,739 7,540 6, (*) 24,235 23,426 22,329 21, (*) 11,220 10,864 10,454 10, (*) 8,538 8,098 7,884 7, (*) 25,279 24,495 23,377 22, (*) 11,704 11,389 10,945 10, (*) 8,901 8,456 8,222 7, (*) 26,309 25,599 24,472 24, (*) 12,182 11,919 11,445 11, (*) 9,261 8,807 8,551 8, (*) 27,322 26,749 25,626 25, (*) 12,650 12,454 11,955 11, (*) 9,614 9,154 8,867 8, (*) 28,305 27,956 26,853 26, (*) 13,106 12,992 12,475 12, (*) 9,960 9,491 9,167 8,752

9 Serene Serene Plus Zone of Treatment A Worldwide Zone of Treatment B Worldwide excluding USA and Canada Zone of Treatment C Restricted in Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand & Vietnam Deductible ,350 Deductible ,350 Deductible ,350 <18 3,879 3,472 2,655 1,836 <18 1,795 1, <18 1,432 1, ,161 5,723 4,847 3, ,853 2,548 1, ,226 1,943 1, ,268 6,827 5,944 4, ,365 3,055 2,433 1, ,611 2,313 1, ,883 9,449 8,580 6, ,575 4,270 3,659 2, ,533 3,222 2,600 1, ,409 10,984 10,133 8, ,282 4,973 4,356 3, ,093 3,769 3,121 2, ,014 11,592 10,750 9, ,563 5,260 4,655 3, ,310 3,986 3,339 2, ,658 12,241 11,407 9, ,861 5,566 4,978 3, ,539 4,218 3,574 2, ,344 12,931 12,107 10, ,178 5,894 5,325 3, ,780 4,461 3,826 2, ,071 13,664 12,850 11, ,514 6,242 5,696 4, ,033 4,720 4,095 2, ,843 14,443 13,641 11, ,872 6,613 6,093 4, ,299 4,994 4,384 3, ,663 15,268 14,479 12, ,252 7,006 6,514 5, ,579 5,283 4,691 3, ,530 16,144 15,369 13, ,654 7,423 6,962 5, ,875 5,589 5,017 3, ,450 17,071 16,314 14, ,079 7,865 7,435 5, ,186 5,912 5,364 3, ,424 18,053 17,314 15, ,529 8,332 7,937 6, ,514 6,254 5,733 4, (*) 19,453 19,093 18,374 16, (*) 9,007 8,825 8,463 6, (*) 6,862 6,615 6,122 4, (*) 20,542 20,193 19,496 17, (*) 9,511 9,346 9,016 7, (*) 7,230 6,998 6,535 5, (*) 21,692 21,356 20,684 18, (*) 10,043 9,894 9,597 7, (*) 7,619 7,403 6,969 5, (*) 22,908 22,585 21,938 19, (*) 10,606 10,472 10,205 8, (*) 8,034 7,832 7,429 5, (*) 24,190 23,881 23,264 21, (*) 11,199 11,079 10,839 9, (*) 8,474 8,287 7,914 6, (*) 25,542 25,248 24,664 22, (*) 11,825 11,717 11,501 9, (*) 8,943 8,769 8,424 6, (*) 26,965 26,689 26,138 24, (*) 12,483 12,386 12,189 10, (*) 9,443 9,281 8,959 7, (*) 28,463 28,205 27,690 25, (*) 13,177 13,086 12,904 11, (*) 9,975 9,826 9,524 7, (*) 30,038 29,799 29,322 27, (*) 13,907 13,819 13,645 12, (*) 10,544 10,402 10,117 8, (*) 31,690 31,472 31,034 28, (*) 14,671 14,585 14,412 12, (*) 11,152 11,015 10,739 9, (*) 33,421 33,224 32,828 30, (*) 15,473 15,384 15,204 13, (*) 11,801 11,665 11,392 9, (*) 35,233 35,056 34,703 32, (*) 16,311 16,215 16,023 14, (*) 12,494 12,355 12,076 10, (*) 37,125 36,970 36,661 34, (*) 17,187 17,080 16,865 15, (*) 13,235 13,088 12,793 11, (*) 39,097 38,964 38,698 36, (*) 18,101 17,977 17,731 16, (*) 14,026 13,865 13,546 11, (*) 41,149 41,037 40,812 38, (*) 19,050 18,907 18,621 17, (*) 14,869 14,690 14,332 12, (*) 43,278 43,186 43,003 40, (*) 20,036 19,869 19,532 18, (*) 15,770 15,564 15,154 13, (*) 45,483 45,409 45,264 43, (*) 21,057 20,859 20,467 19, (*) 16,728 16,491 16,014 14, (*) 47,758 47,702 47,591 45, (*) 22,111 21,881 21,421 20, (*) 17,749 17,470 16,914 15, (*) 50,101 50,059 49,976 47, (*) 23,195 22,929 22,397 22, (*) 18,834 18,507 17,854 15, (*) 52,506 52,475 52,413 50, (*) 24,307 24,002 23,390 23, (*) 19,985 19,601 18,835 16,875 <18 4,278 3,863 3,030 1,964 <18 1,982 1, <18 1,571 1, ,851 6,411 5,531 4, ,171 2,862 2,244 1, ,466 2,172 1, ,097 7,656 6,773 5, ,748 3,437 2,813 1, ,901 2,596 1, ,033 10,604 9,747 8, ,108 4,811 4,217 2, ,934 3,624 3,002 1, ,906 12,487 11,646 9, ,975 5,679 5,090 3, ,644 4,321 3,675 2, ,578 13,162 12,330 10, ,285 6,002 5,436 4, ,876 4,558 3,920 2, ,282 13,871 13,050 11, ,612 6,341 5,800 4, ,116 4,803 4,177 2, ,022 14,618 13,810 12, ,954 6,699 6,186 4, ,367 5,061 4,449 3, ,804 15,407 14,614 12, ,316 7,075 6,594 5, ,628 5,331 4,738 3, ,631 16,243 15,465 13, ,699 7,474 7,024 5, ,902 5,617 5,046 3, ,508 17,129 16,371 14, ,105 7,896 7,478 5, ,195 5,920 5,373 3, ,439 18,071 17,334 15, ,536 8,343 7,957 6, ,505 6,243 5,722 4, ,433 19,075 18,362 16, ,996 8,818 8,462 6, ,838 6,590 6,095 4, ,491 20,148 19,459 17, ,487 9,323 8,994 7, ,195 6,962 6,495 5, (*) 21,623 21,293 20,633 18, (*) 10,011 9,860 9,557 7, (*) 7,581 7,361 6,924 5, (*) 22,834 22,518 21,887 19, (*) 10,572 10,432 10,150 8, (*) 7,998 7,794 7,384 5, (*) 24,127 23,827 23,227 21, (*) 11,171 11,039 10,775 9, (*) 8,451 8,260 7,876 6, (*) 25,509 25,225 24,658 22, (*) 11,810 11,685 11,434 9, (*) 8,940 8,761 8,403 6, (*) 26,981 26,714 26,182 24, (*) 12,492 12,370 12,127 10, (*) 9,470 9,303 8,967 7, (*) 28,548 28,299 27,803 25, (*) 13,218 13,096 12,855 11, (*) 10,043 9,884 9,567 7, (*) 30,210 29,979 29,520 27, (*) 13,986 13,864 13,619 12, (*) 10,658 10,506 10,203 8, (*) 31,968 31,756 31,331 29, (*) 14,800 14,674 14,420 12, (*) 11,318 11,172 10,878 9, (*) 33,818 33,624 33,237 31, (*) 15,657 15,524 15,255 13, (*) 12,022 11,877 11,589 9, (*) 35,757 35,581 35,228 33, (*) 16,555 16,412 16,126 14, (*) 12,770 12,625 12,334 10, (*) 37,778 37,619 37,299 35, (*) 17,490 17,337 17,029 15, (*) 13,557 13,409 13,112 11, (*) 39,870 39,726 39,438 37, (*) 18,460 18,293 17,963 16, (*) 14,382 14,226 13,916 12, (*) 42,021 41,890 41,629 39, (*) 19,454 19,278 18,925 18, (*) 15,237 15,073 14,744 12, (*) 44,212 44,093 43,853 41, (*) 20,469 20,282 19,910 19, (*) 16,118 15,942 15,588 13, (*) 46,423 46,311 46,089 44, (*) 21,492 21,299 20,915 20, (*) 17,014 16,822 16,441 14, (*) 48,628 48,521 48,307 46, (*) 22,512 22,318 21,931 21, (*) 17,912 17,705 17,290 15, (*) 50,795 50,688 50,475 48, (*) 23,516 23,328 22,953 22, (*) 18,800 18,576 18,128 16, (*) 52,889 52,778 52,554 50, (*) 24,486 24,313 23,971 23, (*) 19,662 19,421 18,937 16, (*) 54,868 54,745 54,499 52, (*) 25,402 25,259 24,975 24, (*) 20,477 20,219 19,703 17, (*) 56,682 56,540 56,258 54, (*) 26,240 26,144 25,952 25, (*) 21,223 20,951 20,408 18,438 (*) Renewals only. Age loading applies for new enrolments. Note : Dental Options not available with Essential or Essential Plus.

10 Zone of Treatment A Worldwide Zone of Treatment B Worldwide excluding USA and Canada Zone of Treatment C Restricted in Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand & Vietnam Dental Standard Deductible ,350 Deductible ,350 Deductible ,350 < < < , , , , , , , , (*) 3, (*) 1, (*) 1, (*) 3, (*) 1, (*) 1, (*) 4, (*) 2, (*) 1, (*) 5, (*) 2, (*) 2, (*) 5, (*) (*) 2,247 Dental Plus < < < , , , , , , , , , , , , , (*) 6, (*) 3, (*) 2, (*) 7, (*) 3, (*) 2, (*) 8, (*) 4, (*) 3, (*) 10, (*) 5, (*) 4, (*) 10, (*) 5, (*) 4,017 (*) Renewals only. Age loading applies for new enrolments. Note : Dental Options not available with Essential or Essential Plus. Accidental death and dismemberment (AD&D) This cover will guarantee the payment of a lump sum in case you die in an accident or you incur a permanent disability of at least 20% caused by an accident Lump Sum after accidental death - up to a maximum of $ 675,000 with a minimum of $ 67,500 - cover is available for you and your adult dependants Lump Sum after permanent disability - from at least a permanent disability degree of 20% - cash benefit = sum insured x degree of disability Premium Annual Premium 0.23% of the Capital Insured Capital Insured : Premium : Loss of Income (TI / PD) Temporary incapacity (TI) With the temporary incapacity plan option, you will feel more secure knowing your family will be protected financially if you are totally unable to perform your professional occupation due to illness or accident. You can choose the level of income benefit that is appropriate to you and your family: - up to 80% of pre-disability gross monthly salary; - subject to a maximum of $ 13,500 per month and a minimum of $ 1,350. Income protection during 24 months We will pay you a regular income for as long as you are unable to return to work. After a waiting period of 90 days, the income will start up to a maximum of 24 months. If you are still unable to resume work after 24 months then you will receive a lump sum through the permanent disability option when PD option has been contracted. Permanent disability (PD) (can be taken out only as supplement option to Temporary Incapacity) With this option, you receive a lump sum in case you are affected by a permanent disability of at least 33.33% caused by illness or accident. You can choose the level of sum insured that is appropriate to you: - up to 80% of pre-disability gross monthly salary multiplied by 48 months; - subject to a maximum of $ 648,000 and a minimum of $ 64,800; - when disability is between 33.33% and 66.67% then cash benefit = sum insured x ((3 x n)-1), n = degree of disability (%); - when disability is above 66.67% then cash benefit = sum insured. Additional payment of $ 33,750 If from the start of the disability you need the assistance of a third person to perform the basic activities of daily living (such as feeding, washing yourself) and your degree of disability exceeds 66.67%, then an additional sum of $ 33,750 will be paid. Premium Age Monthly Sum Insured US$ Annual Premium TI PD TI PD % 4.79% % 9.66% % 35.75% % % % %