Bupa Critical Care Offers You Comprehensive Coverage in Latin America, the Caribbean, and the United States of America Within the Provider Network

Membership Guide B U PA CRITICAL CARE 2 INDEX YOUR HEALTHCARE PARTNER...... 2 Welcome to Bupa...... 3 USA Medical Services...... 4 Manage your policy online...... 5 Your coverage...... 6 Deductible options...... 7 GENERAL TERMS AND CONDITIONS Notes about your policy...... 8 Agreement...... 10 Benefits...... 12 Exclusions and limitations...... 16 Administration...... 18 Definitions...... 23 SUPPLEMENT The claim process...... 28 Notification before treatment...... 30 How to file for reimbursement...... 32

3 YOUR HEALTHCARE PARTNER

Bupa is a leading and experienced health insurer, that provides a variety of products and services to residents of Latin America and the Caribbean. Bupa began as a provident association in the United Kingdom in 1947 with just 38,000 members. Today, Bupa looks after the health and wellbeing of millions of individuals around the world, giving us a unique global advantage for the benefit of our members. Since its inception more than 70 years ago, Bupa has maintained a sustained financial growth and continues to consolidate its credentials as a healthcare leader. Bupa has no shareholders, which allows for the reinvestment of all profits to optimize products and services in synergy with accredited healthcare providers. Trust in healthcare personnel and services is critical for everyone. Our commitment to our members for over half a century is testament of our capacity to safeguard your health as the most important patrimony. OUR PURPOSE OUR PEOPLE Bupa’s purpose is longer, healthier, The expertise of our people is essential happier lives. We fulfill this promise by to deliver the best quality healthcare. being our members’ advocate, providing Bupa employs over 85,000 people a range of personalized healthcare worldwide who live up to the highest services and support throughout their quality standards of care, service, and lives. As your healthcare partner, we expertise. We encourage our staff enable you to make informed healthcare members to express their opinions so decisions. We believe that prevention is that we can be distinguished as one of a proactive approach that can positively the best employers of choice. impact your health.

2 WELCOME TO BUPA

Thank you for choosing Critical Care, brought to you by Bupa, one of the largest and most experienced health insurance companies in the world. This Membership Guide contains important information about your policy benefits and conditions, how to contact us, what to do if you need to use your coverage, and how to contact us. Please review your certificate of coverage and other policy documents which show the deductible you selected and any exclusions and/or amendments to your coverage. If you have any questions about your plan, please contact the Bupa Helpline. BUPA CUSTOMER MEDICAL EMERGENCIES SERVICE HELPLINE In the event of a medical emergency Our customer service team is available outside of our usual business hours, Monday through Friday from 9:00 A.M. please contact the USA Medical Services to 5:00 P.M. (EST) to help you with: team at: Questions about your coverage Tel: +1 (305) 275 1500 Fax: +1 (305) 275 1518 Making changes to your coverage [email protected] Updating your personal information Tel: +1 (305) 398 7400 MAILING ADDRESS Fax: +1 (305) 275 8484 17901 Old Cutler Road, Suite 400 [email protected] Palmetto Bay, Florida 33157 www.bupasalud.com USA

3 USA MEDICAL SERVICES

YOUR DIRECT LINE TO MEDICAL EXPERTISE As part of the Bupa group, USA Medical family deserve. In the event of a medical Services provides Bupa insureds with crisis, whether it is verifying benefits professional support at the time of a or the need of an air ambulance, our claim. We understand that it is natural healthcare professionals at USA Medical to feel anxious at a time of ill health, Services are just a phone call away, 24 so we will do everything we can to hours a day, 365 days a year. Our staff help coordinate your hospitalization of healthcare professionals will be in and provide you with the advice and constant communication with you and assistance you require. your family, guiding you through any USA Medical Services wants you to have medical crisis to the proper medical the peace of mind that you and your specialist and/or hospital. WHEN THE WORST HAPPENS, WE ARE JUST A PHONE CALL AWAY In the event of an emergency evacuation, provided, USA Medical Services moni- USA Medical Services provides advanced tors your progress and reports any alert of patient arrival to the medical change in your status to your family facility and maintains continuous critical and loved ones. communication during transport. While When every second of your life counts... treatment and initial care are being count on USA Medical Services. AVAILABLE 24 HOURS A DAY, 365 DAYS A YEAR In the USA: +1 (305) 275-1500 Toll free within the USA: +1 (800) 726-1203 Fax: +1 (305) 275-1518 E-mail address: [email protected] Outside the USA: Phone number can be located on your ID card, or at www.bupasalud.com

4 MANAGE YOUR POLICY ONLINE

As a Bupa member, you have access to a range of online services. At www.bupasalud.com you will find: Information about how to file a claim News about Bupa Information on our range of products Free premium quote REGISTER FOR ONLINE BUPA CARES ABOUT THE SERVICES — FREE AND EASY ENVIRONMENT Through our Online Services, you get Bupa believes that thriving communities access to: and a healthy planet are essential to A complete overview of your policy everyone’s wellbeing. We take care of the health of our members making sure A copy of your application it has a positive impact in society and The status on the reimbursement of the environment. recent claims Bupa engages in sustainability strategies Online premium payments and to ensure our people, products, and receipts services contribute to a better society. Change your demographic informa- We take our environmental impact seri- tion ously, establishing ecological policies that benefit the planet and all individuals Sign up to be a Paperless Customer in our workplace. We are committed PAPERLESS CUSTOMER to enhancing the quality of life of our customers and personnel as well as Our Paperless Customer solution is a those of communities in need. service for you who wish to avoid postal Still in the early stages of our environ- delays, letters lost in the mail, sorting mental journey, we are committed to of insurance documents and filing in making a positive contribution in the binders. When you have logged in to long term, which is why we have taken Online Services, go to My Preferences steps to reduce our carbon footprint. under My Profile, and choose to receive documents online. Once you sign up, you will be responsible for checking all documents and correspondence online.

5 YOUR COVERAGE

GEOGRAPHICAL COVERAGE Bupa Critical Care offers you comprehensive coverage in Latin America, the Caribbean, and the United States of America within the provider network. If you need information about your network, please visit www.bupasalud.com or contact USA Medical Services. However, the insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction.

6 DEDUCTIBLE OPTIONS

We offer a range of annual deductible options to help you reduce the price you pay for your coverage — the higher the deductible, the lower the premium. You can choose between the following deductibles.

Deductible (US$) Plan 1 2 3 4 5 6

In-country 2,000 3,500 5,000 10,000 20,000 50,000

Out-of- 2,000 3,500 5,000 10,000 20,000 50,000 country Max. per 4,000 7,000 10,000 20,000 40,000 100,000 policy

There is only one deductible per person, per policy year. However, to help you reduce the cost of your family’s coverage, we apply a maximum equivalent to two out-of-country deductibles on your policy, per policy year.

7 GENERAL TERMS AND CONDITIONS

NOTES ABOUT YOUR POLICY Your policy documents include this outside the provider network, except Membership Guide (with general as specified under the condition for information about Bupa, the agree- Emergency Medical Treatment. ment, the policy's general conditions, All reimbursements are paid in accor- exclusions and limitations, administra- dance with the Usual, Customary, and tion, definitions, and a supplement Reasonable (UCR) fees for the specific with information about notifications service. UCR is the maximum amount and claims), your Table of Benefits, the insurer will consider eligible for your Certificate of Coverage, and your payment, adjusted for a specific Particular Conditions. region or geographical area. Maximum coverage for all covered Insureds are required to notify USA medical and hospital charges while Medical Services prior to beginning the policy is in effect is limited to the any treatment. terms and conditions of your policy. Unless otherwise stated herein, all The insurer, USA Medical Services, and/ benefits are per insured, per policy or any of their applicable related subsid- year. All amounts are in U.S. dollars. iaries and affiliates will not engage in any transactions with any parties To learn how your product works, refer or in any countries where otherwise to the Benefits, Exclusions and limita- prohibited by the laws in the United tions, Administration, and Definitions States of America. Please contact USA sections in this Membership Guide. Medical Services for more information All benefits are subject to any appli- about this restriction. cable deductible, unless otherwise stated. Any diagnostic or therapeutic procedure, treatment, or benefit is covered only if resulting from a condition covered under this policy. This policy provides coverage within the provider network only. No benefits are payable for services rendered

8 9 AGREEMENT

1.1 BUPA INSURANCE COMPANY: work assignments, student visas, (hereinafter referred to as the and other temporary stays within “insurer”) agrees to pay you (here the United States may be covered inafter referred to as the “policy under certain conditions as long holder”) the benefits provided by as the policyholder’s permanent this policy. All benefits are subject residence remains outside of the to the terms and conditions of this United States. Without prejudice policy. to the aforementioned, the insurer 1.2 TEN (10) DAY RIGHT TO reserves the right to evaluate the EXAMINE THE POLICY: This Policyholder's eligibility in case of policy may be returned within ten a change in country of residence (10) days of receipt for a refund or nationality. Please contact the of all premiums paid. The policy insurer or your agent for further may be returned to the insurer information related to your indi- or to the policyholder’s producer. vidual case. If returned, the policy is void as Eligible dependents under this though no policy had been issued. policy are those who have been 1.3 IMPORTANT NOTICE ABOUT identified on the health insurance THE APPLICATION: This policy application and for whom cover- is issued based on the application age is provided under the policy. and payment of the premium. If Eligible dependents include the any information shown on the policyholder’s spouse or domestic application is incorrect or incom- partner, biological children, legally plete, or if any information has adopted children, stepchildren, been omitted, the policy may be children to whom the policyholder rescinded or cancelled, or cover- has been appointed legal guardian age may be modified at the sole by a court of competent jurisdic- discretion of the insurer. tion, and grandchildren born into the policy from insured dependent 1.4 ELIGIBILITY: This policy can only children under the age of eighteen be issued to residents of Latin (18). America or the Caribbean who are at least eighteen (18) years old Dependent coverage is available (except for eligible dependents), for the policyholder’s dependent and not older than seventy- children up to their nineteenth four (74) years old. There is no (19th) birthday if single, or up maximum renewal age for insureds to their twenty-fourth (24th) already covered under this policy. birthday if single and full-time This policy cannot be issued and students at an accredited college is not available to persons per- or university (minimum twelve manently residing in the United (12) credits per semester) at the States of America. Insureds with time that the policy is issued or renewed. Coverage for such

10 dependents continues through the in effect under the prior policy. next anniversary or renewal date The health insurance application of the policy, whichever comes of the former dependent must be first after reaching nineteen (19) received before the end of the years of age if single, or twenty- grace period for the policy which four (24) years of age if single and previously afforded coverage for a full-time student. the dependent. Coverage for dependent sons or daughters with a child will end under their parent’s policy on the anniversary date after the 1.5 REQUIREMENT TO NOTIFY The insured must dependent son or daughter turns THE INSURER: contact USA Medical Services, eighteen (18) years old, when he Bupa’s claims administrator, at or she must obtain coverage least seventy-two (72) hours in for himself or herself and his or advance of receiving any medical her child under his or her own care. Emergency treatment must individual policy. be notified within seventy-two If a dependent child marries, stops (72) hours of beginning such being a full-time student after his/ treatment. her nineteenth (19th) birthday, If the insured fails to contact USA moves to another country, or if a Medical Services as stated in the dependent spouse ceases to be Table of Benefits, he/she will be married to the policyholder by responsible for thirty percent reason of divorce or annulment, (30%) of all covered medical and coverage for such dependent hospital charges related to the under this policy will terminate claim, in addition to the plan's on the next anniversary or renewal deductible. date of the policy, whichever comes first. Dependents who were covered under a prior policy with the insurer and are otherwise eligible for coverage under their own separate policy, will be approved without underwriting for the same product with equal or higher deductible and with the same conditions and restrictions

11 BENEFITS

IN-PATIENT BENEFITS AND www.bupasalud.com, and LIMITATIONS may change at any time without prior notice. 2.1 HOSPITAL SERVICES: Coverage is only provided when in-patient (b) In order to ensure that the hospitalization is medically nec- provider of medical services essary. Consult your Table of is part of the provider Benefits to confirm coverage. network, all treatments Emergency medical treatment must be coordinated by USA out of network is covered as Medical Services. described in 6.4. (c) In those cases where the 2.2 MEDICAL AND NURSING FEES: provider network is not speci- Physician, surgeon, anesthesi- fied in the insured’s country ologist, assistant surgeon, spe- of residence, there is no cialists, and other medical and restriction on which hospitals nursing fees are covered only may be used in the insured’s when they are medically neces- country of residence. sary for the surgery or treatment and approved in advance by USA OUT-PATIENT BENEFITS Medical Services. Medical and AND LIMITATIONS nursing fees are limited to the 3.1 AMBULATORY SURGERY: lesser of: Ambulatory or out-patient sur- (a) The usual, customary and gical procedures performed in a reasonable fees for the hospital, clinic, or doctor’s office procedure, or are covered according to your Table of Benefits. These surger- (b) Special rates established for ies allow the patient to go home an area or country as deter- the same day that they have the mined by the insurer. surgical procedure. 2.3 PRESCRIPTION DRUGS: Drugs 3.2 OUT-PATIENT SERVICES: prescribed while in-patient are Coverage is only provided when covered as described in your Table medically necessary. of Benefits. 3.3 PRESCRIPTION DRUGS: 2.4 PROVIDER NETWORK: This Prescription drugs first prescribed policy provides coverage within after an in-patient hospitaliza- the provider network only, tion or out-patient surgery for a regardless of whether the treat- medical condition covered by the ment takes place in the insured’s policy are covered as described country of residence or outside in your Table of Benefits. A copy the insured’s country of residence. of the prescription from the treat- There is no coverage outside the ing physician must accompany provider network, except for the claim. emergencies, which are covered under 6.4. All covered expenses, up to the maximum benefit, will first be (a) The list of hospitals and applied towards the deductible. physicians in the provider Once the expenses exceed the network is available from USA deductible amount, the insurer Medical Services or online at will pay the difference between the amount of expenses applied

12 to the deductible and the amount method would result in loss of life of the out-patient prescription or limb. Emergency transportation drug benefit limit. must be provided by a licensed 3.4 PHYSICAL THERAPY AND and authorized transportation REHABILITATION SERVICES: company to the nearest medical Physical therapy and rehabilitation facility. The vehicle or aircraft sessions are covered as described used must be staffed by medi- in your Table of Benefits and must cally trained personnel and must be pre-approved. Updated evi- be equipped to handle a medical dence of medical necessity and emergency. a treatment plan are required in Air ambulance transportation: advance to obtain each approval. (a) All air ambulance trans- A session may include multiple portation must be pre- disciplines such as physical approved and coordinated therapy, occupational therapy and by USA Medical Services. speech language pathology, and will be treated as one session if (b) The insured agrees to hold all are scheduled together, or will the insurer, USA Medical be treated as separate sessions Services, and any company if scheduled on different days or affiliated with the insurer times. or USA Medical Services by way of similar ownership 3.5 HOME HEALTH CARE: Home or management, harmless health care is covered as described from negligence resulting in your Table of Benefits and must from such services, or be pre-approved. Updated evi- negligence resulting from dence of medical necessity and delays or restrictions on treatment plan are required in flights caused by the pilot, advance to obtain each approval. mechanical problems, or governmental restrictions, NEWBORN BENEFITS AND or due to operational condi- LIMITATIONS tions. 4.1 NEWBORN COVERAGE: To be (c) In the event that the covered under the terms of this insured is transported for policy, a newborn must be added the purpose of receiving to the policy. The health insurance treatment, he/she and the application and the premium for accompanying person, if the addition must be received any, shall be reimbursed within thirty-one (31) days of for the expenses for a birth. If the application is received return journey to the place after thirty-one (31) days of birth, from where the insured the application will be subject to was evacuated. The return underwriting. journey shall be made no EVACUATION BENEFITS later than ninety (90) days AND LIMITATIONS after treatment has been completed. Coverage shall 5.1 MEDICAL EMERGENCY EVAC- only be provided for trav- UATION: Emergency transporta- eling expenses equivalent tion (by ground or air ambulance) to the cost of an airplane is covered as described in your ticket on economy class, as Table of Benefits if related to a a maximum. Transportation covered condition for which treat- services must be pre- ment cannot be provided locally, approved and coordinated and transportation by any other by USA Medical Services.

13 OTHER BENEFITS AND LIMITATIONS and/or replacement of prosthetic limbs must be pre-approved by 6.1 CONGENITAL AND/OR HERED- USA Medical Services. ITARY DISORDERS: Conditions that are a consequence of a con- 6.3 SPECIAL TREATMENTS: Prosthesis, genital and/or hereditary disor- appliances, orthotic durable der will only be covered up to medical equipment, implants, ten percent (10%) of the covered radiation therapy, chemotherapy, expenses shown in your Table of and the following highly special- benefits, and are subject to all ized drugs: Interferon beta-1a, policy provisions including the PEGylated Interferon alpha-2a, deductible. The benefit starts once Interferon beta-1b, Etanercept, the congenital and/or hereditary Adalimumab, Bevacizumab, condition has been diagnosed by Cyclosporine A, Azathioprine, and a physician. The benefit is retroac- Rituximab will be covered but must tive to any period prior to the iden- be approved and coordinated in tification of the actual condition. advance by USA Medical Services. For coverage of prosthetic limbs, 6.2 PROSTHETIC LIMBS: Prosthetic please refer to condition 6.2. limb devices include artificial arms, hands, legs, and feet, and 6.4 EMERGENCY MEDICAL TREAT- are covered as described in your MENT (with or without admission): Table of Benefits. The benefit Your policy covers emergency includes all the costs associated medical treatment outside the pro- with the procedure, including any vider network only for conditions therapy related to the usage of covered under this policy when the the new limb. insured’s life or physical integrity is in immediate danger, and the Prosthetic limbs will be covered emergency has been notified to when the individual is capable of USA Medical Services, as provided achieving independent functional- for under his policy. All medical ity or ambulation with the use of expenses from a non-network the prosthesis and/or prosthetic provider in relation to emergency limb device, and the individual medical treatment will be paid as does not have a significant car- if the insured had been treated at diovascular, neuromuscular, or a network hospital. musculoskeletal condition which would be expected to adversely 6.5 EMERGENCY DENTAL TREAT- affect or be affected by the use MENT: Coverage is provided of the prosthetic device (i.e., a for expenses incurred for the condition that may prohibit a medically necessary treatment normal walking pace). of covered accidents, as long as the first expense occurs during Repair of the prosthetic limb is the thirty (30) days following the covered only when anatomical or accident. functional change or reasonable wear and tear renders the item 6.6 HOSPICE/TERMINAL CARE: Hos- nonfunctional and the repair will pice accommodations and termi- make the equipment usable. nal care treatment and services are covered as described in your Table Replacement of the prosthetic of Benefits for patients that have limb is covered only when ana- received a diagnosis for a terminal tomical or functional change or condition with a life expectancy of reasonable wear and tear renders six (6) months or less, and need the item nonfunctional and non- physical, psychological, and social reparable. Initial coverage, repair, care, as well as special equipment

14 fitting or adaptation, nursing care, (c) The costs of organ, cell or and prescribed drugs. This care tissue procurement, trans- must be approved in advance by portation, and harvesting USA Medical Services. including bone marrow, stem 6.7 TRANSPLANT PROCEDURES: cell or cord blood storage or Coverage for transplantation of banking. human organs, cells and tissues is (d) The donor workup, including provided only within the insurer’s testing of potential donors for Provider Network for Transplant a match. Procedures. There is no coverage (e) The hospitalization, surgeries, outside the Provider Network for physician and surgeon’s fees, Transplant Procedures. Coverage anesthesia, medication, and is provided only for the medically any other treatment neces- necessary transplant of the follow- sary during the transplant ing human organs, cells or tissue, procedure. or a combination of these, as explained in your Table of Benefits: (f) Post-transplant care including, but not limited Heart to any medically necessary Heart/lung follow-up treatment resulting Lung from the transplant and any Pancreas complications that arise after Pancreas/kidney the transplant procedure, whether a direct or indirect Kidney consequence of the trans- Liver plant. Bone marrow (g) Medication or therapeutic This transplant benefit begins measures used to ensure the once the need for transplanta- viability and permanence of tion has been determined by the transplanted organ, cell a physician, has been certified or tissue. by a second surgical or medical opinion, and has been approved (h) Home health care, nursing by USA Medical Services, and is care (e.g. wound care, infu- subject to all the terms, condi- sion, assessment, etc.), emer- tions and exclusions of the policy. gency transportation, medical This benefit includes: attention, clinic or office visits, transfusions, supplies, (a) Pre-transplant care, including or medication related to the those services directly related transplant. to evaluation of the need for transplantation, evaluation of the insured for the transplant procedure, and preparation and stabilization of the insured for the transplant procedure. (b) Pre-surgical workup, including all laboratory and X-ray exams, CT scans, Magnetic Resonance Imaging (MRI’s), ultrasounds, biopsies, scans, medications and supplies.

15 EXCLUSIONS AND LIMITATIONS

This policy does not provide coverage or benefits for any of the following, unless specifically included in your Table of Benefits: 7.1 CHARGES RELATED TO NON- includes any surgical treatment COVERED TREATMENT: Treat- for nasal or septal deformity that ment of any illness, injury, or was not induced by trauma. charges arising from any treat- 7.7 PRE-EXISTING CONDITIONS: Any ment, service or supply: charges in connection with pre- (a) That is not medically neces- existing conditions. sary, or 7.8 EXPERIMENTAL OR OFF-LABEL (b) For an insured who is not TREATMENT: Any treatment, under the care of a physician, service, or supply that is not sci- doctor or licensed profes- entifically or medically recognized sional, or for a specific diagnosis, or that is (c) That is not authorized or considered as off label use, exper- prescribed by a physician or imental and/or not approved for doctor, or general use by the U.S. Food and Drug Administration. (d) That is related to custodial care, or 7.9 TREATMENT IN GOVERNMENTAL FACILITY: Treatment in any gov- (e) That takes place at a hospital, ernmental facility, or any expense but for which the use of if the insured would be entitled to hospital facilities is not neces- free care. Service or treatment for sary. which payment would not have 7.2 SELF-INFLICTED ILLNESS OR to be made had no insurance INJURY: Any care or treatment, coverage existed, or that have while sane or insane, received been placed under the direction due to self-inflicted illness or of government authority. injury, suicide, attempted suicide, 7.10 MENTAL AND BEHAVIORAL alcohol use or abuse, drug use DISORDERS: Diagnostic proce- or abuse, or the use of illegal dures or treatment of psychiatric substances or illegal use of con- disorders, unless resulting from trolled substances, including any treatment for a covered condition. accident resulting from any of the Mental illnesses and/or behav- aforementioned criteria. ioral or developmental disorders, 7.3 EXAMINATIONS AND AIDS FOR chronic fatigue syndrome, sleep EYES AND EARS: Routine eye and apnea, and any other sleep dis- ear examinations, hearing aids, orders. eye glasses, contact lenses, radial 7.11 CHARGES IN EXCESS OF UCR: keratotomy and/or other proce- Any portion of any charge in dures to correct eye refraction excess of the usual, customary disorders. and reasonable charge for the 7.4 ALTERNATIVE MEDICINE: Chi- particular service or supply for the ropractic care, naturopathic or geographical area, or appropriate homeopathic treatment, naturo- level of treatment being received. pathic or homeopathic medica- 7.12 COMPLICATIONS OF NON- tions, acupuncture and any type COVERED CONDITIONS: Treat- of alternative medicine. ment or service for any medical, 7.5 TREATMENT DURING WAITING mental, or dental condition related PERIOD: Any illness or injury to or arising as a complication of not caused by an accident or a those medical, mental, or dental disease of infectious origin which services or other conditions specif- is first manifested within the first ically excluded by an amendment sixty (60) days from the effective to, or not covered by, this policy. date of the policy. 7.13 DENTAL TREATMENT NOT 7.6 COSMETIC SURGERY: Cosmetic RELATED TO COVERED ACCI- surgery or medical treatment DENT: Any dental treatment or which is primarily for beautifica- service not related to a covered tion, unless required due to the accident, or when first expense treatment of an injury, deformity occurs after thirty (30) days from or illness that compromises func- the date of a covered accident. tionality and that first occurred 7.14 POLICE OR MILITARY RELATED while the insured was covered INJURIES: Treatment of injuries under this policy. This also resulting while in service as a

16 member of a police or military 7.19 PERSONAL OR HOME-BASED unit, or from participation in war, ARTIFICIAL KIDNEY EQUIPMENT: riot, civil commotion, illegal activi- Personal or homebased artificial ties, and resulting imprisonment. kidney equipment, unless autho- 7.15 HIV/AIDS: Acquired immune rized in writing by the insurer. deficiency syndrome (AIDS), HIV 7.20 TISSUE AND/OR CELL STORAGE: positive or AIDS related illnesses, Storage of bone marrow, stem cell, including tumors in the presence cord blood, or other tissue or cell, of AIDS. except as provided for under the 7.16 ELECTIVE HOSPITAL ADMIS- conditions of the policy. Cost SION: An elective admission related to the acquisition and more than twenty-three (23) implantation of an artificial heart, hours before a planned surgery, other artificial or animal organs, unless authorized in writing by and all expenses for cryopreser- the insurer. vation of more than twenty-four (24) hours. 7.17 TREATMENT BY IMMEDIATE FAMILY MEMBER: Treatment 7.21 TREATMENT RELATED TO RADIA- performed by the spouse, parent, TION OR NUCLEAR CONTAMINA- sibling, or child of any insured TION: Injury or illness caused by, under this policy. or related to, ionized radiation, pollution or contamination, radio- 7.18 OVER-THE-COUNTER AND activity from any nuclear material, NON-PRESCRIPTION DRUGS: nuclear waste, or the combustion Over the counter or non-prescrip- of nuclear fuel or nuclear devices. tion drugs, prescription medications that are not first prescribed 7.22 TREATMENT OF THE JAW: Any during an in-patient hospitaliza- expenses associated with the tion, and prescription medications treatment of the upper maxilla, that are not prescribed as part the jaw, and/or the complex of of treatment after out-patient muscles, nerves, or other tissue surgery, as well as the following: related to the temporomandibular joint caused by a dental condition, (a) Drugs that are not medically previous dental treatment, and/or necessary, including any their complications, including but drugs given in connection not limited to any diagnosis where with a service or supply that the primary condition is dental. is not medically necessary. 7.23 CERVICAL CANCER: Cancer (b) Any contraceptive drugs or in-situ of the cervix. devices, even if ordered for non-contraceptive purposes. 7.24 SKIN CANCER: Skin cancer with the exception of melanoma. (c) Drugs or immunizations to prevent disease or allergies. 7.25 CARDIOVASCULAR PROCE- DURES: Any cardiovascular pro- (d) Drugs for tobacco depen- cedure not requiring surgery, with dency. the exception of balloon angio- (e) Cosmetic drugs, even if plasty. ordered for non-cosmetic 7.26 PROFESSIONAL SPORTS OR purposes. HAZARDOUS ACTIVITIES: Treat- (f) Drugs taken at the same time ment for injuries resulting from and place where the prescrip- the participation in any sport or tion is ordered. hazardous activity for compensation or as a professional. (g) Charges for giving, adminis- tering or injecting drugs. 7.27 DEGENERATIVE DISEASES: Charges related to degenerative (h) Any refill that is more than diseases including, but not limited the number of refills ordered to Creutzfeldt-Jacob disease, Hun- by the physician, or is made tington disease, multiple sclerosis, more than one year after normal pressure hydrocephalus, the latest prescription was Pick disease, Alzheimer’s disease, written. senile dementia, Parkinson’s (i) Therapeutic devices, appli- disease. ances or injectables, including 7.28 EPIDEMIC/PANDEMIC DISEASES: colostomy supplies and Treatment for or arising from support garments, regardless any epidemic and/or pandemic of intended use. disease and vaccinations, medi- (j) Progesterone suppositories. cines, or preventive treatment for (k) Vitamin supplements. or related to any epidemic and/or pandemic disease are not covered.

17 ADMINISTRATION

GENERAL (a) Only injuries caused by an accident occurring during the 8.1 AUTHORITY: No producer has the first sixty (60) days after the authority to change the policy or effective date of the policy or to waive any of its conditions. the addition of a new insured, After the policy has been issued, will be covered. no change shall be valid unless approved in writing by an officer or (b) Illnesses known or diagnosed the chief underwriter of the insurer, after the first sixty (60) days and such approval is endorsed by of coverage from the effective an amendment to the policy. date of the policy or sixty (60) days from the addition of a 8.2 CURRENCY: All currency values new insured will be covered stated in this policy are in U.S. from the date of the diagnosis. dollars (US$). (c) Covered diseases diagnosed 8.3 ENTIRE CONTRACT-CONTROLLING within sixty (60) days after CONTRACT: The policy (this docu- the effective date of the policy ment), the health insurance applica- will be covered after two (2) tion, the certificate of coverage, and years. any riders or amendments thereto, shall constitute the entire contract (d) Congenital disorders will be between the parties. Translations covered after two (2) years are provided for the convenience of the effective date of the of the insured. The English version policy. of this policy will prevail and is the 9.3 BEGINNING AND ENDING OF controlling contract in the event of INSURANCE COVERAGE: Subject any question or dispute regarding to the conditions of this policy, this policy. benefits begin on the effective 8.4 PPACA RIGHTS AND DISCLAIMER: date of the policy and not on the This policy does NOT provide all of date of application for insurance. the rights and protections of the Coverage begins at 00:01 hours Affordable Care Act (i.e., the U.S. Eastern Standard Time (USA) on health care law). These include, the policy’s effective date and ter- but are not necessarily limited to, minates at 24:00 hours Eastern one or more of the protections Standard Time (USA): of the Public Health Service Act. (a) On the expiration date of the A Health Insurance Marketplace, policy, or through which individuals may enroll in a qualified health plan (b) Upon non-payment of the and possibly qualify for federal premium, or subsidies, is not currently available (c) Upon written request from the outside of the continental United policyholder to terminate his/ States. To learn more about the her coverage, or Health Insurance Marketplace and (d) Upon written request from the protections under the U.S. health policyholder to terminate a care law, visit www.HealthCare.gov dependent’s coverage, or or call 1-800-318-2596. (e) Upon written notification from POLICY the insurer, as allowed by the conditions of this policy. 9.1 POLICY ISSUANCE: The policy is If a policyholder would like to ter- deemed issued or delivered upon minate coverage for any reason, its receipt by the policyholder in he/she may only do so as from his/her country of residence. the anniversary date with two (2) 9.2 WAITING PERIOD: All insureds months written notice. have a right to the benefits pro- 9.4 POLICY MODE: All policies are vided by this policy once the deemed annual policies. Premiums following waiting periods have are to be paid annually, unless the elapsed, which will start on the insurer authorizes other mode of effective date of the policy or, for payment. the new insureds, on the date they were added to the policy: 9.5 CHANGE OF PRODUCT OR PLAN: The policyholder can request to

18 change a product or plan at any sixty-five percent (65%) of the anniversary date. This request premium. The policy fee, USA must be submitted in writing and Medical Services fee, and thirty- received before the anniversary five percent (35%) of the base date. Some requests are subject premium are non-refundable. The to underwriting evaluation. During unearned portion of the premium the first sixty (60) days from the is based on the number of days effective date of the change, corresponding to the payment benefits payable for any illness mode, minus the number of days or injury not caused by accident the policy was in effect. or disease of infectious origin, will be limited to the lesser of benefits RENEWAL provided by the new plan or the 10.1 PREMIUM PAYMENT: The policy- prior plan. During the first ten (10) holder is responsible for paying months after the effective date of the premium on time. Premium the change, benefits for maternity, payment is due on the renewal date newborn, and congenital will be of the policy or any other due date limited to the lesser benefit pro- authorized by the insurer. Premium vided by either the new plan or notices are provided as a courtesy, prior plan. During the first six (6) and the insurer provides no guar- months after the effective date antee of delivering such notices. If of the change, transplant benefits a policyholder has not received a will be limited to the lesser benefit premium notice thirty (30) days provided by either the new plan prior to the premium payment due or prior plan. date, and the policyholder does not 9.6 CHANGE OF COUNTRY OF know the amount of the premium RESIDENCE: The insured must payment, he/she should contact notify the insurer in writing of his/her producer or the insurer. any change of his/her country of Payment may also be made online residence within thirty (30) days at www.bupasalud.com. of its occurrence. A change of 10.2 PREMIUM RATE CHANGES: country of residence may result in The insurer retains the right to modification of coverage, deduct- change the premium at the time ible, or premium according to the of each renewal date. This right geographical area, subject to the will be exercised on a “class” basis insurer’s procedures. only on the renewal date of each 9.7 TERMINATION OF COVER- respective policy. AGE UPON TERMINATION OF 10.3 GRACE PERIOD: If premium POLICY: In the event a policy payment is not received by the terminates for any reason, cov- due date, the insurer will allow a erage ceases on the effective grace period of thirty (30) days date of the termination, and the from the due date for the premium insurer will only be responsible to be paid. If the premium is not for any covered treatment under received by the insurer prior to the terms of the policy that took the end of the grace period, this place before the effective date of policy and all of its benefits will termination of the policy. There be deemed terminated as of the is no coverage for any treatment original due date of the premium. that occurs after the effective date Benefits are not provided under of the termination, regardless of the policy during the grace period. when the condition first occurred or how much additional treatment 10.4 POLICY CANCELLATION OR may be required. NON-RENEWAL: The insurer retains the right to cancel, modify 9.8 REFUNDS: If a policyholder or rescind the policy if statements cancels the policy after it has been on the health insurance applica- issued, reinstated or renewed, tion are found to be misrepresen- the insurer will not refund the tations, incomplete, or if fraud unearned portion of the premium. has been committed, leading the If the insurer cancels the policy for insurer to approve an application any reason under the terms of this when, with the correct or com- policy, the insurer will refund the plete information, the insurer unearned portion of the premium would have issued a policy with minus administrative charges and policy fees, up to a maximum of

19 restricted coverage or declined to opinions required and coordinated provide insurance. by USA Medical Services are If the insured changes country covered. In the event the second of residence, and the insured’s surgical opinion contradicts or current plan is not available in does not confirm the need for the insured’s new country of resi- surgery, the insurer will also pay dence, the insurer retains the right for a third surgical opinion from not to renew or to modify a policy a physician chosen in agreement in terms of rates, deductibles or between the insured and USA benefits, generally and specifi- Medical Services. If the second or cally, in order to offer the insured third surgical opinion confirms the the closest equivalent insurance need for surgery, benefits for the coverage available, if any. surgery will be paid according to this policy. Submission of a fraudulent claim is also grounds for rescission or IF THE INSURED DOES NOT cancellation of the policy. OBTAIN A REQUIRED SECOND SURGICAL OPINION, THE The insurer retains the right to INSURED WILL BE RESPONSIBLE cancel, non-renew or modify FOR THIRTY PERCENT (30%) OF a policy on a “block” basis as ALL COVERED MEDICAL AND defined in this policy, and the HOSPITAL CHARGES RELATED insurer will offer the insured the TO THE CLAIM, IN ADDITION TO closest equivalent insurance THE PLAN DEDUCTIBLE. coverage available, if any. No individual insured shall be inde- 11.3 DEDUCTIBLE: pendently penalized by cancella- (a) All insureds under the policy tion or modification of the policy have an in-country and an due solely to a poor claim record. out-of-country deductible 10.5 REINSTATEMENT: If the policy responsibility per policy year was not renewed within the grace according to the plan selected period, it can be reinstated within by the policyholder. When sixty (60) days after the grace applicable, the corresponding period at the insurer’s discretion, if deductible amount is applied the insured provides new evidence per insured, per policy year of insurability consisting of a new before benefits are paid or health insurance application and reimbursed to the insured. any other information or docu- All deductible amounts paid ment required by the insurer. No accumulate towards the reinstatement will be authorized corresponding maximum after ninety (90) days of the ter- deductible per policy, which mination date of the policy. is equivalent to the sum of two individual deductibles. CLAIMS All insureds under the policy contribute to meeting the 11.1 DIAGNOSIS: For a condition to in-country and out-of-country be considered a covered illness or maximum amounts of the disorder, copies of laboratory tests policy. Once the maximum results, X-rays, or any other report deductible amounts of the or result of clinical examinations policy are met, the insurer on which the diagnosis was based, will consider all individual are required as part of the positive deductible responsibilities as diagnosis by a physician. met. 11.2 REQUIRED SECOND SURGICAL (b) Any eligible charges incurred OPINION: If a surgeon has recom- by an insured during the last mended a non-emergency surgi- three (3) months of the policy cal procedure, the insured must year will apply to that policy notify USA Medical Services at year’s deductible and will also least seventy-two (72) hours prior be carried over to be applied to the scheduled procedure. If a towards that insured’s deduct- second surgical opinion is deemed ible for the following policy necessary by either the insurer or year. USA Medical Services, it must be conducted by a physician chosen (c) In case of a serious accident, and arranged by USA Medical Ser- no deductible shall apply vices. Only those second surgical for the period of the first

20 hospitalization only. For all tions of charges in excess of these hospitalizations thereafter, amounts are the responsibility of the corresponding deductible the insured. If the policyholder is shall apply. deceased, the insurer will pay any 11.4 PROOF OF CLAIM: The insured unpaid benefits to the beneficiary must provide written proof of loss or estate of the deceased policy- consisting of original itemized holder. USA Medical Services must bills, medical records, and a claim receive the complete medical and form properly completed and non-medical information required signed to USA Medical Services in order to determine compensa- at 17901 Old Cutler Road, Suite bility before: 1) direct payment is 400, Palmetto Bay, Florida 33157, approved; or 2) policyholder is within one hundred eighty (180) reimbursed. days after the treatment or service The insurer, USA Medical Services, date. Failure to do so will result in and/or any of their applicable the claim being denied. A com- related subsidiaries and affiliates pleted claim form per incident is will not engage in any transac- required for all claims submitted. tions with any parties or in any For claims related to car accidents, countries where otherwise pro- the following additional documen- hibited by the laws in the United tation is required for review: police States of America. Please contact reports, first insurance proof of USA Medical Services for more coverage, emergency medical information about this restriction. report, and results of toxicologi- 11.6 COORDINATION OF BENEFITS: If cal screening. Claim forms are the insured has another policy that provided with the policy or may provides benefits also covered by be obtained by contacting your this policy, benefits will be coor- producer or USA Medical Ser- dinated. vices at the address shown herein or through our website, www. All claims incurred in the country bupasalud.com. Bills received of residence must be submitted in currencies other than U.S. in the first instance against the dollars (US$) will be processed other policy. This policy shall in accordance with the exchange only provide benefits when such rate determined on the date of benefits payable under the other service at the insurer’s discretion. policy have been paid out and the Additionally, the insurer reserves policy limits of such policy have the right to issue the payment or been exhausted. reimbursement in the currency Outside the country of residence, in which the service or treatment Bupa Insurance Company will was invoiced. In order for ben- function as the primary insurer efits to be paid under this policy, and retains the right to collect dependent children, after their any payment from local or other nineteenth (19th) birthday, must insurers. provide a certificate or affidavit The following documentation is from a college or university as required to coordinate benefits: evidence that they were full-time Explanation of Benefits (EOB) and students at the time the policy copy of bills covered by the local was issued or renewed, AND a insurance company containing written statement signed by the information about the diagnosis, policyholder that the dependent date of service, type of service, child’s marital status is single. and covered amount. 11.5 PAYMENT OF CLAIMS: It is the 11.7 PHYSICAL EXAMINATIONS: The insurer’s policy to make pay- insurer shall have the right and ments directly to physicians and opportunity to request a physical hospitals worldwide. When this examination at its own expense, of is not possible, the insurer will any insured whose illness or injury reimburse the policyholder either is the basis of a claim, when and the contractual rate given to the as often as considered necessary insurer by the provider involved by the insurer before the claim is or in accordance with the usual, agreed. customary, and reasonable fees for that geographical area, which- 11.8 DUTY TO COOPERATE: The ever is less. Any charges or por- insured shall make all medical

21 reports and records available to 11.11 CLAIMS ARBITRATION, LEGAL the insurer and, when requested ACTIONS, AND JURY WAIVER: by the insurer, shall sign all neces- Any disagreement that may sary authorization forms for the persist upon completion of the insurer to obtain medical reports claims appeal as determined and records. Failure to cooper- herein, must first be submitted ate with the insurer or failure to for arbitration. In such cases, authorize the release of all medical the insured and the insurer will records requested by the insurer submit their difference to three (3) may cause a claim to be denied. arbiters: Each party selecting an 11.9 SUBROGATION AND INDEM- arbiter, and the third arbiter to be NITY: The insurer has a right of selected by the arbiters named by subrogation or reimbursement the parties herein. In the event of from or on behalf of an insured disagreement between the arbi- to whom it has paid any claims, if ters, the decision will rest with such insured has recovered all or the majority. Either the insured part of such payments from a third or the insurer may initiate arbitra- party. Furthermore, the insurer tion by written notice to the other has the right to proceed at its party demanding arbitration and own expense in the name of the naming its arbiter. The other party insured, against third parties who shall have twenty (20) days after may be responsible for causing receipt of said notice within which a claim under this policy, or who to designate its arbiter. The two may be responsible for providing (2) arbiters named by the parties, indemnity of benefits for any claim within ten (10) days thereafter, under this policy. shall choose the third arbiter and the arbitration shall be held at the 11.10 CLAIMS APPEALS: In the event place hereinafter set forth ten (10) of a disagreement between the days after the appointment of the insured and the insurer regarding third arbiter. If the other party this insurance policy and/or its does not name its arbiter within conditions, before beginning any twenty (20) days, the complaining arbitration or legal proceeding, party may designate the second the insured shall request a review arbiter and the other party shall of the matter by the Bupa Insur- not be aggrieved thereby. Arbi- ance Company appeals commit- tration shall take place in Miami- tee. In order to begin such review, Dade County, Florida, USA, or if the insured must submit a written approved by the insurer, in the request to the appeals commit- policyholder’s country of resi- tee. This request shall include dence. The insured and the insurer copies of all relevant information agree that each party will pay their sought to be considered, as well own expenses in regards to the as an explanation of the decision arbitration. that should be reviewed and why. The request shall be sent to the The insured confers exclusive attention of the Bupa Insurance jurisdiction in Miami-Dade County, Company appeals coordinator, c/o Florida for the determination of USA Medical Services. Upon sub- any rights under this policy. The mission of a request for review, the insurer and any insured covered appeals committee will determine by this policy hereby expressly whether any further information agree to trial by judge in any and/or documentation is needed legal action arising directly or and act to timely obtain it. The indirectly from this policy. The appeals committee will notify the insurer and the insured further insured of its decision and the agree that each party will pay underlying rationale within thirty their own attorneys’ fees and (30) days. costs, including those incurred in arbitration.

22 DEFINITIONS ACCIDENT: An unfortunate incident violent suspension of the fundamental that occurs unexpectedly and suddenly, brain functions, either by ischemia or provoked by an external cause, always hemorrhage. without the insured’s intention, which CERTIFICATE OF COVERAGE: causes injury or bodily trauma and Document of the policy that specifies requires immediate ambulatory medical the effective date, conditions, extent attention and/or patient’s hospital and limitations of coverage, and lists admission. The medical information the policyholder and each covered related to the accident will be evaluated dependent. by the insurer, and the compensability will be determined under the general CHEMOTHERAPY: Use of chemical policy’s provisions. agents prescribed by a physician for the treatment and control of cancer. ACCIDENTAL BODILY INJURY: Damage inflicted to the body caused by a sudden CLASS: The insureds of all policies and unforeseen external cause. of the same type, including but not AIR AMBULANCE TRANSPORTATION: limited to benefits, deductibles, age Emergency air transportation from the group, country, plan, year groups, or a hospital where the insured is admitted combination of any of these. to the nearest suitable hospital where CONGENITAL AND/OR HEREDITARY treatment can be provided. DISORDER: Any disorder or illness AMENDMENT: A document added to acquired during conception or the the policy by the insurer that clarifies, fetal stage of development as a result explains, or modifies the policy. of the genetic make-up of the parents or environmental factors, whether or ANNIVERSARY DATE: Annual occur- not it is manifested or diagnosed before rence of the effective date of the policy. birth, at birth, after birth, or years later. APPLICANT: The individual who COUNTRY OF RESIDENCE: The country completes the health insurance applica- where the policyholder has indicated tion for coverage. to have his/her physical residence, or APPLICATION: Written statements on a his/her country of origin, or the country form by an applicant about themselves he/she has informed the insurer to be and/or their dependents, used by the his/her residence afterwards in writing. insurer to determine acceptance or CUSTODIAL CARE: Assistance with denial of the risk. The health insurance the activities of daily living that can application includes any oral statements be provided by non-medical/nursing made by an applicant during a medical trained personnel (bathing, dressing, interview held by the insurer, medical grooming, feeding, toileting, etc.). history, questionnaire, and other document provided to, or requested by, the DEDUCTIBLE: The amount of covered insurer prior to the issuance of the policy. charges that must be paid by the insured before policy benefits are payable. BLOCK: The insureds of a policy type Charges incurred in the country of (including deductible) or a territory. residence are subject to an in-country CALENDAR YEAR: January 1 through deductible. Charges incurred outside December 31 of any given year. the country of residence are subject to an out-of-country deductible. CANCER: Illness manifested by the presence of a malignant tumor, characterized DEPENDENT: Eligible dependents by growth and proliferation of malignant under this policy are those who have cells, capable of cell transfers and inva- been identified on the health insurance sion of other organs not directly related. application and for whom coverage The capacity to make metastasis is a is provided under the policy. Eligible characteristic of all malignant tumors. dependents include: CEREBROVASCULAR ACCIDENT: (a) The policyholder’s spouse or Disorder consisting of the abrupt and domestic partner (b) Biological children

23 (c) Legally adopted children A will and/or life insurance (d) Stepchildren policy which designates the other as primary beneficiary (e) Children to whom the policyholder has been appointed legal guardian The policyholder and domestic partner by a court of competent jurisdiction must jointly sign the required affidavit of domestic partnership. (f) Grandchildren born into the policy from insured dependent children DONOR: Person dead or alive from under the age of eighteen (18). whom one or more organs, cells or tissue have been removed with the purpose DIAGNOSTIC PROCEDURES: Medically of transplanting to the body of another necessary procedures and laboratory person (recipient). testing used to diagnose or treat medical conditions, including pathology, X-rays, EMERGENCY: A medical condition mani- ultrasound, and MRI/CT/PET scans. festing itself by acute signs or symptoms which could reasonably result in placing DOMESTIC PARTNER: A person of the the insured’s life or physical integrity in opposite or same sex with whom the immediate danger if medical attention policyholder has established a domestic is not provided within twenty-four (24) partnership. hours. DOMESTIC PARTNERSHIP: A relation- EMERGENCY DENTAL TREATMENT: ship between the policyholder and one Treatment necessary to restore or other person of the opposite or same replace damaged or lost teeth in a sex. All the following requirements apply covered accident. to both persons: EMERGENCY MEDICAL TREATMENT: (a) They must not be currently married Medically necessary attention or services to, or be a domestic partner of, due to an emergency. another person under either statu- tory or common law. EPIDEMIC: The occurrence of more cases than expected of a disease or (b) They must share the same perma- other health condition in a given area nent residence and the common or among a specific group of persons necessities of life. during a particular period, and declared (c) They must be at least eighteen (18) as such by the World Health Organization years of age. (WHO), or the Pan American Health (d) They must be mentally competent Organization (PAHO) in Latin America, to consent to contract. or the United States Centers for Disease Control and Prevention (CDC), or a local (e) They must be financially interde- government or equivalent body (i.e. local pendent and must have furnished ministry of health) where the epidemic documents to support at least two is developing. Usually, the cases are (2) of the following conditions of presumed to have a common cause or such financial interdependence: to be related to one another in some way. i. They have a single dedicated EXPERIMENTAL: The service, procedure, relationship of at least one (1) device, drug, or treatment that does year not adhere to the standard of practice ii. They have joint ownership of guidelines accepted in the United States a residence of America regardless of the place where iii. They have at least two (2) of the service is performed. Drugs must the following: have approval from the U.S. Food and Drug Administration (FDA) for use for A joint ownership of an the diagnosed condition, or other federal automobile or state government agency approval A joint checking, bank or required in the United States of America, investment account independent of where the medical treat- A joint credit account ment is incurred or where bills are issued. A lease for a residence GRACE PERIOD: The thirty-day (30-day) identifying both partners period after the policy’s due date during as tenants which the insurer will allow the policy to be renewed.

24 GROUND AMBULANCE TRANSPORTA- insured who is admitted to a hospital. TION: Emergency transportation to a These services also include local calls, hospital by ground ambulance. TV, and newspapers. Private nurse and HAZARDOUS ACTIVITIES: Any activity standard private room upgrade to a that exposes the participant to any suite or junior suite are not included in foreseeable danger or risk. Examples hospital services. of hazardous activities include, but are ILLNESS: An abnormal condition of the not limited to: aviation sports, rafting or body, manifested by signs, symptoms, canoeing involving white water rapids and/or abnormal findings in medical in excess of grade 5, tests of velocity, exams, which make this condition scuba diving at a depth of more than different than the normal state of the thirty (30) meters, bungee jumping, and body. participation in any extreme sport, or IN-PATIENT HOSPITALIZATION: participation in any sport as a profes- Medical or surgical care that due to its sional or for compensation. intensity must be rendered during a HIGHLY SPECIALIZED DRUGS: Drugs hospital stay of twenty-four (24) hours with a high unit cost that have a or more. The severity of the illness must significant role in maintaining patients also justify the medical necessity of in an out-patient setting, prescribed hospitalization. Treatment limited to and supervised by a specialist to treat the emergency room is not considered conditions that are uncommon, severe, in-patient hospitalization. or resistant to first line treatment. INFECTIOUS DISEASE: A clinical HOME HEALTH CARE: Care of the condition resulting from the presence of insured in the insured’s home, prescribed pathogenic microbial agents, including and certified in writing by the insured’s pathogenic viruses, pathogenic bacteria, treating physician, as required for the fungi, protozoa, multicellular parasites, proper treatment of the illness or and aberrant proteins known as prions, injury, and used in place of in-patient that can be transmitted from person treatment in a hospital. Home health to person. care includes the services of a skilled INJURY: Damage inflicted to the body licensed professional (nurse, therapist, by an external cause. etc.) outside the hospital, and does not include custodial care. INSURED: An individual for whom a health insurance application has been HOSPICE/TERMINAL CARE: Care that completed, the premium paid, coverage the insured receives following diagnosis approved and initiated by the insurer. of a terminal condition, including The term “insured” includes the poli- physical, psychological, and social care, cyholder and all dependents covered as well as accommodation in a bed, under this policy. nursing care, and prescribed drugs. This care must be approved in advance by MEDICALLY NECESSARY: A treatment, USA Medical Services. service, or medical supply prescribed by a treating physician and approved and HOSPITAL: Any institution legally coordinated by USA Medical Services. A licensed as a medical or surgical facility treatment, service, or medical supply will in the country in which it is located, not be considered medically necessary if: that is a) primarily engaged in providing diagnostic and therapeutic facilities for (a) It is provided only as a convenience clinical and surgical diagnosis, treatment to the insured, the insured’s family, and care of injured and sick persons or the provider (e.g. private nurse, by or under the supervision of a staff standard private room upgrade to of physicians; and b) not a place of suite or junior suite, etc.), or rest, a place for the aged, a nursing or (b) It is not appropriate for the insured’s convalescent home or institution, or a diagnosis or treatment, or long-term care facility. (c) It exceeds the level of care needed to HOSPITAL SERVICES: Hospital staff, provide adequate and appropriate nurses, scrub nurses, standard private diagnosis or treatment, or or semi-private room and board, and other medically necessary treatments or services ordered by a physician for the

25 (d) Falls outside the standard of prac- PANDEMIC: An epidemic occurring over tice, as established by professional a widespread area (multiple countries boards by discipline (MD, physical or continents) and usually affecting a therapy, nursing, etc.), or substantial proportion of the population. (e) It is custodial in nature. PHYSICIAN OR DOCTOR: A professional MYOCARDIAL INFARCTION: Illness legally licensed to practice medicine in consisting in the death of part of the the country where treatment is provided heart muscle as a consequence of a while acting within the scope of his/ deficient blood flow to the area. The her practice. The term “physician” or diagnosis must be supported by new “doctor” shall also apply to a profes- and relevant changes in the electrocar- sional legally licensed to practice as a diogram (EKG), and an increase in the dentist. levels of cardiac enzymes. POLICY DUE DATE: The date on which NEUROLOGICAL ILLNESSES: Diseases the premium is due and payable. during which the central nervous system POLICY EFFECTIVE DATE: The date and/or the peripheral nervous system are stated in the certificate of coverage, on affected by a pathological process with which coverage under this policy begins. origin and location within the structures POLICY YEAR: The period of twelve of central nervous system and/or the (12) consecutive months beginning on peripheral nervous system. It will not be the effective date of the policy and considered a neurological disease to the any subsequent twelve-month period effects of this insurance any disease or thereafter. disorder that affects the central nervous system and/or the peripheral nervous POLICYHOLDER: The named applicant system in a secondary way, or that was on the health insurance application. caused by conditions or factors not This individual is the person entitled related to the nervous system. to receive reimbursement for covered medical expenses and the return of any NEUROSURGERY: Any surgical proce- unearned premium. dure of the central nervous system and/or the peripheral nervous system, PRE-EXISTING CONDITION: A condi- that includes the brain, the spinal cord, tion: peripheral nerves, and the blood vessels (a) That is diagnosed by a physician of the brain and the spinal medulla. prior to the effective date of the NEWBORN: An infant from the moment policy or its reinstatement, or of birth through the first thirty-one (31) (b) For which medical advice or treat- days of life. ment was recommended by, or NURSE: A professional legally licensed received from, a physician prior to to provide nursing care in the country the effective date of the policy or where the treatment is provided. its reinstatement, or OPEN CARDIAC REVASCULARIZATION (c) For which any symptom and/or sign, SURGERY AND ANGIOPLASTY: Surgery if presented to a physician prior to of coronary arteries with the purpose of the effective date of the policy, correcting a narrowing or obstruction by would have resulted in the diagnosis means of revascularization (by-pass), of an illness or medical condition. performed after symptoms of angina PRESCRIPTION DRUGS: Medications or myocardial infarction. whose sale and use are legally restricted OUT-PATIENT SERVICES: Medical treat- to the order of a physician. ments or services provided or ordered PROVIDER NETWORK: A group of by a physician for the insured when hospitals and physicians approved and he/she is not admitted in a hospital. contracted to treat insureds on behalf of Out-patient services include services the insurer. The list of hospitals and physi- performed in a hospital or emergency cians in the provider network is available room if these services have a duration of from USA Medical Services or online at less than twenty-four (24) hours. www.bupasalud.com, and may change at any time without prior notice.

26 PROVIDER NETWORK FOR SEVERE BURNS: Injury of tissues caused TRANSPLANT PROCEDURES: A group by the action of physical or chemical of hospitals and physicians contracted agents. This policy will only consider on behalf of the insurer for the purpose severe burns those classified as third of providing transplant benefits to degree burns. the insured. The list of hospitals and SEVERE TRAUMA AND/OR POLY- physicians in the Provider Network for TRAUMA: Severe injury to one or more Transplant Procedures is available from organs or body systems caused by a USA Medical Services and may change physical external action that seriously at any time without prior notice. endangers one or more vital functions RADIATION THERAPY: Treatment of of the organism or even life, and that illnesses by way of radiation for the requires immediate hospitalization for purpose of stopping the proliferation twenty-four (24) hours or more. of malignant cells. STEPCHILD: Child born to or adopted RECIPIENT: The person who has by the spouse or domestic partner of received, or is in the process of receiving a policyholder, whom the policyholder an organ, cell or tissue transplant. has not legally adopted. REHABILITATION SERVICES: Treat- TERMINAL CONDITION: An active, ment provided by a legally licensed progressive, and irreversible illness or health professional intended to enable condition that, without life-sustaining people who have lost the ability to procedures, will result in death in the function normally through a serious near future, or a state of permanent injury, illness, surgery, or for treatment unconsciousness from which recovery of pain, to reach and maintain their is unlikely. normal physical, sensory, and intel- TRANSLUMINAL PERCUTANEOUS lectual function. These services may ANGIOPLASTY: Dilation of a blood include: medical care, physical therapy, vessel by inserting a catheter through occupational therapy and others. the skin to the area of narrowing, where RENAL INSUFFICIENCY: Terminal stage a balloon is inflated to flatten the plaque of a chronic bilateral kidney disease that against the wall of the artery. represents the total and irreversible loss TRANSPLANT PROCEDURE: Procedure of the renal function. A regular renal in which an organ, cell (e.g. stem dialysis or a kidney transplant will then cell, bone marrow, etc.), or tissue is become necessary. implanted from one part to another or RENEWAL DATE: This is the date when from one individual to another of the the premium payment is due. It may same species, or when an organ, cell, occur on a date different from the anni- or tissue is removed from the same versary date, depending on the mode individual and then received back. of payment authorized by the insurer. TREATMENT: Medical or surgical care SECOND SURGICAL OPINION: The of a patient. medical opinion of a physician other USUAL, CUSTOMARY, AND than the current treating physician. REASONABLE (UCR): It is the maximum SEPTICEMIA (SEVERE INFECTIOUS amount the insurer will consider eligible DISORDER): A disorder caused by for payment under a health insurance the proliferation of bacteria and the plan. This amount is determined based presence of its toxins in the blood on a periodic review of the prevailing that manifests itself with at least four charges for a particular service adjusted of the following conditions: Positive for a specific region or geographical blood culture, rectal temperature over area. 38.5°C (101.3°F), anemia, leukocytosis (>12,000) or leucopoenia (<4,000), thrombocytopenia (<140,000), coagula- tion disorders, and metabolic acidosis. Condition must be severe enough to warrant special care in an Intensive Care Unit or Step Down Unit.

27 SUPPLEMENT

THE CLAIM PROCESS

Insureds are required to notify USA Medical Services as soon as they know they will need any type of treatment. FOUR REASONS WHY YOU SHOULD NOTIFY USA MEDICAL SERVICES AT +1 (305) 275 1500 1. Assistance in understanding and coordinating your benefits with direct 24-hour access to our team of professional personnel. 2. Support from our staff offering guidance to you or your family for the best possible medical care and services: top rated hospitals, reputable physicians and community resources. 3. Access to qualified representatives with extensive experience in the industry to help you avoid or reduce unnecessary medical expenses and overcharges. 4. By notifying us, we can provide the best possible care management before, during and after your treatment or service.

28 BEFORE Once USA Medical Services is notified that an insured needs any type of treatment, our staff begins handling the case by communicating directly with the patient’s doctor and medical facility. As soon as we receive all the necessary information from your provider, including medical records, we will coordinate direct payment and confirm your benefits. This is how we guarantee our insureds a smooth admission to the hospital without worrying about payments or reimbursement. Additionally, we are here to coordinate and schedule air ambulances and second surgical and medical opinions. DURING During treatment and/or hospitalization, our professional staff continues to monitor the patient by communicating frequently with the doctor and hospital staff, and following up on needed treatments, progress and outcomes. We can also provide information and support to your family about the latest medical advances and treatments. Members of our staff visit patients, contact families to provide assistance, answer questions, and ensure that the patient is receiving the best quality service. AFTER Following the patient’s treatment or discharge from the hospital, our staff at USA Medical Services will coordinate any follow-up treatment or therapy, and will make the necessary arrangements until the payment of the claim is completed.

29 NOTIFICATION BEFORE TREATMENT

This section shows you what to do if your doctor informs you that you need a procedure or follow-up treatment. It also tells you what information you will need when you contact us, and what we will do to help you during the claim process. The authorization of a claim is handled by our team of professionals at USA Medical Services. They will help you get access to treatment as promptly as possible and are there to offer you guidance and information, as well as confirm coverage for any procedure. Please make sure that you have notified USA Medical Services by calling +1 (305) 275 1500 or sending an e-mail to [email protected] at least 72 hours in advance of receiving any medical care, or within the first 72 hours of receiving emergency treatment. IF YOUR DOCTOR TELLS YOU THAT YOU NEED TO SEE A SPECIALIST OR HAVE SOME TESTS DONE Call or send an e-mail to USA Medical Services. It will help us speed up your claim if you have the following details on hand: 1. The name of your referring doctor 2. Who you have been referred to 3. The test you need 4. What hospital you would like to go to It will also help if you can ask your doctor for a copy of his/her case notes or records regarding your condition, as we will need to review them. You can email or fax them to us. USA Medical Services will make arrangements for the tests, and confirm your coverage with the doctor and hospital. This normally takes a few days once we have all the information we need.

30 IF YOUR DOCTOR TELLS YOU THAT YOU NEED SURGERY OR OTHER IN-PATIENT/DAY-PATIENT TREATMENT Call or send an email to USA Medical Services. When you contact us, we will need the following: 1. The condition/symptoms being treated 2. The proposed treatment 3. Your referring doctor 4. The doctor and hospital you would like to go to Again, it will help us expedite your claim promptly if you send us copies of your doctor’s case notes or records. Once we have all of the information we need, we will: 1. Verify your policy is in effect for the time of your treatment 2. Verify that the condition and treatment is eligible under the terms of your plan 3. Confirm coverage to the hospital and doctor 4. Schedule with the hospital a convenient appointment for you Once you leave the hospital: To fully settle your claim, we will need a claim form, medical records, original invoices and the case notes. We usually receive these directly from the hospital; however, it may delay your claim if we do not get all these items and have to request them. Once your claim has been approved, we will confirm the amounts paid and notify you of any amount you need to pay the hospital or doctor (for example, the deductible you chose on your plan). In most cases, USA Medical Services will pay the hospital and doctor directly, but there are some cases when this may not be possible. This is usually the case when treatment took place in a hospital that is not part of a Bupa hospital network, if you did not notify us of the treatment, or if we require more information about your condition. IF YOUR DOCTOR RECOMMENDS PHYSICAL THERAPY OR REHABILITATION FOLLOWING SURGERY Call or send an e-mail to USA Medical Services. When you contact us, we will need the following: 1. Your therapy plan 2. The therapist you will be seeing Your doctor should provide a therapy plan that outlines how many therapist sessions you need and what kind of progress you are expected to make. We need to see this plan before we approve your therapy.

31 HOW TO FILE FOR REIMBURSEMENT

If you have followed the right steps, we are probably in the process of issuing a direct payment to your provider. However, there are circumstances when this is not possible, and we will need to process a reimbursement to you. In those cases, there are certain guidelines that you should follow, which can be found below. In order to expedite the processing of your claim, please be sure to complete the following steps: 1. Complete the claim form. Copy of the claim form can be found in your policy kit or at www.bupasalud.com. 2. Attach all medical documents if you have not already sent them in. For example: Physician’s summary Diagnostic and lab tests Prescription Medical equipment request 3. Enclose all original receipts. For example: Invoices Proof of payment 4. Send the claim no later than 180 days from the date of service to: USA Medical Services 17901 Old Cutler Road, Suite 400 Palmetto Bay, Florida 33157, USA Tel. +1 (305) 275 1500 • Fax: +1 (305) 275 1518

32 33 SECTION TITLE SUPPLEMENT

34 17901 Old Cutler Road, Suite 400 Palmetto Bay, Florida 33157 Tel. +1 (305) 398 7400 Fax +1 (305) 275 8484 www.bupasalud.com [email protected]

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