Membership Guide B U PA OPTIMUM

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...... 17 Administration...... 19 Definitions...... 25 SUPPLEMENT The claim process...... 30 Notification before treatment...... 32 How to file for reimbursement...... 34

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 this policy, brought to you by Bupa, one of the largest and most experienced health insurance companies in the world. Your policy offers the highest quality healthcare coverage around the world for expatriates and their families, frequent international travelers, and business people with busy and demanding needs. This Membership Guide contains important information about your policy benefits and conditions, how to contact us, and what to do if you need to use your coverage. Please review your certificate of coverage and other 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 evacu- care are being provided, USA Medical ation, USA Medical Services provides Services monitors your progress and advanced alert of patient arrival to the reports any change in your status to medical facility and maintains contin- your family and loved ones. uous critical communication during When every second of your life counts... transport. While treatment and initial count on USA Medical Services. AVAILABLE 24 HOURS A DAY, 365 DAYS A YEAR In the USA: +1 (305) 275-1500 Free of charge from 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 strate- Online premium payments and gies to ensure our people, products, receipts and services contribute to a better Change your demographic informa- society. We take our environmental tion impact seriously, establishing ecological policies that benefit the planet and all Sign up to be a Paperless Customer individuals in our workplace. We are PAPERLESS CUSTOMER committed to enhancing the quality of life of our customers and personnel as Our Paperless Customer solution is a well as 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 offers you comprehensive worldwide coverage within the provider network. If you need information about the provider network, please visit www.bupasalud.com or contact us directly. 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. OPTIONAL ADDITIONAL COVERAGE Bupa offers a Maternity and Perinatal Complications Rider for additional coverage, which can be included when you purchase your policy or at renewal time. The benefits provided under this rider are subject to all the terms, conditions, exclusions, limitations, and restrictions of your policy. Please consult your Table of Benefits to find out if this rider is available under your plan. The Maternity and Perinatal applies after the effective date of the Complications Rider offers a rider. Once issued, the rider will be US$500.000 lifetime optional coverage renewed annually upon the anniversary for complications of the pregnancy, date of the underlying policy, as long complications of delivery, and perinatal as the additional premium required for complications (not related to congenital the rider is paid. Available for Plans 3, or hereditary disorders) such as 4, and 5 only. prematurity, low birth weight, jaundice, hypoglycemia, respiratory distress, and birth trauma. A 10-month waiting period

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

In-country 2.000 3.500 5.000 10.000 20.000

Max. per 4.000 7.000 10.000 20.000 40.000 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 deductibles on your policy, per policy year. COINSURANCE

Out-patient treatment and services are subject to a twenty percent (20%) coinsurance up to two thousand five hundred dollars (US$2.500) per insured and five thousand dollars (US$5.000) per policy, per policy year. Cancer treatment and dialysis are not subject to coinsurance.

7 GENERAL TERMS AND CONDITIONS

NOTES ABOUT YOUR POLICY Your policy documents include this Your policy provides coverage Membership Guide (with general within the provider network only. information about Bupa, the agree- All in-patient treatment must take ment, the policy's general conditions, place in a provider network hospital. exclusions and limitations, administra- No benefits are payable for services tion, definitions, and a supplement rendered outside the provider with information about notifications network, except as specified under and claims), your Table of Benefits, the condition for Emergency Medical your Certificate of Coverage, and your Treatment. Particular Conditions. All reimbursements are paid in accor- Maximum coverage for all covered dance with the Usual, Customary, medical and hospital charges while and Reasonable (UCR) fees for the the policy is in effect is limited to the specific service. UCR is the maximum terms and conditions of your policy. amount the insurer will consider Unless otherwise stated herein, all eligible for payment, adjusted for a benefits are per insured, per policy specific region or geographical area. year. All amounts are in U.S. dollars. All out-patient treatment is subject To learn how your product works, refer to 20% coinsurance, unless otherwise to the Benefits, Exclusions and limita- stated. tions, Administration, and Definitions The insurer, USA Medical Services, sections in this Membership Guide. and/or any of their applicable related All benefits are subject to any appli- subsidiaries and affiliates will not cable deductible, unless otherwise engage in any transactions with any stated. parties or in any countries where Any diagnostic or therapeutic proce- otherwise prohibited by the laws in dure, treatment, or benefit is covered the United States of America. Please only if resulting from a condition contact USA Medical Services for more covered under this policy. information about this restriction.

8 SUPPLEMENT

9 AGREEMENT

1.1 BUPA INSURANCE COMPANY: United States. Please contact Bupa (hereinafter referred to as the or your agent for further informa- “insurer”) agrees to pay you tion related to your individual case. (hereinafter referred to as the Eligible dependents under this “policyholder”) the benefits pro- policy are those who have been vided by this policy. All benefits identified on the health insurance are subject to the terms and application and for whom cover- conditions of this policy. age is provided under the policy. 1.2 TEN (10) DAY RIGHT TO Eligible dependents include the EXAMINE THE POLICY: This policyholder’s spouse or domestic policy may be returned within ten partner, biological children, legally (10) days of receipt for a refund adopted children, stepchildren, of all premiums paid. The policy children to whom the policyholder may be returned to the insurer has been appointed legal guardian or to the policyholder’s Master by a court of competent jurisdic- General Agent. If returned, the tion, and grandchildren born into policy is void as though no policy the policy from insured dependent had been issued. children under the age of eighteen 1.3 IMPORTANT NOTICE ABOUT (18). THE APPLICATION: This policy Dependent coverage is available is issued based on the application for the policyholder’s dependent and payment of the premium. If children up to their nineteenth any information shown on the (19th) birthday if single, or up application is incorrect or incom- to their twenty-fourth (24th) plete, or if any information has birthday if single and full-time been omitted, the policy may be students at an accredited college rescinded or cancelled, or cover- or university (minimum twelve age may be modified at the sole (12) credits per semester) at the discretion of the insurer. time that the policy is issued 1.4 ELIGIBILITY: This policy can only or renewed. Coverage for such be issued in Latin America or the dependents continues through Caribbean to policyholders who the next anniversary or renewal are at least eighteen (18) years old date of the policy, whichever (except for eligible dependents), comes first after reaching nine- and not older than seventy- teen (19) years of age if single, four (74) years old. There is no or twenty-four (24) years of age maximum renewal age for insureds if single and a full-time student. already covered under this policy. Coverage for dependent sons or This policy cannot be issued and daughters with a child will end is not available to persons per- under their parent’s policy on manently residing in the United the anniversary date after the States of America. Insureds with dependent son or daughter turns work assignments, student visas, eighteen (18) years old, when he and other temporary stays within or she must obtain coverage the United States may be covered for himself or herself and his or under certain conditions as long her child under his or her own as the policyholder’s permanent individual policy. residence remains outside of the

10 If a dependent child marries, stops being a full-time student after his/ her nineteenth (19th) birthday, moves to another country, or if a dependent spouse ceases to be married to the policyholder by reason of divorce or annulment, coverage for such dependent under this policy will terminate on the next anniversary or renewal date of the policy, whichever comes first. Dependents who were covered under a prior policy with the insurer and are otherwise eli- gible 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 in effect under the prior policy. The health insurance application of the former dependent must be received before the end of the grace period for the policy which previously afforded coverage for the dependent. 1.5 REQUIREMENT TO NOTIFY THE INSURER: The insured must contact USA Medical Services, the insurer’s claims administrator, at least seventy-two (72) hours in advance of receiving any medical care. Emergency treatment must be notified within seventy-two (72) hours of beginning such treatment. If the insured fails to contact USA Medical Services as stated herein, he/she will be responsible for thirty percent (30%) of all covered medical and hospital charges related to the claim, in addition to the plan’s deductible.

11 BENEFITS

IN-PATIENT BENEFITS OUT-PATIENT BENEFITS AND LIMITATIONS AND LIMITATIONS 2.1 HOSPITAL SERVICES: Coverage 3.1 AMBULATORY SURGERY: is provided as described in your Ambulatory or out-patient sur- Table of Benefits only when in- gical procedures performed in a patient hospitalization is medically hospital, clinic, or doctor’s office necessary. are covered as described in your 2.2 MEDICAL AND NURSING FEES: Table of Benefits. These surger- Physician, surgeon, anesthesi- ies allow the patient to go home ologist, assistant surgeon, spe- the same day that they have the cialists, and other medical and surgical procedure. Ambulatory nursing fees are covered only surgery is subject to coinsurance. when they are medically neces- 3.2 OUT-PATIENT SERVICES: sary for the surgery or treatment Coverage is only provided as and approved in advance by USA described in your Table of Benefits Medical Services. Medical and when medically necessary. All nursing fees are limited to the out-patient treatment is subject lesser of: to coinsurance, unless otherwise (a) The usual, customary and specified in your Table of Benefits. reasonable fees for the proce- 3.3 PRESCRIPTION DRUGS: dure, or Prescription drugs first pre- (b) Special rates established for an scribed after hospitalization or area or country as determined out-patient surgery for a medical by the insurer. condition covered by the policy are covered as described in the 2.3 PRESCRIPTION DRUGS: Drugs Table of Benefits. A copy of the prescribed while in-patient are prescription from the treating covered as described in your Table physician must accompany the of Benefits. claim. All covered expenses, up 2.4 PROVIDER NETWORK: Your to the maximum benefit, will first policy provides coverage within be applied towards the deduct the provider network in the United Once the expenses exceed the States of America and open deductible amount, the insurer network in the rest of the world. will pay the difference between There is no coverage outside the the amount of expenses applied to provider network in the United the deductible and the amount of States of America, except for the out-patient prescription drug emergencies, which are covered benefit limit. under 6.4. 3.4 PHYSICAL THERAPY AND (a) The list of hospitals and REHABILITATION SERVICES: physicians in the provider Physical therapy and rehabilitation network is available from USA sessions are covered as described Medical Services or online at in your Table of Benefits and must www.bupasalud.com, and may be pre-approved. Updated evi- change at any time without dence of medical necessity and prior notice. a treatment plan are required in (b) In order to ensure that the advance to obtain each approval. provider of medical services is A session may include multiple dis- part of the provider network, ciplines such as physical therapy, all treatments must be coordi- occupational therapy, and speech nated by USA Medical Services. language pathology, and will be treated as one session if all are 2.5 COMPANION OF A scheduled together, or will be HOSPITALIZED CHILD: Charges treated as separate sessions if included in the hospital bill for scheduled on different days or overnight hospital accommoda- times. tions for the companion of a hospi- talized insured child under the age 3.5 HOME HEALTH CARE: Home of eighteen (18) will be payable as health care is covered as described described in your Table of Benefits. in your Table of Benefits and must be pre-approved. Updated

12 evidence of medical necessity and with the same conditions and treatment plan are required in and restrictions in effect under advance to obtain each approval. the prior policy. If there is no 3.6 ROUTINE HEALTH CHECKUP: gap in coverage, the ten (10) Routine physical examinations calendar month waiting period may include diagnostic studies for the daughter’s policy will be and vaccinations. reduced by the time she was covered under her parent’s MATERNITY BENEFITS AND policy. LIMITATIONS (f) Complications of maternity are covered under 4.3. 4.1 PREGNANCY, MATERNITY, AND BIRTH (Plans 1 and 2 only): 4.2 NEWBORN COVERAGE: (a) The maximum benefit covered (a) Provisional coverage: per pregnancy is described in If born from a covered preg- your Table of Benefits. nancy, each newborn will (b) Pre- and post-natal treatment, automatically be covered for childbirth, cesarean deliveries, complications of birth and for and well baby care are included any injury or illness during the under this benefit. first ninety (90) days after (c) Covered pregnancies are those birth, as described in your for which the actual date of Table of Benefits. delivery is at least ten (10) If not born from a covered calendar months after the pregnancy, there is no effective date of coverage for provisional coverage for the the respective insured female. newborn. (d) In addition to the above, the (b) Permanent coverage: following conditions regarding i. Automatic addition: For pregnancy, maternity, and birth the purpose of adding apply to eligible dependent a newborn child to the sons or daughters and their parent’s policy without children. On the anniversary underwriting, the parent’s date after the insured depen- policy must have been dent son or daughter turns in effect for at least ten eighteen (18) years old, he or (10) consecutive calendar she must obtain coverage for months. To be added, a himself or herself and his or copy of the birth certificate her child under his or her own including the newborn’s individual policy if he or she full name, gender, and wants to maintain coverage for date of birth must be his or her child. He or she must submitted within ninety submit written notification, (90) calendar days of birth. which will be approved without If the birth certificate is not underwriting for a product with received within ninety (90) the same or lower pregnancy, calendar days of birth, an maternity, and birth benefits, International Healthcare with the same or higher Solutions Insurance deductible, and with the same Application is required for conditions and restrictions in the addition and will be effect under the prior policy. subject to underwriting. (e) To be eligible for pregnancy, The premium for the addi- maternity, and birth coverage, tion is due at the time of an insured dependent daughter the notification of birth. age eighteen (18) or older must Coverage with applicable submit written notification. The deductible will then be notification must be received effective as of the date of before the actual date of birth up to the policy limits. delivery, and will be approved ii. Non-automatic addition: without underwriting for a The addition of children product with the same or born before the parent’s lower pregnancy, maternity, policy has been in effect for and birth benefits, with the at least ten (10) consecu- same or higher deductible, tive calendar months is

13 subject to underwriting. considered a complication To be added to their of pregnancy, maternity, and parent’s policy, a completed birth. International Healthcare (e) Complications caused by a Solutions Insurance covered condition that was Application, birth certifi- diagnosed before the preg- cate, and premium payment nancy, and/or consequences are required. thereof, will be covered up to The addition of adopted policy limits. children, children born as Consult your Table of Benefits a result of a fertility treat- to confirm if your plan offers the ment, and children born option to purchase the Maternity by a surrogate mother are and Perinatal Complications subject to underwriting. An Rider. However, this rider is not International Healthcare available for dependent children. Solutions Insurance Application and a copy of EVACUATION BENEFITS the birth certificate must AND LIMITATIONS be submitted, which will be subject to the standard 5.1 MEDICAL EMERGENCY underwriting procedures. EVACUATION: Emergency trans- portation (by ground or air ambu- (c) Well baby care is covered as lance) is covered as described in described in your Table of your Table of Benefits if related Benefits. to a covered condition for which 4.3 COMPLICATIONS OF PREGNANCY, treatment cannot be provided MATERNITY, AND BIRTH (Plans 1 locally, and transportation by any Maternity complications other method would result in loss and 2 only): of life or limb. Emergency trans- and/or newborn complications of portation must be provided by birth (not related to congenital or a licensed and authorized trans- hereditary disorders), such as pre- portation company to the nearest maturity, low birth weight, jaundice, medical facility. The vehicle or hypoglycemia, respiratory distress, aircraft used must be staffed by medically trained personnel and and birth trauma are covered as must be equipped to handle a follows: medical emergency. (a) This benefit shall apply only if Air ambulance transportation: all the stipulations in 4.1 and (a) All air ambulance transporta- 4.2 of this policy have been tion must be pre-approved and met. coordinated by USA Medical (b) This benefit does not apply Services. to complications related to (b) The insured agrees to hold the any condition excluded or not insurer, USA Medical Services, covered by the policy, including and any company affiliated but not limited to maternity with the insurer or USA Medical and newborn complications of Services by way of similar birth in a pregnancy that is the ownership or management, result of any type of fertility harmless from negligence treatment or any type of resulting from such services, assisted fertility procedure, or or negligence resulting from pregnancies where the actual delays or restrictions on flights date of delivery takes place caused by the pilot, mechanical during the ten (10) calendar problems, or governmental month maternity waiting restrictions, or due to opera- period. tional conditions. (c) Ectopic pregnancies and (c) In the event that the insured miscarriages are covered up is transported for the purpose to the maximum amount listed of receiving treatment, he/she in this benefit. and the accompanying person, (d) For the purpose of this policy, if any, shall be reimbursed a cesarean delivery is not for the expenses for a return journey to the place from

14 where the insured was evacu- of the prosthetic device (i.e., a ated. The return journey shall condition that may prohibit a be made no later than ninety normal walking pace). (90) days after treatment has Repair of the prosthetic limb is been completed. Coverage covered only when anatomical or shall only be provided for trav- functional change or reasonable eling expenses equivalent to wear and tear renders the item the cost of an airplane ticket on nonfunctional and the repair will economy class, as a maximum. make the equipment usable. Transportation services must be pre-approved and coordi- Replacement of the prosthetic nated by USA Medical Services. limb is covered only when ana- tomical or functional change or 5.2 REPATRIATION OF MORTAL reasonable wear and tear renders REMAINS: In the event an insured the item nonfunctional and non- dies outside of his/her country reparable. Initial coverage, repair, of residence, the insurer will pay and/or replacement of prosthetic the charges toward repatriation of limbs must be pre-approved by the deceased’s remains to his/her USA Medical Services. country of residence if the death resulted from a covered condi- 6.3 SPECIAL TREATMENTS: tion under the terms of the policy. Prosthesis, appliances, orthotic Coverage is limited to only those durable medical equipment, services and supplies necessary implants, radiation therapy, to prepare the deceased’s body chemotherapy, and the follow- and to transport the deceased ing highly specialized drugs: to his/her country of residence. Interferon beta-1a, PEGylated Arrangements must be coordi- Interferon alpha-2a Alfa, Interferon nated in conjunction with USA beta-1b, Etanercept, Adalimumab, Medical Services. Bevacizumab, Cyclosporine A, Azathioprine, and Rituximab will OTHER BENEFITS AND LIMITATIONS be covered but must be approved and coordinated in advance by 6.1 CONGENITAL AND/OR USA Medical Services. For cover- HEREDITARY DISORDERS: age of prosthetic limbs, please Congenital and/or hereditary dis- refer to 6.2. orders are covered as described in your Table of Benefits. The benefit 6.4 EMERGENCY MEDICAL begins once the congenital and/ TREATMENT (with or without or hereditary condition has been admission): Your policy covers diagnosed by a physician. The emergency medical treatment benefit is retroactive to any period outside the provider network only prior to the identification of the when the insured’s life or physical current condition. integrity is in immediate danger, and the emergency has been noti- 6.2 PROSTHETIC LIMBS: Prosthetic fied to USA Medical Services, as limb devices include artificial provided for under this policy. All arms, hands, legs, and feet, and medical expenses from a non- are covered as described in your network provider in relation to Table of Benefits. The benefit emergency medical treatment will includes all the costs associated be paid as if the insured had been with the procedure, including any treated at a network hospital. therapy related to the usage of the new limb. 6.5 EMERGENCY DENTAL TREATMENT: Only emergency Prosthetic limbs will be covered dental treatment needed as a when the individual is capable of result of a covered accident, and achieving independent function- that takes place within ninety (90) ality or ambulation with the use of days of the date of such accident, the prosthesis and/or prosthetic will be covered under this policy. limb device, and the individual does not have a significant car- 6.6 HOSPICE/TERMINAL CARE: diovascular, neuromuscular, or Hospice accommodations and musculoskeletal condition which terminal care treatment and ser- would be expected to adversely vices are covered as described in affect or be affected by the use your Table of Benefits for patients that have received a diagnosis for a terminal condition with a life

15 expectancy of six (6) months or not subject to coinsurance. This less, and need physical, psycho- transplant benefit begins once the logical, and social care, as well need for transplantation has been as special equipment fitting or determined by a physician, has adaptation, nursing care, and been certified by a second surgi- prescribed drugs. This care must cal or medical opinion, and has be approved in advance by USA been approved by USA Medical Medical Services and is subject to Services, and is subject to all the deductible and coinsurance. terms, conditions and exclusions 6.7 NOSE AND NASAL SEPTUM of the policy. DEFORMITY: When nose or nasal This benefit includes: septum deformity is the result of (a) Pre-transplant care, including trauma during a covered accident, those services directly related surgical treatment will only be to evaluation of the need for covered if authorized in advance transplantation, evaluation of by USA Medical Services. The evi- the insured for the transplant dence of trauma in the form of procedure, and preparation fracture must be confirmed radio- and stabilization of the graphically (X-rays, CT scan, etc.). insured for the transplant 6.8 PRE-EXISTING CONDITIONS: procedure. Pre-existing conditions fall into (b) Pre-surgical workup, including two (2) categories: all laboratory and X-ray (a) Disclosed at the time of the exams, CT scans, Magnetic application: Resonance Imaging (MRI’s), ultrasounds, biopsies, scans, i. Free of symptoms, signs, medications and supplies. and treatment during the five (5) year period prior (c) The costs of organ, cell or to the effective date of the tissue procurement, trans- policy, pre-existing condi- portation, and harvesting including bone marrow, stem tions are covered upon cell or cord blood storage or expiration of the sixty-day banking. (60-day) waiting period, unless specifically excluded (d) The donor workup, including by an amendment to the testing of potential donors policy. for a match. ii. With symptoms, signs, or (e) The hospitalization, surgeries, treatment any time during physician and surgeon’s fees, the five (5) year period anesthesia, medication, and prior to the effective date any other treatment neces- of the policy, pre-existing sary during the transplant conditions will be covered procedure. after two (2) years from the (f) Post-transplant care effective date of the policy, including, but not limited unless specifically excluded to any medically necessary by an amendment to the follow-up treatment resulting policy. from the transplant and any complications that arise after (b) Not disclosed at the time the transplant procedure, of application: Pre-existing whether a direct or indirect conditions not disclosed at consequence of the trans- the time of the application plant. will NEVER be covered during the lifetime of the (g) Medication or therapeutic policy. Furthermore, the measures used to ensure the insurer retains the right to viability and permanence of rescind, cancel or modify the the transplanted organ, cell policy based on the insured’s or tissue. failure to disclose any such (h) Home health care, nursing conditions. care (e.g. wound care, infusion, assessment, etc.), 6.9 TRANSPLANT PROCEDURES: emergency transportation, Transplant procedures are medical attention, clinic or covered as described in your Table of Benefits. This benefit is

16 office visits, transfusions, will also be covered if proven to supplies, or medication have been contracted as a result related to the transplant. of an accident occurring­ during 6.10 COMPLEMENTARY THERAPIST: the course of a normal occupa- Out-patient treatment received tion for the following professions:­ from an osteopathic doctor, a chi- doctors, dentists, nurses, labora- ropractor, and/or a psychiatrist tory personnel, ancillary hospi- is covered as described in your tal workers, medical and dental Table of Benefits, and subject to assistants, ambulance personnel,­ coinsurance. midwives, fire brigade per­sonnel, police officers, and prison offi- 6.11 HIV/AIDS: Diseases related to cers. The insured shall notify the AIDS and HIV antibodies­ (HIV insurer within fourteen (14) days positive) are covered as described after such accident, and at the in your Table of Benefits if proven same time provide a negative HIV to be caused by a blood transfu- antibody test dated prior to the sion received after the effective date of the policy. The HIV virus accident. 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- 7.4 ALTERNATIVE MEDICINE: COVERED TREATMENT: Homeopathic treatment, acupunc- Treatment of any illness, injury, ture, and any type of alternative or charges arising from any treat- medicine, except as described in ment, service or supply: your Table of Benefits. (a) That is not medically necessary, 7.5 TREATMENT DURING WAITING or PERIOD: Any illness or injury not (b) For an insured who is not under caused by an accident or a disease the care of a physician, doctor of infectious origin which is first or licensed professional, or manifested within the first sixty (60) days from the effective date (c) That is not authorized or of the policy. prescribed by a physician or doctor, or 7.6 COSMETIC SURGERY: Cosmetic surgery or medical treatment (d) That is related to custodial care, which is primarily for beautifica- or tion, unless required due to the (e) That takes place at a hospital, treatment of an injury, deformity but for which the use of or illness that compromises func- hospital facilities is not neces- tionality and that first occurred sary. while the insured was covered 7.2 SELF-INFLICTED ILLNESS OR under this policy. This also INJURY: Any care or treatment, includes any surgical treatment while sane or insane, received due for nasal or septal deformity that to self-inflicted illness or injury, was not induced by trauma. suicide, attempted suicide, alcohol 7.7 PRE-EXISTING CONDITIONS: use or abuse, drug use or abuse, Any charges in connection with or the use of illegal substances pre-existing conditions, except or illegal use of controlled sub- as defined and addressed in this stances, including any accident policy. resulting from any of the afore- 7.8 EXPERIMENTAL OR OFF-LABEL mentioned criteria. TREATMENT: Any treatment, 7.3 EXAMINATIONS AND AIDS FOR service, or supply that is not sci- EYES AND EARS: Routine eye and entifically or medically recognized ear examinations, hearing aids, for a specific diagnostic, or that is eye glasses, contact lenses, radial considered as off label use, experi- keratotomy, and/or other proce- mental and/or not approved for dures to correct eye refraction general use by the U.S. Food and disorders. Drug Administration.

17 7.9 TREATMENT IN GOVERNMENTAL 7.17 TREATMENT BY IMMEDIATE FACILITY: Treatment in any gov- FAMILY MEMBER: Treatment ernmental facility, or any expense performed by the spouse, parent, if the insured would be entitled to sibling, or child of any insured free care. Service or treatment for under this policy. which payment would not have 7.18 OVER-THE-COUNTER AND NON- to be made had no insurance PRESCRIPTION DRUGS: Over the coverage existed, or that have counter or non-prescription drugs, been placed under the direction as well as the following: of government authority. (a) Drugs that are not medically 7.10 MENTAL AND BEHAVIORAL necessary, including any drugs DISORDERS: In-patient diagnos- given in connection with a tic procedures and/or treatment service or supply that is not of psychiatric disorders, mental medically necessary. illnesses, and/or behavioral or developmental disorders, chronic (b) Any contraceptive drugs or fatigue syndrome, sleep apnea, devices, even if ordered for and any other sleep disorders, non-contraceptive purposes. unless resulting from treatment (c) Drugs or immunizations to for a covered condition. prevent allergies. 7.11 CHARGES IN EXCESS OF UCR: (d) Drugs for tobacco dependency. Any portion of any charge in (e) Cosmetic drugs, even if ordered excess of the usual, customary for non-cosmetic purposes. and reasonable charge for the par- ticular service or supply for the (f) Drugs taken at the same time geographical area, or appropriate and place where the prescrip- level of treatment being received. tion is ordered. 7.12 COMPLICATIONS OF NON- (g) Charges for giving, adminis- COVERED CONDITIONS: tering or injecting drugs. Treatment or service for any (h) Any refill that is more than the medical, mental, or dental condi- number of refills ordered by tion related to or arising as a com- the physician, or is made more plication of those medical, mental, than one year after the latest or dental services or other condi- prescription was written. tions specifically excluded by an amendment to, or not covered by (i) Therapeutic devices, appli- this policy. ances or injectables, including colostomy supplies and 7.13 DENTAL TREATMENT NOT support garments, regardless RELATED TO COVERED of intended use. ACCIDENT: Any dental treatment or service not related to a covered (j) Progesterone suppositories. accident, or that occurs beyond (k) Vitamin supplements. ninety (90) days from the date 7.19 PERSONAL OR HOME- of a covered accident. BASED ARTIFICIAL KIDNEY 7.14 POLICE OR MILITARY RELATED EQUIPMENT: Personal or home- INJURIES: Treatment of injuries based artificial kidney equipment, resulting while in service as a unless authorized in writing by member of a police or military the insurer. unit, or from participation in war, 7.20 TISSUE AND/OR CELL STORAGE: riot, civil commotion, illegal activi- Storage of bone marrow, stem ties, and resulting imprisonment. cell, or other tissue or cell, except 7.15 HIV/AIDS: The Acquired Immune umbilical cord blood as provided Deficiency Syndrome (AIDS), HIV for under the conditions of the positive or AIDS-related illnesses, policy. Cost related to the acqui- except when coverage is included sition and implantation of an in your Table of Benefits. artificial heart, other artificial or animal organs, and all expenses 7.16 ELECTIVE HOSPITAL for cryopreservation of more than ADMISSION: An elective admis- sion more than twenty-three (23) twenty-four (24) hours. hours before a planned surgery, 7.21 TREATMENT RELATED TO unless authorized in writing by RADIATION OR NUCLEAR the insurer. CONTAMINATION: Injury or illness caused by, or related to,

18 ionized radiation, pollution or con- 7.26 FERTILITY AND INFERTILITY tamination, radioactivity from any TREATMENTS: Any kind of nuclear material, nuclear waste, or fertility and infertility treatment the combustion of nuclear fuel or and procedure, including but not nuclear devices. limited to tubal ligation, vasec- 7.22 MEDICAL EXAMINATIONS AND tomy, and any other elective pro- CERTIFICATES: Any medical cedure to prevent pregnancy that examination or diagnostic study is meant to be permanent, as well which is part of a routine physical as reversal of voluntary steriliza- examination, including vaccina- tion, artificial insemination, and tions and the issuance of medical the use of a surrogate mother. certificates and examinations as 7.27 FERTILITY AND INFERTILITY to the suitability for employment TREATMENT COMPLICATIONS: or travel, except as described in Maternity complications as a your Table of Benefits. result of any type of fertility and 7.23 WEIGHT RELATED TREATMENT: infertility treatment or any type of Any expense, service or treatment assisted fertility procedure. for obesity, weight control, or any 7.28 MATERNITY TREATMENT form of food supplement, except DURING WAITING PERIOD: All as provided for in this policy. maternity-related treatment to a 7.24 GROWTH TREATMENT: mother or a newborn during the Treatment by a bone growth stim- ten (10) month pregnancy and ulator, bone growth stimulation maternity waiting period. or treatment relating to growth 7.29 ABORTION: Any voluntarily hormone, regardless of the reason induced termination of pregnancy, for prescription. unless the mother’s life is in immi- 7.25 CONDITIONS RELATED TO nent danger. SEX OR GENDER ISSUES AND 7.30 PODIATRIC CARE: Pedicures, SEXUALLY TRANSMITTED special shoes, and inserts of any DISEASES: Any expense for type or form. gender reassignment, sexual dys- 7.31 EPIDEMIC/PANDEMIC DISEASES: function including but not limited Treatment for or arising from to impotence, inadequacies, disor- any epidemic and/or pandemic ders related to sexually transmit- disease and vaccinations, medi- ted human papillomavirus (HPV), cines, or preventive treatment for and any other sexually transmitted or related to any epidemic and/or diseases. pandemic disease are not covered. ADMINISTRATION

GENERAL 8.4 PPACA RIGHTS AND 8.1 AUTHORITY: No consultant has DISCLAIMER: This policy does the authority to change the policy NOT provide all of the rights and or to waive any of its conditions. protections of the Affordable Care After the policy has been issued, Act (i.e., the U.S. health care law). no change shall be valid unless These include, but are not nec- approved in writing by an officer essarily limited to, one or more or the chief underwriter of the insurer, and such approval is of the protections of the Public endorsed by an amendment to Health Service Act. A Health the policy. Insurance Marketplace, through 8.2 CURRENCY: All currency values which individuals may enroll in stated in this policy are in U.S. a qualified health plan and pos- dollars (US$). sibly qualify for federal subsidies, 8.3 ENTIRE CONTRACT- is not currently available outside CONTROLLING CONTRACT: of the continental United States. The policy (this document), the To learn more about the Health International Healthcare Solutions Insurance Marketplace and pro- Insurance Application, the certifi- tections under the U.S. health care cate of coverage, and any riders or law, visit www.HealthCare.gov or amendments thereto, shall consti- call 1-800-318-2596. tute the entire contract between the parties.

19 POLICY the first sixty (60) days from the effective date of the change, 9.1 POLICY ISSUANCE: The policy is benefits payable for any illness deemed issued or delivered upon or injury not caused by accident its receipt by the policyholder in or disease of infectious origin, will his/her country of residence. be limited to the lesser of benefits 9.2 WAITING PERIOD: This policy provided by the new plan or the contains a sixty-day (60-day) prior plan. During the first ten (10) waiting period, during which only months after the effective date of illnesses or injuries caused by an the change, benefits for maternity, accident occurring within this newborn, and congenital will be period, or diseases of infectious limited to the lesser benefit pro- origin that first manifest them- vided by either the new plan or selves within this period, will be prior plan. During the first six (6) covered. months after the effective date 9.3 BEGINNING AND ENDING OF of the change, transplant benefits INSURANCE COVERAGE: Subject will be limited to the lesser benefit to the conditions of this policy, provided by either the new plan benefits begin on the effective or prior plan. date of the policy and not on the 9.6 CHANGE OF COUNTRY OF date of application for insurance. RESIDENCE: The insured must Coverage begins at 00:01 hours notify the insurer in writing of Eastern Standard Time (USA) on any change of his/her country of the policy’s effective date and ter- residence within thirty (30) days minates at 24:00 hours Eastern of its occurrence. A change of Standard Time (USA): country of residence may result in (a) On the expiration date of the modification of coverage, deduct- policy, or ible, or premium according to the geographical area, subject to the (b) Upon non-payment of the insurer’s procedures. premium, or 9.7 TERMINATION OF COVERAGE (c) Upon written request from UPON TERMINATION OF the policyholder to terminate POLICY: In the event a policy his/her coverage, or terminates for any reason, cov- (d) Upon written request from erage ceases on the effective the policyholder to terminate date of the termination, and the a dependent’s coverage, or insurer will only be responsible (e) Upon written notification for any covered treatment under from the insurer, as allowed the terms of the policy that took by the conditions of this place before the effective date of policy. termination of the policy. There is no coverage for any treatment If a policyholder would like to ter- that occurs after the effective date minate coverage for any reason, of the termination, regardless of he/she may only do so as from when the condition first occurred the anniversary date with two (2) or how much additional treatment months written notice. may be required. All policies are 9.4 POLICY MODE: 9.8 REFUNDS: If a policyholder deemed annual policies. Premiums cancels the policy after it has been are to be paid annually, unless the issued, reinstated or renewed, insurer authorizes other mode of the insurer will not refund the payment. unearned portion of the premium. 9.5 CHANGE OF PRODUCT OR PLAN: If the insurer cancels the policy for The policyholder can request to any reason under the terms of this change a product or plan at any policy, the insurer will refund the anniversary date. This request unearned portion of the premium must be submitted in writing and minus administrative charges and received before the anniversary policy fees, up to a maximum of date. Some requests are subject sixty-five percent (65%) of the to underwriting evaluation. During premium. The policy fee, USA

20 Medical Services fee, and thirty- coverage goes into effect as per five percent (35%) of the base the next renewal date or anniver- premium are non-refundable. The sary date, whichever comes first, unearned portion of the premium after the death of the policyholder. is based on the number of days corresponding to the payment RENEWAL mode, minus the number of days 10.1 PREMIUM PAYMENT: The policy- the policy was in effect. holder is responsible for paying 9.9 WAIVING OF WAITING PERIOD: the premium on time. Premium The insurer will waive the waiting payment is due on the renewal period only if: date of the policy or any other (a) Other medical expense insur- due date authorized by the insurer. ance for the insured was in Premium notices are provided as a effect with another company courtesy, and the insurer provides for at least one (1) continuous no guarantee of delivering such year, and notices. If a policyholder has not received a premium notice thirty (b) The effective date of this (30) days prior to the premium policy begins within sixty (60) payment due date, and the policy- days of the expiration of the holder does not know the amount previous coverage, and of the premium payment, he/she (c) The prior coverage is should contact his/her Master disclosed in the health insur- General Agent or the insurer. ance application, and Payment may also be made online (d) We receive the prior policy at www.bupasalud.com. and a copy of the receipt 10.2 PREMIUM RATE CHANGES: for the last year’s premium The insurer retains the right to payment, with the health change the premium at the time insurance application. of each renewal date. This right If the waiting period is waived, will be exercised on a “class” basis benefits payable for any condition only on the renewal date of each manifested during the first sixty respective policy. (60) days of coverage are limited, 10.3 GRACE PERIOD: If premium while the policy is in effect, to the payment is not received by the lesser benefit provided by either due date, the insurer will allow a this policy or the prior policy. grace period of thirty (30) days 9.10 EXTENDED COVERAGE TO from the due date for the premium ELIGIBLE DEPENDENTS UPON to be paid. If the premium is not DEATH OF POLICYHOLDER: In received by the insurer prior to the event of the death of the poli- the end of the grace period, this cyholder, the insurer will provide policy and all of its benefits will continued coverage as described be deemed terminated as of the in your Table of Benefits, for the original due date of the premium. surviving dependents insured Benefits are not provided under under this policy at no charge if the policy during the grace period. the cause of the death of the poli- 10.4 POLICY CANCELLATION OR cyholder results from a covered NON-RENEWAL: The insurer condition under this policy. This retains the right to cancel, modify benefit only applies to covered or rescind the policy if statements dependents under the existing on the health insurance applica- policy, and will automatically ter- tion are found to be misrepresen- minate in the event of marriage tations, incomplete, or if fraud of the surviving spouse/domestic has been committed, leading the partner, or for surviving depen- insurer to approve an application dents who are not otherwise when, with the correct or com- eligible for coverage under this plete information, the insurer policy and/or are issued their own would have issued a policy with separate policy. This extended restricted coverage or declined to coverage does not apply to any provide insurance. optional rider. The extended

21 If the insured changes country conducted by a physician chosen of residence, and the insured’s and arranged by USA Medical current plan is not available in Services. Only those second surgi- the insured’s new country of resi- cal opinions required and coordi- dence, the insurer retains the right nated by USA Medical Services are not to renew or to modify a policy covered. In the event the second in terms of rates, deductibles or surgical opinion contradicts or benefits, generally and specifi- does not confirm the need for cally, in order to offer the insured surgery, the insurer will also pay the closest equivalent insurance for a third surgical opinion from coverage available, if any. a physician chosen in agreement Submission of a fraudulent claim between the insured and USA is also grounds for rescission or Medical Services. If the second cancellation of the policy. or third surgical opinion confirms the need for surgery, benefits for The insurer retains the right to the surgery will be paid according cancel, non-renew or modify to this policy. a policy on a “block” basis as defined in this policy, and the Consult your Table of Benefits insurer will offer the insured for more details on this clause's the closest equivalent insur- requirements and if your policy ance coverage available, if any. includes a fee for non-compliance. No individual insured shall be 11.3 DEDUCTIBLE: independently penalized by (a) All insureds under the policy cancellation or modification of have a deductible responsibility the policy due solely to a poor per policy year for treatment claim record. in-country or out-of-country 10.5 REINSTATEMENT: If the policy according to the plan selected was not renewed within the grace by the policyholder. When period, it can be reinstated within applicable, the corresponding sixty (60) days after the grace deductible amount is applied period at the insurer’s discretion, if per insured, per policy year the insured provides new evidence before benefits are paid or of insurability consisting of a new reimbursed to the insured. health insurance application and All deductible amounts paid any other information or docu- accumulate towards the ment required by the insurer. No corresponding maximum reinstatement will be authorized deductible per policy, which after ninety (90) days of the ter- is equivalent to the sum of mination date of the policy. two individual deductibles. All insureds under the policy CLAIMS contribute to meeting the 11.1 DIAGNOSIS: For a condition to in-country or 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 will on which the diagnosis was based, consider all individual deduct- are required as part of the positive ible responsibilities as met. diagnosis by a physician. (b) Any eligible charges incurred 11.2 REQUIRED SECOND SURGICAL by an insured during the last OPINION: If a surgeon has recom- three (3) months of the policy mended a non-emergency surgi- year will apply to that policy cal procedure, the insured must year’s deductible and will also notify USA Medical Services at be carried over to be applied least seventy-two (72) hours prior towards that insured’s deduct- to the scheduled procedure. If a ible for the following policy second surgical opinion is deemed year. necessary by either the insurer or (c) In case of a serious accident, USA Medical Services, it must be no deductible shall apply

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

23 is the basis of a claim, when and arbiters, the decision will rest with as often as considered necessary the majority. Either the insured or by the insurer before the claim is the insurer may initiate arbitra- agreed. tion by written notice to the other 11.8 DUTY TO COOPERATE: The party demanding arbitration and insured shall make all medical naming its arbiter. The other party reports and records available to shall have twenty (20) days after the insurer and, when requested receipt of said notice within which by the insurer, shall sign all neces- to designate its arbiter. The two sary authorization forms for the (2) arbiters named by the parties, insurer to obtain medical reports within ten (10) days thereafter, and records. Failure to cooper- shall choose the third arbiter and ate with the insurer or failure to the arbitration shall be held at authorize the release of all medical the place hereinafter set forth ten records requested by the insurer (10) days after the appointment may cause a claim to be denied. of the third arbiter. If the other party does not name its arbiter 11.9 CLAIMS APPEALS: In the event within twenty (20) days, the com- of a disagreement between the plaining party may designate the insured and the insurer regarding second arbiter and the other party this insurance policy and/or its shall not be aggrieved thereby. conditions, before beginning any Arbitration shall take place in arbitration or legal proceeding, the Miami-Dade County, Florida, USA, insured shall request a review of or if approved by the insurer, in the matter by the Bupa Insurance the policyholder’s country of resi- Company appeals committee. In dence. The insured and the insurer order to begin such review, the agree that each party will pay their insured must submit a written own expenses in regards to the request to the appeals commit- arbitration. tee. This request shall include copies of all relevant information The insured confers exclusive sought to be considered, as well jurisdiction in Miami-Dade County, as an explanation of the decision Florida for the determination of that should be reviewed and why. any rights under this policy. The The request shall be sent to the insurer and any insured covered attention of the Bupa Insurance by this policy hereby expressly Company appeals coordinator, c/o agree to trial by judge in any USA Medical Services. Upon sub- legal action arising directly or mission of a request for review, the indirectly from this policy. The appeals committee will determine insurer and the insured further whether any further information agree that each party will pay and/or documentation is needed their own attorneys’ fees and and act to timely obtain it. The costs, including those incurred appeals committee will notify the in arbitration. insured of its decision and the 11.11 SUBROGATION AND INDEMNITY: underlying rationale within thirty The insurer has a right of subroga- (30) days. tion or reimbursement from or 11.10 CLAIMS ARBITRATION, LEGAL on behalf of an insured to whom ACTIONS, AND JURY WAIVER: it has paid any claims, if such Any disagreement that may insured has recovered all or part persist upon completion of the of such payments from a third claims appeal as determined party. Furthermore, the insurer herein, must first be submitted has the right to proceed at its for arbitration. In such cases, own expense in the name of the the insured and the insurer will insured, against third parties who submit their difference to three may be responsible for causing (3) arbiters: Each party selecting a claim under this policy, or who an arbiter, and the third arbiter to may be responsible for providing be selected by the arbiters named indemnity of benefits for any claim by the parties herein. In the event under this policy. of disagreement between the

24 DEFINITIONS

ACCIDENT: An unfortunate incident including but not limited to hyperbili- that occurs unexpectedly and suddenly, rubinemia (jaundice), cerebral hypoxia, provoked by an external cause, always hypoglycemia, prematurity, respiratory without the insured’s intention, which distress and birth trauma. causes injury or bodily trauma and COMPLICATIONS OF PREGNANCY, requires immediate ambulatory medical MATERNITY, AND/OR BIRTH: Any attention and/or patient’s hospital condition caused by, and/or that occurs admission. The medical information as a result of the pregnancy, maternity, related to the accident will be evaluated or birth (not related to congenital or by the insurer, and the compensability hereditary disorders). For the purpose will be determined under the general of this coverage, cesarean deliveries policy’s provisions. are not considered a complication of ACCIDENTAL BODILY INJURY: pregnancy, maternity, and/or birth. Damage inflicted to the body caused CONGENITAL AND/OR HEREDITARY by a sudden and unforeseen external DISORDER: Any disorder or illness cause. acquired during conception or the AIR AMBULANCE TRANSPORTATION: fetal stage of development as a result Emergency air transportation from the of the genetic make-up of the parents hospital where the insured is admitted or environmental factors, whether or to the nearest suitable hospital where not it is manifested or diagnosed before treatment can be provided. birth, at birth, after birth, or years later. AMENDMENT: A document added to COUNTRY OF RESIDENCE: The country the policy by the insurer that clarifies, where: explains, or modifies the policy. (a) The insured resides the majority of ANNIVERSARY DATE: Annual occur- any calendar or policy year, or rence of the effective date of the policy. (b) The insured has resided more APPLICANT: The individual who than one hundred eighty (180) completes the health insurance applica- continuous days during any three tion for coverage. hundred sixty-five (365) day period BLOCK: The insureds of a policy type while the policy is in effect. (including deductible) or a territory. COVERED PREGNANCY: Covered CALENDAR YEAR: January 1 through pregnancies are those for which the December 31 of any given year. policy provides pregnancy benefits and the actual date of delivery is at CERTIFICATE OF COVERAGE: least ten (10) calendar months after Document of the policy that specifies the effective date of coverage for the the effective date, conditions, extent respective insured female. This ten (10) and limitations of coverage, and lists calendar month waiting period applies the policyholder and each covered regardless of whether or not the sixty dependent. (60) day waiting period for coverage CLASS: The insureds of all policies under this policy has been waived. of the same type, including but not CUSTODIAL CARE: Assistance with limited to benefits, deductibles, age the activities of daily living that can group, country, plan, year groups, or a be provided by non-medical/nursing combination of any of these. trained personnel (bathing, dressing, COINSURANCE: The part of the medical grooming, feeding, toileting, etc.). bills the insured must pay for out-patient DEDUCTIBLE: The amount of covered treatment or services. charges that must be paid by the insured COMPLICATIONS OF NEWBORN: before policy benefits are payable. Any disorder related to the birth of a DEPENDENT: Eligible dependents newborn, not caused by congenital or under this policy are those who have hereditary factors, manifested during been identified on the health insurance the first thirty-one (31) days of life,

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

26 place where the service is performed. HOSPITAL SERVICES: Hospital staff, Drugs must have approval from the nurses, scrub nurses, standard private Food and Drug Administration (FDA) or semi-private room and board, and in the United States of America for use other medically necessary treatments or for the diagnosed condition, or other services ordered by a physician for the federal or state government agency insured who is admitted to a hospital. approval required in the United States These services also include local calls, of America, independent of where the TV, and newspapers. Private nurse and medical treatment is incurred or where standard private room upgrade to a bills are issued. suite or junior suite are not included in GRACE PERIOD: The thirty-day hospital services. (30-day) period after the policy’s due ILLNESS: An abnormal condition of the date during which the insurer will allow body, manifested by signs, symptoms, the policy to be renewed. and/or abnormal findings in medical GROUND AMBULANCE exams, which make this condition TRANSPORTATION: Emergency different than the normal state of the transportation to a hospital by ground body. ambulance. IN-PATIENT HOSPITALIZATION: HIGHLY SPECIALIZED DRUGS: Drugs Medical or surgical care that due to its with a high unit cost that have a intensity must be rendered during a significant role in maintaining patients hospital stay of twenty-four (24) hours in an out-patient setting, prescribed or more. The severity of the illness must and supervised by a specialist to treat also justify the medical necessity of conditions that are uncommon, severe, hospitalization. Treatment limited to or resistant to first line treatment. the emergency room is not considered in-patient hospitalization. HOME HEALTH CARE: Care of the insured in the insured’s home, prescribed INFECTIOUS DISEASE: A clinical and certified in writing by the insured’s condition resulting from the presence of treating physician, as required for the pathogenic microbial agents, including proper treatment of the illness or pathogenic viruses, pathogenic bacteria, injury, and used in place of in-patient fungi, protozoa, multicellular parasites, treatment in a hospital. Home health and aberrant proteins known as prions, care includes the services of a skilled that can be transmitted from person licensed professional (nurse, therapist, to person. etc.) outside the hospital, and does not INJURY: Damage inflicted to the body include custodial care. by an external cause. HOSPICE/TERMINAL CARE: Care that INSURED: An individual for whom a the insured receives following diagnosis health insurance application has been of a terminal condition, including completed, the premium paid, coverage physical, psychological, and social care, approved and initiated by the insurer. as well as accommodation in a bed, The term “insured” includes the poli- nursing care, and prescribed drugs. This cyholder and all dependents covered care must be approved in advance by under this policy. USA Medical Services. INTERNATIONAL HEALTHCARE HOSPITAL: Any institution legally SOLUTIONS INSURANCE APPLICATION: licensed as a medical or surgical facility Written statements on a form by an in the country in which it is located, applicant about themselves and/or their that is a) primarily engaged in providing dependents, used by the insurer to deter- diagnostic and therapeutic facilities for mine acceptance or denial of the risk. clinical and surgical diagnosis, treatment The International Healthcare Solutions and care of injured and sick persons Insurance Application includes any oral by or under the supervision of a staff statements made by an applicant during of physicians; and b) not a place of a medical interview held by the insurer, rest, a place for the aged, a nursing or medical history, questionnaire, and other convalescent home or institution, or a document provided to, or requested by, long-term care facility. the insurer prior to the issuance of the policy.

27 MEDICALLY NECESSARY: A treatment, POLICY DUE DATE: The date on which service, or medical supply prescribed by the premium is due and payable. a treating physician and approved and POLICY EFFECTIVE DATE: The date coordinated by USA Medical Services. stated in the certificate of coverage, on A treatment, service, or medical supply which coverage under this policy begins. will not be considered medically neces- The period of twelve sary if: POLICY YEAR: (12) consecutive months beginning on (a) It is provided only as a convenience the effective date of the policy and to the insured, the insured’s family, any subsequent twelve-month period or the provider (e.g. private nurse, thereafter. standard private room upgrade to The named applicant suite or junior suite, etc.), or POLICYHOLDER: on the health insurance application. (b) It is not appropriate for the insured’s This individual is the person entitled diagnosis or treatment, or to receive reimbursement for covered (c) It exceeds the level of care needed to medical expenses and the return of any provide adequate and appropriate unearned premium. diagnosis or treatment, or PRE-EXISTING CONDITION: A condi- (d) Falls outside the standard of prac- tion: tice, as established by professional (a) That is diagnosed by a physician boards by discipline (MD, physical prior to the effective date of the therapy, nursing, etc.), or policy or its reinstatement, or (e) It is custodial in nature. (b) For which medical advice or treat- NEWBORN: An infant from the moment ment was recommended by, or of birth through the first thirty-one (31) received from, a physician prior to days of life. the effective date of the policy or NURSE: A professional legally licensed its reinstatement, or to provide nursing care in the country (c) For which any symptom and/or where the treatment is provided. sign, if presented to a physician OUT-PATIENT SERVICES: Medical treat- prior to the effective date of the ments or services provided or ordered policy, would have resulted in the by a physician for the insured when diagnosis of an illness or medical he/she is not admitted in a hospital. condition. Out-patient services include services PRESCRIPTION DRUGS: Medications performed in a hospital or emergency whose sale and use are legally restricted room if these services have a duration of to the order of a physician. less than twenty-four (24) hours. PROVIDER NETWORK: A group of PANDEMIC: An epidemic occurring over hospitals and physicians approved and a widespread area (multiple countries contracted to treat insureds on behalf or continents) and usually affecting a of the insurer. The list of hospitals and substantial proportion of the population. physicians in the provider network is PHYSICIAN OR DOCTOR: A profes- available from USA Medical Services or sional legally licensed to practice medi- online at www.bupasalud.com, and may cine in the country where treatment is change at any time without prior notice. provided while acting within the scope RECIPIENT: The person who has of his/her practice. The term “physi- received, or is in the process of receiving cian” or “doctor” shall also apply to a an organ, cell or tissue transplant. professional legally licensed to practice REHABILITATION SERVICES: as a dentist. Treatment provided by a legally licensed health professional intended to enable

28 people who have lost the ability to near future, or a state of permanent function normally through a serious unconsciousness from which recovery injury, illness, surgery, or for treatment is unlikely. of pain, to reach and maintain their TRANSPLANT PROCEDURE: Procedure normal physical, sensory, and intel- in which an organ, cell (e.g. stem lectual function. These services may cell, bone marrow, etc.), or tissue is include: medical care, physical therapy, implanted from one part to another or occupational therapy and others. from one individual to another of the RENEWAL DATE: This is the date when same species, or when an organ, cell, the premium payment is due. It may or tissue is removed from the same occur on a date different from the anni- individual and then received back. versary date, depending on the mode USUAL, CUSTOMARY, AND of payment authorized by the insurer. REASONABLE (UCR): It is the maximum RIDER: A document added to the policy amount the insurer will consider eligible by the insurer which adds and details for payment under a health insurance an optional coverage. plan. This amount is determined based ROUTINE HEALTH CHECKUP: A on a periodic review of the prevailing medical examination taken at regular charges for a particular service adjusted intervals to verify a normal state of for a specific region or geographical health or discover a disease in its early area. stages. A checkup does not include any WELL BABY CARE: Routine medical test or consultation to follow-up on a care provided to a healthy newborn. disease already diagnosed. SECOND SURGICAL OPINION: The medical opinion of a physician other than the current treating physician. SERIOUS ACCIDENT: An unforeseen trauma occurring without the insured’s intention, which implies a sudden external cause and violent impact on the body, resulting in demonstrable bodily injury that requires immediate in-patient hospitalization for twenty-four (24) hours or more within the next few hours after the occurrence of the severe injury to avoid loss of life or physical integrity. Severe injury shall be determined to exist upon agreement by both the treating physician and the insurer’s medical consultant, after review of the triage notes, emergency room and hospital admission medical records. STEPCHILD: Child born to or adopted by the spouse or domestic partner of a policyholder, whom the policyholder has not legally adopted. TERMINAL CONDITION: An active, progressive, and irreversible illness or condition that, without life-sustaining procedures, will result in death in the

29 SUPPLEMENT

THE CLAIM PROCESS

Your policy requires you to notify USA Medical Services before any 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.

30 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. 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 Services will make arrangements for the doctor for a copy of his/her case notes tests, and confirm your coverage with or records regarding your condition, as the doctor and hospital. This normally we will need to review them. You can takes a few days once we have all the email or fax them to us. USA Medical information we need. 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

32 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.

33 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

34 35 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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