This document outlines the full benefits available in 4 modules under an insurance plan with a maximum limit of $2,000,000 per insured person. Module I covers hospitalization, outpatient surgery, and medical evacuation benefits. Module II covers outpatient benefits including consultations, diagnostic tests, and medicines. Module III provides $10,000 in maternity benefits per pregnancy. Module IV covers routine and major restorative dental treatment with annual limits of $700 and $1,500 respectively.

1. benefits
Listed below are the full benefits available. Benefits payable in respect of any one insured person are subject to an all-inclusive limit per
period of insurance of US$2,000,000
Hospitalization & Out-patient Surgery
module I - Limit per period of insurance - US$ 2,000,000
Hospital Services
Standard Private Room and Board Fully Covered
Parental Accommodation Fully Covered
Other Medical Expenses (theatre fees, x-rays, blood etc.) Fully Covered
Intensive Care Fully Covered
Surgeon’s Fees Fully Covered
Anaesthetist Fees Fully Covered
Professional Fees Fully Covered
Psychiatric Inpatient Hospital Care Fully Covered
Children Born During the period of Insurance Fully Covered
Reconstructive surgery Fully Covered
Complications of pregnancy Fully Covered
Clinical Surgery, Chemotherapy & Dialysis
Clinical Surgery Fully Covered
Chemotherapy Fully Covered
Dialysis Fully Covered
Pre-hospitalization
Pre-hospitalization benefits for up to 30 days before a covered confinement Fully Covered
Post hospitalization
Post hospitalization benefits for up to 90 days following a covered confinement Fully Covered
Pre-Approved Medical Evacuation & Repatriation (Up to a maximum of US$ 500,000 per event)
Transportation expenses by air and/or surface transportation Fully Covered
Accompanying person Fully Covered
Repatriation to home country within three months after completion of treatment Fully Covered
Mortal Remains US$ 15,000
Emergency Room Treatment
Emergency Room Treatment Fully Covered
Emergency Dental Treatment
Emergency Dental Treatment to repair damage to sound Fully Covered
natural teeth within 14 days of accident
Local Transport by Ambulance
Transport to and from hospital prescribed by an attending physician Fully Covered
Organ Transplant
Organ transplantation costs (human organs only) US$ 300,000 per transplant
Direct cost of surgery to remove an organ for transplant 30% of the total transplantation cost
Private Nursing, Home Nursing
Private nursing in hospital when certified necessary by an attending physician Fully Covered
Home nursing prescribed by an attending physician US$ 135 per day up to a maximum of
US$ 5,400 per period of insurance
Hospital Cash Benefit
If treatment received free of charge (maximum of 60 days in US$ 100 per day up to a maximum of
each period of insurance) US$ 6,000 per period of insurance
Rehabilitation
Rehabilitation treatment at an authorized rehabilitation centre US$ 355 per day up to a maximum of
(maximum of 90 days per illness) US$ 31,950 per period of insurance
Second Opinion Services
Medical Second Opinion Services provided by Mediguide America Fully Covered
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2. benefits
module II - Out-patient Benefits
General Practitioners & Specialists
GP consultations Fully Covered
Specialists Fully Covered
Psychiatrists for a mental and nervous condition US$ 130 per consultation
(maximum of four consultations per period of insurance) up to a maximum of US$ 520
per period of insurance
Physiotherapy prescribed by an attending physician US$ 100 per consultation
Complementary Medicine
Chinese doctor consultation with prescribed traditional chinese Up to US$ 50 per session to a
medicine, acupuncturist, dietetic guidance, chiropractor, maximum of 10 sessions per period
and osteopath of insurance inclusive of all disciplines
Diagnostic Tests prescribed by an attending physician
Lab tests, analysis Fully Covered
X-Ray Fully Covered
ECG Fully Covered
Scan and endoscopic exams Fully Covered
Hearing Aids
Hearing Aids prescribed by an attending physician US$ 325 per appliance
(50% co-insurance percentage)
Appliances
Slings and Bandages Fully Covered
Arch Support Fully Covered
Rent of Medical Appliances Fully Covered
Medicines and drugs
Medicines and drugs prescribed by an attending physician Fully Covered
Medical check up
Medical check up US$ 300 per period of insurance
Maternity Benefit
module III - Limit per Pregnancy – US$ 10,000
Maternity
Delivery including pre and post natal treatment, vitamins and US$ 10,000 per pregnancy
supplements prescribed by the attending physician, elective
and emergency caesarian sections
module IV - Dental
The following services are covered when rendered to an Insured Person by a dentist or oral hygienist:
Routine Dental Treatment up to US$ 700 per year Major Restorative Dental Work up to US$ 1,500 per year
• Examinations • Removal of impacted, buried or unerupted teeth
• Tooth cleaning • Removal of roots
• Normal composite fillings • Root Canal Treatment
• Inlay (excluding gold inlays) • Removal of solid odontomes
• Onlay (excluding gold onlays) • Apicetomy
• Extractions • New or repair of Bridge Work (excluding gold bridge work)
• Sealant • New or repair of Crowns (excluding all gold crowns)
• New or repair of Upper and Lower Dentures
Date revised: 24/09/09 02 of 02