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 Overage 45440-10002 Plan 002 Sub office 002 BODY REPATRIATION AMOUNT OF INSURANCE Each Eligible Insured Up to age 65 years: AED 50,000 Age between 65-70 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. Plan No. Maximum Benefit per Insured per Policy year METLIFE ALICO s Medical Network Geographical Scope Coverage outside the Geographical Scope Daily Room and Board (Average Private Room) 45440-10000 45440-10002- Plan 002 Overage - Plan 002 AED 1,000,000 AED 500,000 Executive UAE,GCC, ME, ISC & SE ASIA Emergency non-elective In-patient treatment Worldwide whilst Insured is on vacation/business trips for a maximum of 60 days (emergency cases) 100% inside MetLife Alico Network within UAE Up to AED 850 outside MetLife Alico Network within UAE Up to AED 850 for Government Hospitals within UAE Up to AED 850 outside UAE; in GCC, ME, ISC & SE ASIA Up to AED 1,700 outside UAE; Worldwide for emergency cases Page 1 of 7
Intensive Care Unit Co-Insurance In-Patient & Out-Patient American Hospital Dubai 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 (Prior approval required) Organ Transplant (Cost of surgery in respect of the insured person as recipient and the 100% inside MetLife Alico Network within UAE Outside MetLife Alico Network & within geographical scope double the daily room and board limit per disability for 30 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 90% on direct billing 50% Interventional cardiac surgery Out-Patient / Day Care 80% R&C on cash reimbursement basis 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 350 & AED 450 inside UAE outside MetLife Alico s Network & in Government Hospitals for GP & Specialist respectively Up to AED 350 & AED 450 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 750 (For a Child under the age of 18 years) Page 2 of 7
organ donor at the time of transplant surgery) Renal Dialysis Nursing at home (Immediately after or instead of hospitalization) Acts of Terrorism (Passive exposure) Maternity (For a private room) On cash reimbursement basis Alternative Medicine On cash reimbursement basis Emergency Dental Treatment for accidental damage to natural teeth Psychiatric Treatment Medical Evacuation For Normal Delivery / Caesarian Section / Ectopic / Extra-Uterine Pregnancy, Miscarriage/Legal Abortion & Complications of Maternity: AED 20,000 Co-Insurance: 100% Deductible: Nil Waiting Period: Nil 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. dental services for the treatment of accidental injuries to sound natural teeth through violent external means within six months of the accident 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 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
ELIGIBILITY Minimum 18 years; Maximum 65 years. Employees / Spouses Coverage shall be extended up to the age of seventy (70) without providing evidence of insurability to the insurance company at double the premium rates and half the benefits. 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
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
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
Alarm Centers contact details: AZERBAIJAN Baku Tel: +994 (0) 12 937 354 AUSTRALIA Sydney Tel: +61 (0) 2 9372 2468 CAMBODIA Phnom Penh Tel: +855 (0) 23 216 911 CHAD N Djamena Tel: +235 52 25 01 CHINA Beijing Tel: +86 (0) 10 6462 9112 Guangzhou Tel: +86 (0) 20 8735 1051 Nanjing Tel: +86 (0) 25 480 2842 Shekou Tel: +86 (0) 755 2669 3667 Tianjin Tel: +86 (0) 22 2352 0143 CZECH REPUBLIC Prague Tel: +420 222 111 155 FRANCE Paris Tel: +33 (0)1 5563 3155 GERMANY Stuttgart Tel: +49 (0) 711 9077 4100 INDIA New Delhi Tel: +91 (0) 11 2335 2702 INDONESIA Jakarta Tel: +62 (0) 21 750 5980 Jakarta (2) Tel: +62 (0) 21 5255367 Bali Tel: +62 (0) 361 720 100 JAPAN Tokyo Tel: +81 (0) 3 5210 4334 KAZAKHSTAN Almaty Tel: +7 (0) 3272 581 911 Atyrau Tel: +7 (0) 3122 586 911 MYANMAR Yangon Tel: +95 (0) 1 667 879 MALAYSIA Kuala Lumpur Tel: +60 (0) 3 27163033 MYANMAR Yangon Tel: +95 (0) 1 667 877 NEW ZEALAND Auckland Tel: +64 (0) 9 359 1635 NIGERIA Lagos Tel: +234 (0) 1 461 7710 Port Harcourt Tel: +234 (0) 84 611436 Warri Tel: +234 (0) 53 255023 PHILIPPINES Manila Tel: +63 (0) 2 637 0707 RUSSIA Moscow Tel: +7 (095) 937 6477 SINGAPORE Tel: +65 6338 7800 SOUTH AFRICA Johannesburg Tel: +27 (0) 11 541 1350 SOUTH KOREA Seoul Tel: +82 (0) 2 790 7561 SPAIN Madrid Tel: +34 (0) 91 572 4363 SWITZERLAND Geneva Tel: +41 (0) 22 785 6464 TAIWAN (ROC) Taipei Tel: +886 (0) 2 2523 2220 THAILAND Bangkok Tel: +66 (0) 2 256 7146 UNITED KINGDOM London Tel: +44 (0) 20 8762 8008 USA Philadelphia Tel: +1 (0) 215 245 4707 VIETNAM Ho Chi Minh City Tel: +84 (0) 8 829 8520 Hanoi Tel: +84 (0) 4 934