International Comprehensive Health Insurance Programme Member Handbook Aetna International

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions International Comprehensive Health Insurance Programme Member Handbook Aetna International LAC (5/13)

2 For over 160 years, Aetna has been working to make it easier for our members to access insurance coverage. Our first class service places you at the centre of everything we do; so you can access the care you need, when you need it. This member handbook contains helpful information about your International Comprehensive Health Insurance Programme; a plan through the Jamaica Co-operative Credit Union League (JCCUL), including plan overview and benefits, how to file a medical claim, how to contact us and much more. It s time for you to experience the Aetna difference. Plan overview 3 Plan Benefits 4 Definitions 16 General conditions 19 Exclusions 22 Complaints procedures 24 How to file a claim 26 2

3 Plan Overview Within this document you will find key features of the health plan, including details on the benefits and contact information for the International Member Service Centre, which you may reach by dialling the phone number on your member ID card. Our service philosophy At Aetna, we place you and those important to you at the centre of everything we do. We provide you with tools that help you live a healthier life through innovative global coverage, wellness and care management solutions. 24x7 member services Our multilingual, multicultural member service professionals are available to assist you around the clock. Personalised support is available by phone, or fax to: Help you find health care Answer your questions about claims, benefits and cover levels Process claims in many languages and more International Health Advisory Team At the heart of our first-class service is the International Health Advisory Team (IHAT ). IHAT is made up of a clinical staff that s trained to support you in meeting your health care needs. This team interacts one-on-one with our members to provide support to meet many health care needs including, worldwide coordination of routine and urgent medical care, assistance finding doctors and facilities among many others. To reach the IHAT team just call your Member Service Centre at the phone number on your member ID card. Innovative tools and resources With your cover you ll have access to tools and resources that help you navigate your health care experience, including: Global Health Databank Aetna International s web based Global Health DataBank is a unique service that s available to you. It provides up to the minute information on: Thousands of carefully selected doctors, hospitals and clinics worldwide Medical specialties and qualification profiles of individual practitioners City level assessments of the best available medical provision, emergency services and local embassy contact details Local issues affecting your health and safety, including recommended vaccination requirements Translations of medical terms and drug names Extensive travel health information and alerts Local knowledge To access Global Health Databank please visit Reliable access to some of the world s leading health care professionals Aetna is committed to building strong and secure partnerships with health care professionals around the world; so that you have access to quality care when and where you may need it. That s why we have negotiated simplified prepayment procedures with thousands of medical facilities worldwide. Called direct settlement arrangements, these agreements make accessing care easier and cover any eligible up front costs associated with your care or treatment, such as planned inpatient treatment, a maternity stay, day-patient services, or high cost outpatient services such as MRIs and CT scans. This is a significant benefit if you re faced with a more expensive medical procedure. You also have the freedom to pay up front for care received at any health care professional worldwide*, and submit a claim to us for reimbursement. To find a direct settlement facility in your region: 1. Visit 2. Click on Member Downloads & Links on the right hand side of the page 3. Click on International Direct Settlement Network *Based on regulatory and legal requirements, Aetna reserves the right to refuse to offer cover in certain countries. 3

4 Benefits Product Option: Global 1 We will provide insurance within the terms of the group policy, in respect of eligible medical conditions (including those as a result of an accident). The policy provides for medical expenses insurance only. No benefits are payable for medical expenses incurred before the date of entry, after the period of cover has expired or after the cover has terminated, even if the expenses were incurred as a result of an accident, medical condition, injury or disease which occurred, commenced or existed during the period of cover. Benefits may be paid after the period of cover has expired or the cover has terminated but only for treatment received before the period of cover has expired or the cover has terminated. The following benefits are covered under this product option up to a maximum of US$2,000,000 per insured person per period of cover subject to any specific limits set out under each benefit and subject to the obligation of each insured person to pay the deductible and coinsurance as set out in the section headed limits of cover in this product. All benefits are subject to amounts being no more than reasonable and customary charges. This plan has two deductible options (please refer to your Schedule of Cover for your deductible): $0 deductible in Jamaica/$2000 deductible worldwide or $500 deductible in Jamaica/$5000 deductible worldwide 4

5 1. Medical Facility and Home Health Care Charges: a) Hospital charges: i) Operating room fees and other charges incurred for the treatment of a medical condition. ii) Room and board costs, limited to a standard private room rate, and associated charges, including admittance to the intensive care unit, and charges for nursing by a qualified nurse. iii) Charges for applicable services and supplies as set out in i) and ii) above for day-patient and outpatient treatment. b) Home health care charges: Treatment made in the home of the insured person, by a home health care agency under a home health care plan. Such treatment will cover: i) Part-time or intermittent care by a qualified nurse ii) Part-time or intermittent services of a home health care provider for patient care as recommended by a home health care agency iii) Laboratory services provided by or for a home health care agency. Benefits will not be paid in respect of any services or supplies that are not part of the home health care plan, any services of a person who lives with you or members of their family, any members of your family, the services of a social worker or any costs of transportation. Home health care benefits are limited to 20 days per period of cover. All treatment under this benefit is conditional upon precertification by us. Without our written consent prior to treatment, we will not be liable to pay any benefit. c) General charges applicable to all medical facilities: i) Room and board costs, limited to a standard private room rate and associated charges ii) Drugs and dressings iii) Diagnostic X-ray and laboratory work iv) Anaesthetics v) Oxygen and gas therapy 2. Physician and Specialist Physician Fees: a) Physician and specialist physician fees for surgical operations and medical services received whilst an inpatient. b) Anesthetist fees 3. Psychiatric Illness: Inpatient treatment in a recognised psychiatric unit of a hospital, limited to 30 days per period of cover and 90 days maximum per lifetime. All treatment under this benefit is conditional upon precertification from us, and must at all times be administered under the direct control of a registered psychiatric physician. Without our written confirmation prior to such treatment, we will not be liable to pay any benefit. Initial consultation with a physician (not a psychiatric physician), which results in a psychiatric referral, is covered without the requirement for precertification. 4. Maternity Cover: Costs associated with normal pregnancy and childbirth and any related condition. Benefits are limited to childbirth, pre- and post-natal check ups and delivery costs. No expenses are eligible for payment under this benefit until the insured person has been continuously covered by this policy for 10 months from the date of entry. 5. Complications of Pregnancy: Treatment of a medical condition, which arises during the antenatal stages of pregnancy, or a medical condition which arises during childbirth and requires a recognised obstetric procedure. Cover is provided for caesarean sections required on medical grounds and does not include voluntary caesarean sections. No expenses are eligible for payment under this benefit until the insured person has been continuously covered by this policy for 10 months from the date of entry. 6. Emergency Local Road Ambulance: Transportation costs to a hospital by authorised local ambulance services in the event of an emergency. 7. Evacuation: Evacuation costs of an insured person in the event of medically necessary treatment not being readily available at the place of the incident, to the nearest appropriate medical facility or the country of choice of the insured person, providing it has, in our opinion, suitable medical facilities, for the purpose of admission to a medical facility as an inpatient or day-patient (excluding normal maternity or childbirth costs, but extended to include benefit number 5 Complications of Pregnancy). 5

6 Evacuation is subject to precertification by us prior to travel and certified instructions from the attending physician or specialist physician, including confirmation that the required treatment is unavailable at the place of incident. Extended to cover the costs for one other person to travel with the insured person, as an escort, if medically necessary, or for one parent to accompany a child requiring treatment provided that the child is under the age of 18 years. Our medical advisors will decide the most appropriate method of transportation for the evacuation and the most appropriate medical facility to which you will be evacuated. 8. Additional Travel Expenses Following Evacuation: Economy class airline ticket to return the insured person and one other person who has travelled as an escort to your country of residence or to the country where evacuation occurred. 9. Routine Check ups and Inoculations: Benefit available after one year s membership and every subsequent two years and limited to US$300 per insured person per period of cover. This benefit is not available within the first 12 months from the commencement date of this benefit or the date of entry, whichever is the later. Such routine check ups /tests to include: a) Blood and cholesterol checks b) Height/weight body mass index c) Resting blood pressure d) Urine analysis e) Cardiac examination f) Bilateral mammogram/breast examination g) Testicular/prostate examination/psa/ DRE Tests h) Exercise electrocardiogram (ECG) i) Well-baby checks including physical examinations, measurements, sensory screening, neuropsychiatric evaluation, development screening, as well as hereditary and metabolic screening at birth, immunisations, urine analysis, tuberculin tests and haematocrit, haemoglobin and other blood tests, including tests to screen for sickle haemoglobinopathy; all as recommended by a physician or specialist physician. Limited to a maximum of six (6) consultations per newborn per year from birth until the dependent child reaches the age of 2 years. j) Routine gynaecological tests, including pap tests. k) Vaccinations, including those medically necessary for travel. 10. Outpatient Dialysis Benefit: We pay eligible expenses for treatment for or associated with haemodialysis (meaning the removal of waste matter from your blood by passing it though a kidney machine or dialyser) or peritoneal dialysis (meaning the removal of waste matter from your blood by introducing fluid into your abdomen, which acts as a filter). We pay for short term kidney dialysis, if you need this immediately before or after a kidney transplant. We also pay if the kidney dialysis is needed temporarily for sudden kidney failure resulting from a disease, illness or injury affecting another part of your body. We will cover the cost of outpatient dialysis benefit at 80%. For this benefit, exclusion number 3 does not apply. 11. Mortal Remains: In the event of death from an eligible medical condition: i) Costs of transportation of body or ashes of an enrolled person to his/her country of nationality or country of residence. or; ii) Burial or cremation costs at the place of death in accordance with reasonable and customary practice. This benefit is limited to US$10,000 per enrolled person. 12. Physician and Specialist Physician Fees: a) Physician and specialist physician consultation fees. Medical services in a physician s office are limited to 20 visits per period of cover. Outpatient rehabilitation (physical, occupational and speech therapy) is limited to 60 visits per period of cover. b) Diagnostic and surgical procedures, including pathology, X-rays, MRI, CT and PET scans. c) Outpatient psychiatric treatment, which is limited to a total of 20 visits per period of cover. 13. Drugs and Dressings: Outpatient drugs and dressings prescribed by a physician or specialist physician are limited to US$1,000 per year. 6

7 14. Dental Cover and Optical Cover: Up to a total amount of US$2,000 for eligible dental and optical treatment that you receive from a dental or optical practitioner per period of cover. This is the overall total amount we will pay for all such dental and optical treatment received by each person covered under the plan. We will only cover the cost of eligible dental treatment at 50% for routine and major dental treatment and 80% for emergency treatment. Eligible optical treatment is covered at 100%. Eligible dental treatment By eligible routine dental treatment, we mean examinations you received from a dental practitioner without general anaesthetic and which is necessary to maintain dental fitness, such as two check ups each membership year, fillings, extractions, scaling and polishing, radiography (for example an X-ray) or prescribed antibiotics. By eligible major dental treatment, we mean the costs for the removal of impacted, buried or unerupted teeth, removal of roots, removal of solid odontomes, apicectomy, new or repair of bridge work, new or repair of crowns, root canal treatment, and new or repair of upper or lower dentures. We will only pay a call out charge for emergency dental treatment. This will be for the first visit only. We will not pay a call out charge for any follow-up visits relating to the same dental injury or condition. We pay for eye tests carried out by a legally qualified optician, and for prescribed spectacles, including frames and lenses and contact lenses up to the total limit stated above. 7

8 Global 1 Summary of Benefits Maximum benefit payable for eligible conditions per person per year Benefits are subject to the policy deductible and limits are per period of cover, unless otherwise stated. Deductible options Outpatient treatment Outpatient diagnostic Medical services in a doctor s office Limited to a total of 20 visits each membership year Outpatient psychiatric treatment Limited to a total of 20 visits each membership year Outpatient rehabilitation (physical, occupational and speech therapy) Limited to a total of 60 visits each membership year Outpatient prescription drugs by a doctor Outpatient surgical procedures MRI, CT and PET scans (head and body scanning) Outpatient therapeutic services (radiotherapy, chemotherapy and oncology) Day-case and inpatient treatment Inpatient hospital and related services Intensive care unit benefit Doctors fees for surgical and medical services Inpatient therapeutic services MRI, CT and PET scans Cancer tests, drugs and consultants fees for oncology Psychiatric treatment Limited to a total of 30 days each membership year and 90 days lifetime maximum Other benefits Outpatient dialysis benefit Emergency local road ambulance Home nursing Limited to 20 days each membership year Maternity cover Available after being a member for 10 months Health checks Available in the second membership year and every subsequent two membership years Outpatient dental and optical treatment Routine dental Major restorative Emergency dental Vision Up to combined total of US$2,000 Congenital anomalies Evacuation cover Mortal remains i. Transportation of a body or ashes to the country of nationality or country of residence, or ii. Burial or cremation costs at the place of death US$2,000,000 US$0 deductible in Jamaica/ US$2,000 deductible worldwide or US$500 deductible in Jamaica/ US$5,000 deductible worldwide 80% of eligible expenses up to US$1,000 80% of eligible expenses up to US$300 50% of eligible expenses 50% of eligible expenses 80% of eligible expenses up to US$500,000 per lifetime up to US$10,000 8

9 Product Option: Global 2 The following benefits are covered under this product option up to a maximum of US$1,000,000 per insured person per period of cover subject to any specific limits set out under each benefit and subject to the obligation of each insured person to pay the deductible and coinsurance as set out in the section headed limits of cover in this product. All benefits are subject to amounts being no more than reasonable and customary charges. This plan has two deductible options (please refer to your Schedule of Cover for your deductible): $0 deductible in Jamaica/$2000 deductible worldwide or $500 deductible in Jamaica/$5000 deductible worldwide 1. Medical Facility and Home Health Care Charges: a) Hospital charges: i) Operating room fees and other charges incurred for the treatment of a medical condition. ii) Room and board costs, limited to a standard private room rate, and associated charges, including admittance to the intensive care unit, and charges for nursing by a qualified nurse. iii Charges for applicable service and supplies as set out in i) and ii) above for day-patient and outpatient treatment. b) Home health care charges: Treatment made in the home of the insured person, by a home health care agency under a home health care plan. Such treatment will cover: i) Part-time or intermittent care by a qualified nurse ii) Part-time or intermittent services of a home health care provider for patient care as recommended by a home health care agency iii) Laboratory services provided by or for a home health care agency. Benefits will not be paid in respect of any services or supplies that are not part of the home health care plan, any services of a person who lives with you or members of their family, any members of your family, the services of a social worker or any costs of transportation. Home health care benefits are limited to 20 days per period of cover. All treatment under this benefit is conditional upon precertification by us. Without our written consent prior to treatment, we will not be liable to pay any benefit. c) General charges applicable to all medical facilities: i) Room and board costs, limited to a standard private room rate and associated charges ii) Drugs and dressings iii) Diagnostic X-ray and laboratory work iv) Anaesthetics v) Oxygen and gas therapy 2. Physician and Specialist Physician Fees: a) Physician and specialist physician fees for surgical operations and medical services received whilst an inpatient. b) Anesthetist fees 3. Psychiatric Illness: Inpatient treatment in a recognised psychiatric unit of a hospital, limited to 30 days per period of cover and 90 days maximum per lifetime. All treatment under this benefit is conditional upon precertification from us, and must at all times be administered under the direct control of a registered psychiatric physician. Without our written confirmation prior to such treatment, we will not be liable to pay any benefit. Initial consultation with a physician (not a psychiatric physician), which results in a psychiatric referral is covered without the requirement for precertification. 4. Maternity Cover: Costs associated with normal pregnancy and childbirth and any related condition. Benefits are limited to childbirth, pre- and post-natal check ups and delivery costs. No expenses are eligible for payment under this benefit until the insured person has been continuously covered by this policy for 10 months from the date of entry. 9

10 5. Complications of Pregnancy: Treatment of a medical condition, which arises during the antenatal stages of pregnancy, or a medical condition which arises during childbirth and requires a recognised obstetric procedure. Cover is provided for caesarean sections required on medical grounds and does not include voluntary caesarean sections. No expenses are eligible for payment under this benefit until the insured person has been continuously covered by this policy for 10 months from the date of entry. 6. Emergency Local Road Ambulance: Transportation costs to a hospital by authorised local ambulance services in the event of an emergency. 7. Evacuation: Evacuation costs of an insured person in the event of medically necessary treatment not being readily available at the place of the incident, to the nearest appropriate medical facility or the country of choice of the insured person, providing it has, in our opinion, suitable medical facilities, for the purpose of admission to a medical facility as an inpatient or day-patient (excluding normal maternity or childbirth costs, but extended to include benefit 5) complications of pregnancy). Evacuation is subject to precertification by us prior to travel and certified instructions from the attending physician or specialist physician, including confirmation that the required treatment is unavailable at the place of incident. Extended to cover the costs for one other person to travel with the insured person, as an escort, if medically necessary, or for one parent to accompany a child requiring treatment provided that the child is under the age of 18 years. Our medical advisors will decide the most appropriate method of transportation for the evacuation and the most appropriate medical facility to which you will be evacuated. 8. Additional Travel Expenses Following Evacuation: Economy class airline ticket to return the insured person and one other person who has travelled as an escort to your country of residence or to the country where evacuation occurred. 9. Routine Check ups and Inoculations: Benefit available after one year s membership and every subsequent two years and limited to US$300 per insured person per period of cover. This benefit is not available within the first 12 months from the commencement date of this benefit or the date of entry, whichever is the later. Such routine check ups/tests to include: a) Blood and cholesterol checks b) Height/weight body mass index c) Resting blood pressure d) Urine analysis e) Cardiac examination f) Bilateral mammogram/breast examination g) Testicular/prostate examination/psa/dre Tests h) Exercise electrocardiogram (ECG) i) Well-baby checks including physical examinations, measurements, sensory screening, neuropsychiatric evaluation, development screening, as well as hereditary and metabolic screening at birth, immunisations, urine analysis, tuberculin tests and haematocrit, haemoglobin and other blood tests, including tests to screen for sickle hemoglobinopathy; all as recommended by a physician or specialist physician. Limited to a maximum of six (6) consultations per newborn per year from birth until the dependent child reaches the age of 2 years. j) Routine gynaecological tests, including pap tests. k) Vaccinations, including those medically necessary for travel. 10. Outpatient Dialysis Benefit: We pay eligible expenses for treatment for or associated with haemodialysis (meaning the removal of waste matter from your blood by passing it though a kidney machine or dialyser) or peritoneal dialysis (meaning the removal of waste matter from your blood by introducing fluid into your abdomen, which acts as a filter). We pay for short term kidney dialysis, if you need this immediately before or after a kidney transplant. We also pay if the kidney dialysis is needed temporarily for sudden kidney failure resulting from a disease, illness or injury affecting another part of your body. We will only cover the cost of outpatient dialysis benefit at 80%. For this benefit only, exclusion 3 does not apply. 11. Mortal Remains: In the event of death from an eligible medical condition: i) Costs of transportation of body or ashes of an enrolled person to his/ her country of nationality or country of residence. or; ii) Burial or cremation costs at the place of death in accordance with reasonable and customary practice. This benefit is limited to US$10,000 per enrolled person. 10

11 Global 2 Summary of Benefits Maximum benefit payable for eligible conditions per person per year Benefits are subject to the policy deductible and limits are per period of cover, unless otherwise stated. Deductible options Outpatient treatment Outpatient surgical procedures MRI, CT and PET scans (head and body scanning) Outpatient therapeutic services (radiotherapy, chemotherapy and oncology) Hospitalisation Inpatient hospital and related services Intensive care unit benefit Doctors fees for surgical and medical services Inpatient therapeutic services MRI, CT and PET scans Psychiatric treatment Limited to a total of 30 days each membership year and 90 days lifetime maximum Other benefits Outpatient dialysis benefit Emergency local road ambulance Home nursing Limited to 20 days each membership year Maternity cover Available after being a member for 10 months Health checks Available in the second membership year and every subsequent two membership years Congenital anomalies Evacuation cover Mortal remains i. Transportation of a body or ashes to the country of nationality or country of residence, or ii. Burial or cremation costs at the place of death US$1,000,000 US$0 deductible in Jamaica/ US$2,000 deductible worldwide or US$500 deductible in Jamaica/ US$5,000 deductible worldwide 80% of eligible expenses Up to US$300 Up to US$500,000 per lifetime Up to US$10,000 11

12 Product Option: Global Share The following benefits are covered under this product option up to a maximum of US$1,000,000 per insured person per period of cover subject to any specific limits set out under each benefit and subject to the obligation of each insured person to pay the deductible and coinsurance as set out in the section headed limits of cover in this product. All benefits are subject to amounts being no more than reasonable and customary charges. This plan has the following deductibles: $1,000 deductible in Jamaica/$2,500 deductible worldwide 1. Medical Facility and Home Health Care Charges: a) Hospital charges: i) Operating room fees and other charges incurred for the treatment of a medical condition. ii) Room and board costs, limited to a standard private room rate, and associated charges, including admittance to the intensive care unit, and charges for nursing by a qualified nurse. iii) Charges for applicable service and supplies as set out in i) and ii) above for day-patient and outpatient treatment. Benefit is limited to US$750 per day (increased to US$2,000 if admitted to the intensive care unit) b) Home health care charges: Treatment made in the home of the insured person, by a home health care agency under a home health care plan. Such treatment will cover: i) Part-time or intermittent care by a qualified nurse ii) Part-time or intermittent services of a home health care provider for patient care as recommended by a home health care agency iii) Laboratory services provided by or for a home health care agency benefits will not be paid in respect of any services or supplies that are not part of the home health care plan, any services of a person who lives with you or members of their family, any members of your family, the services of a social worker or any costs of transportation. Home health care benefits are limited to US$250 per day and 20 days per period of cover. All treatment under this benefit is conditional upon precertification by us. Without our written consent prior to treatment, we will not be liable to pay any benefit. c) General charges applicable to all medical facilities: i) Room and board costs, limited to a standard private room rate and associated charges ii) Drugs and dressings iii) Diagnostic X-ray and laboratory work iv) Anaesthetics v) Oxygen and gas therapy 2. Physician and Specialist Physician Fees: a) Physician and specialist physician fees for surgical operations and medical services received whilst an inpatient. b) Anesthetist fees 3. Psychiatric Illness: Inpatient treatment in a recognised psychiatric unit of a hospital, limited to US$750 per day and 30 days per period of cover and 90 days maximum per lifetime. All treatment under this benefit is conditional upon precertification from us and must at all times be administered under the direct control of a registered psychiatric physician. Without our written confirmation prior to such treatment, we will not be liable to pay any benefit. However, initial consultation with a physician (not a psychiatric physician), which results in a psychiatric referral is covered without the requirement for precertification. 12

13 4. Maternity Cover: Costs associated with normal pregnancy and childbirth and any related condition. Benefits are limited to childbirth, pre- and post-natal check ups and delivery costs. Benefit is limited to US$5,000 for each pregnancy. No expenses are eligible for payment under this benefit until the insured person has been continuously covered by this policy for 10 months from the date of entry. 5. Complications of Pregnancy: Treatment of a medical condition, which arises during the antenatal stages of pregnancy, or a medical condition which arises during childbirth and requires a recognised obstetric procedure. Cover is provided for caesarean sections required on medical grounds and does not include voluntary caesarean sections. (Benefit is limited to US$9,000 for each pregnancy). No expenses are eligible for payment under this benefit until the insured person has been continuously covered by this policy for 10 months from the date of entry. 6. Emergency Local Road Ambulance: Transportation costs to a hospital by authorised local ambulance services in the event of an emergency. Benefit is limited to US$1,500 per incident. 7. Evacuation: Evacuation costs of an insured person in the event of medically necessary treatment not being readily available at the place of the incident, to the nearest appropriate medical facility or the country of choice of the insured person, providing it has, in our opinion, suitable medical facilities, for the purpose of admission to a medical facility as an inpatient or day-patient (excluding normal maternity or childbirth costs, but extended to include benefit 5, complications of pregnancy). Evacuation is subject to precertification by us prior to travel and certified instructions from the attending physician or specialist physician, including confirmation that the required treatment is unavailable at the place of incident. Extended to cover the costs for one other person to travel with the insured person, as an escort, if medically necessary or for one parent to accompany a child requiring treatment provided that the child is under the age of 18 years. Our medical advisors will decide the most appropriate method of transportation for the evacuation and the most appropriate medical facility to which you will be evacuated. 8. Additional Travel Expenses Following Evacuation: Economy class airline ticket to return the insured person and one other person who has travelled as an escort to your country of residence or to the country where evacuation occurred. 9. Routine Check ups and Inoculations: Benefit available after one year s membership and every subsequent two years and limited to US$200 per insured person per period of cover. This benefit is not available within the first 12 months from the commencement date of this benefit or the date of entry, whichever is the later. Such routine check ups/tests to include: a) Blood and cholesterol checks b) Height/weight body mass index c) Resting blood pressure d) Urine analysis e) Cardiac examination f) Bilateral mammogram/breast examination g) Testicular/prostate examination/psa/ DRE Tests h) Exercise electrocardiogram (ECG) i) Well-baby checks including physical examinations, measurements, sensory screening, neuropsychiatric evaluation, development screening, as well as hereditary and metabolic screening at birth, immunisations, urine analysis, tuberculin tests and haematocrit, haemoglobin and other blood tests, including tests to screen for sickle hemoglobinopathy; all as recommended by a physician or specialist physician. Limited to a maximum of six (6) consultations per newborn per year from birth until the dependent child reaches the age of 2 years. j) Routine gynaecological tests, including pap tests. k) Vaccinations, including those medically necessary for travel. 10. Outpatient Dialysis Benefit: We pay eligible expenses for treatment for or associated with haemodialysis (meaning the removal of waste matter from your blood by passing it though a kidney machine or dialyser) or peritoneal dialysis (meaning the removal of waste matter from your blood by introducing fluid into your abdomen, which acts as a filter). We pay for short term kidney dialysis, if you need this immediately before or after a kidney transplant. We also pay if the kidney dialysis is needed temporarily for sudden kidney failure resulting from a disease, illness or injury affecting another part of your body. Benefit is paid in full up to $80 per visit. For this benefit only, exclusion 3 does not apply. 13

14 11. Mortal Remains: In the event of death from an eligible medical condition: i) Costs of transportation of body or ashes of an enrolled person to his/ her country of nationality or country of residence. or; ii) Burial or cremation costs at the place of death in accordance with reasonable and customary practice. This benefit is limited to US$10,000 per enrolled person. 12. Physician and Specialist Physician Fees: a) Physician and specialist physician consultation fees. Medical services in a physician s office are paid in full to US$80 per visit and 20 visits per period of cover (includes acupuncture and homeopathic treatment). Outpatient rehabilitation (physical, occupational and speech therapy) is paid in full to US$40 and 60 visits per period of cover. b) Diagnostic procedures, including pathology, X-rays, MRI, CT and PET scans. Benefit is limited to US$700 per exam for diagnostic imaging (including EKG, ultrasound and endoscopy) and US$750 per scan. Benefit for pathology and X-rays is paid in full up to US$400 per visit. c) Outpatient surgical procedures: benefit is 100% (paid in full) of eligible expenses. d) Outpatient psychiatric treatment: benefit is limited to US$80 and a total of 20 visits per period of cover. 13. Drugs and Dressings: Outpatient drugs and dressings prescribed by a physician or specialist physician are limited to US$500 per year. 14. Dental Cover and Optical Cover: Up to a total amount of US$1,000 for eligible dental and optical treatment that you receive from a dental or optical practitioner per period of cover. This is the overall total amount we will pay for all such dental and optical treatment received by each person covered under the plan. We will only cover the cost of eligible dental treatment at 50% for routine treatment and 80% for emergency treatment. Eligible optical treatment is covered at 100%. Eligible routine dental treatment By eligible routine dental treatment, we mean examinations you received from a dental practitioner without general anaesthetic and which is necessary to maintain dental fitness such as two check ups each membership year, filings, extractions, scaling and polishing, radiography (for example an X-ray) or prescribed antibiotics. We will only pay a call-out charge for emergency dental treatment. This will be for the first visit only. We will not pay a call-out charge for any follow-up visits relating to the same dental injury or condition. We pay for eye tests carried out by a legally qualified optician, and for prescribed spectacles, including frames and lenses and contact lenses up to the total limit stated above. 15. Organ Transplant: Benefit is limited to US$500,000 per lifetime. Covered transplants are: a) Heart b) Heart/lung c) Lung d) Kidney e) Kidney/pancreas f) Liver g) Allogeneic bone marrow h) Autologous bone marrow 16. Congenital Conditions: Treatment of congenital anomalies which manifest themselves after your date of entry or which manifest themselves in a dependent child within 12 months of birth. This benefit excludes any hereditary medical conditions. Benefit is limited to US$25,000 per policy year and US$500,000 per lifetime. 17. Oncology: Outpatient treatment received for cancer. Benefit is 100% (Paid in Full) of eligible expenses. 14

15 Global Share Summary of Benefits Maximum benefit payable for eligible conditions per person per year Benefits are subject to the policy deductible and limits are per period of cover, unless otherwise stated. Deductible option Outpatient treatment Outpatient diagnostics i) MRI, CT and PET scans ii) Diagnostic imaging (including EKG, Ultrasound and Endoscopy) iii) X-ray and pathology Medical services in a doctor s office (including acupuncture and homeopathic treatment) Limited to a total of 20 visits each membership year Outpatient psychiatric treatment Limited to a total of 20 visits each membership year Outpatient rehabilitation (physical, occupational and speech therapy) Limited to a total of 60 visits each membership year Outpatient prescription drugs by a doctor Outpatient surgical procedures Oncology Day-case and inpatient treatment Inpatient hospital and related services limited to US$750 per day Intensive care unit benefit Parent accommodation benefit children under 18 years of age Doctors fees for surgical and medical services MRI, CT and PET scans Oncology Dialysis benefit Organ transplant benefit Psychiatric treatment limited to 30 days each membership year and 90 days lifetime maximum Other benefits Outpatient dialysis benefit Emergency local road ambulance Home nursing limited to 20 days each membership year Maternity cover available after being a member for 10 months Complications of pregnancy not including costs of delivery Health checks available in the second membership year and every subsequent two membership years Outpatient dental and optical treatment Routine dental Emergency dental Vision Up to a combined total of US$1,000 Congenital anomalies Evacuation cover Mortal remains i. Transportation of a body or ashes to the country of nationality or country of residence, or ii. Burial or cremation costs at the place of death US$1,000,000 US$1,000 deductible in Jamaica/ US$2,500 deductible worldwide up to US$750 per scan up to US$700 per exam up to US$400 per scan up to US$80 per visit up to $80 per visit up to US$40 per visit up to US$ % of eligible expenses 100% of eligible expenses up to US$750 per day up to US$2,000 per day up to US$250 per day up to US$500,000 per lifetime up to US$750 per day up to US$80 per visit up to US$1,500 per incident up to US$250 per day up to US$5,000 per normal deliveries or US$9,000 for medically necessary caesarean deliveries up to US$200 50% of eligible expenses 80% of eligible expenses up to US$25,000 per membership year and US$500,000 per lifetime up to US$50,000 up to US$10,000 15

16 Definitions To help you understand your policy the following words and phrases used anywhere within your policy have specific meanings, which are set out in this section. Accident: An unexpected, unforeseen and involuntary external event resulting in injury occurring whilst your policy is in force. Act of terrorism: An act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s), committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear. Acute: A medical condition, which is brief, has a definite end point and which we, on medical advice, determine responds to and can be cured by treatment. Advice: Any consultation by a physician or specialist physician including the issue of drugs and dressings or repeat prescriptions. Appliances: Devices and equipment when used as an integral part of a surgical procedure and is administered by a physician or specialist Benefits: The insurance cover provided by this policy and any extensions or restrictions shown in the Schedule of Cover or in any endorsements (if and where applicable). Bodily injury: Injury, which is caused solely by an accident which results in the insured person s dismemberment, disablement or other physical external injury. Chronic: A medical condition or related condition lasting a long time with no definite end point or one which we, on medical advice, determine does not respond to treatment or cannot be cured by treatment. Coinsurance: The percentage of the total value of the incurred expenses for which the principal member/insured person is responsible for each and every medical condition for each period of cover. Commencement date: The date shown on the Schedule of Cover on which cover under this policy commences. For the purpose of this policy, cover starts from 00:01 am on the date shown on the Schedule of Cover. Congenital anomaly: Any genetic, physical, or biochemical (metabolic) defect, disease, or malformation (which may be hereditary or due to an influence during gestation), and which may or may not be obvious at birth. Convalescence: Physical, occupational or speech therapy, vocational guidance, independent living advice and exercises, retraining, educational pursuits and other services given to an insured person following an eligible medical condition, to assist the insured person, as much as is reasonably possible, to readapt to life in the community and/or to restore them to the state of health he/she enjoyed prior to such medical condition occurring. Convalescent Facility: An institution licensed to provide 24-hour chargeable qualified nurse care, through supervision by a full-time physician, and physical restoration services to help patients achieve self care in daily living activities. This does not extend to any institution providing long term care for the elderly, custodial or educational care or for care of mental disorders. Country of nationality: For the purpose of this policy, this will be the country to which you hold a passport. Country of residence: The country in which you have your habitual residence (residing for a period of no less than 6 months per period of cover) at the time this policy is first taken out or at each subsequent renewal date/review date. Date of entry: The date shown on the Schedule of Cover on which an insured person was first included under the policy. Day-patient: Treatment in a defined medical facility where the patient is admitted to a bed but does not stay overnight. Deductible: The amount payable by an insured person in respect of expenses incurred for treatment before any benefits are paid under the policy for each period of cover. Dental practitioner: A person who is licensed by the relevant licensing authority to practice dentistry in the country where the dental treatment is given. Dependents: A spouse or adult partner and/or unmarried children who are not more than 21 years old and residing with the principal member, or not more than 25 years old if in full time education, at the date of entry or at any subsequent renewal date/review date. All dependents must be named as an insured person in the Schedule of Cover. Drugs and dressings: Drugs, medicines and dressings prescribed by a physician or specialist physician. 16

17 Eligible person: A person that satisfies the requirements for enrolment. An eligible person is one who is either your spouse or adult partner, or your unmarried children who are not more than 21 years old and residing with you, or your unmarried children who are not more than 25 years old if in full time education, at the date of entry or at any subsequent renewal date. Children under the age of 21 years old not residing with you, will be accepted for coverage providing the application is signed by a legal parent or guardian. (The term partner shall mean husband, wife or the person permanently living with you (whether or not of the same sex) in a similar relationship). All eligible persons must be named as enrolled persons in the Schedule of Cover. Emergency: A medical condition placing you in a situation that would lead to the loss of life or limb if immediate inpatient or day-patient treatment were not given. Emergency dental treatment: Treatment that you urgently require to alleviate pain, inability to eat, or treatment of a dental condition which presents an immediate and serious threat to your general health. Enrolled person: You and/or the eligible persons identified in the Schedule of Cover as an enrolled person. Evacuation: Costs incurred in moving an insured person from the place of incident to the nearest appropriate medical facility, as determined by the attending physician in conjunction with our medical advisors. All airline tickets will be limited to economy class. Health care provider: A health care provider that has contracted to supply services for a pre-agreed charge and is included in our directory of medical facilities named as preferred care providers. You are entitled to ask us for a list of preferred care providers. Providers accepting directsettlement are listed on our website under Member Downloads & Links. Hereditary: Transmitted from parents to offspring, inherited and which presents symptoms at birth. Home Health care agency: A company or other organisation providing qualified nurses, and other therapeutic services, to fulfill the requirements of a home health care plan and which: a) Is supervised full-time by a physician. b) Keeps a complete medical record of each patient. c) Has a full-time administrator. d) Meets any licensing or certification standards of the country where it is situated. Home Health care plan: A plan providing for the care and treatment of an eligible medical condition or injury that is prescribed in writing by the attending physician or specialist physician and is an alternative to confinement in a hospital or convalescent facility. Home Health care provider: A heath care worker with sufficient training and qualifications to comply with any relevant regulation within the country in which the treatment is undertaken who provides basic nursing care. In the USA, such health care workers should be LPN or RN qualified. Hospice care: Palliative treatment and supportive care given to patients diagnosed by a physician or specialist physician as having a terminal illness. Hospital: An institution, which is legally licensed as a medical or surgical hospital under the laws of the country in which it is situated. Inpatient: An insured person who stays in a medical facility bed and is admitted for one or more nights solely to receive treatment. Major medical condition: Cancer, heart, lung, orthopedic or psychiatric related conditions. Medical advice: Notice from the relevant professional body as to established medical practice and/or established medical opinion in relation to any medical condition or treatment. Medical condition: Any injury, illness or disease including psychiatric illness. Medical Facility: A hospital which: a) Provides 24 hour nursing care by qualified nurses. b) Is supervised full-time by a physician. c) Has at least one physician on call at all times. d) Keeps a complete medical record of each patient. e) Has a full-time administrator. f) Meets any licensing or certification standards of the country where it is situated. g) Is a fee-charging establishment. Medically necessary: A medical service or treatment, which in the opinion of a qualified physician is appropriate and consistent with the diagnosis and which in accordance with generally accepted medical standards could not have been omitted without adversely affecting the insured person s condition or the quality of medical care rendered. Member/insured person/you/your: A person who is employed by a plan sponsor, or is a covered dependent of an employee, and benefits from a group plan selected by the policyholder. Newborn: A baby who is within the first 16 weeks of its life following delivery. Organ transplant: The replacement of vital organs (including bone marrow) as a consequence of an underlying medical condition. Outpatient treatment: An insured person who receives treatment by a physician or specialist physician but is not admitted to a bed in a medical facility. 17

18 Palliative treatment: Any treatment given in an independent physician s opinion for the purpose of offering Temporary relief of symptoms and where it is not given to cure the medical condition causing the symptoms. Partner: The term partner shall mean husband, wife or the person permanently living with you (whether or not of the same sex) in a similar relationship. Period of cover: The period for which you will be covered by this policy as set out in the Schedule of Cover. This will be the period starting from the date of entry or any subsequent renewal date/review date as applicable. Physician: A person who has attained primary degrees in medicine or surgery by attending a medical school recognised by the World Heath Organisation and who is licensed by the relevant authority to practice medicine in the country where the treatment is given. Physician Benefits: The insurance cover provided by this policy and any extensions or restrictions shown in the Schedule of Cover or in any endorsements (if and where applicable). Physiotherapist/physical therapist: A person who is registered and licensed to practice physiotherapy in the country in which treatment is given. Policy: Our contract of insurance with you providing cover as detailed in this document. The application form and Schedule of Cover form part of the contract and must be read together with this policy. Pre-existing condition: A medical or health condition for which medical advice was sought or for which there was a diagnosis or which treatment was recommended prior to the entry date. Preferred care provider: A health care provider that has contracted to supply services for a pre-agreed charge and is included in our directory of medical facilities named as preferred care providers. You are entitled to ask for a list of preferred care providers. Principal member: The person named as principal member in the Schedule of Cover. Prosthesis: An artificial body part. Under this policy, prosthesis will be limited to an artificial limb or eye. Psychiatric physician: A physician specialising in psychiatry or who has the training or experience recognised in the country in which they are resident to do the required evaluation and treatment of psychiatric illness. Qualified nurse: A qualified nurse whose name is on any register or roll of nurses, maintained by any statutory nursing registration body within the country in which he/she is a resident. Reasonable and customary charges: The average amount charged in respect of valid services or treatment costs, as determined in our experience in a particular country, area or region and substantiated by an independent third party, being a practicing physician, specialist physician or government health department. Rehabilitation: Assisting a member who, following a medical condition, requires physical therapy and assistance in independent living to restore them as much as medically necessary or practically able to the position in which they were in prior to such medical condition occurring. Related condition: Any medical condition is a related condition if we, on medical advice, determine that one is the direct result of the other or if each is a result of the same injury, illness or disease. Renewal date/review date: The anniversary of the commencement date of the policy. Review date: The anniversary of the commencement date of the policy where cover is provided on a monthly basis. The review date will be the date on which any changes to the policy terms or premium rates become effective for the forthcoming review period. Room and Board: Charges made by a medical facility for the provision of a room, bed and other necessary services made on a daily or weekly standard private room rate. Schedule of cover: The schedule giving details of the principal member and the insured persons eligible for cover, the benefits applicable and any extensions, restrictions or endorsements applicable. Specialist physician: A registered physician, who currently holds a substantive consultant appointment in that specialty in a medical facility, currently holds a substantive consultant appointment which we on professional advice or medical advice accept as being of equivalent professional status, or is recognised as such by the statutory bodies of the relevant country. Terminal illness: A medical prognosis of six months or less to live. Treatment: Surgical, medical or other procedures the sole purposes of which are the cure or relief of a medical condition. Underwriters: The insurance company or companies named as underwriters as detailed in the Schedule of Cover. We/Us/Our: Goodhealth Worldwide (Global) Limited c/o Aetna International on behalf of underwriters. 18

19 General conditions 1. Subrogation Clause: If we pay benefits under this policy for covered medical expenses incurred and if it is found that you were repaid for all or some of those expenses by another source including any other insurance policy as outlined in general condition 16, we will have the right to a refund from you. Where necessary, we retain the right to deduct such refund from any impending or future claim settlements or to cancel the policy void from the commencement date, with a refund of premium. Other than with our written consent, you have no entitlement to admit liability for any eventuality or give promise of any undertaking, which is binding upon you, your dependents, or any other person named in the policy. 2. Family/dependent cover: You and your dependents are required to be covered under the same policy with identical benefits. Where we find that this is not the case, you will be asked to comply with this request at your next renewal date/review date. Failure to comply with this condition will result in the termination of the policy. 3. Children: Newborn children will be accepted for cover from birth. Acceptance of newborn babies is subject to written notification within 30 days of birth and receipt of the full premium within a further 30 days following notification. Children who are not more than 21 years old, residing with you, or 25 years old if in full-time education, at the date of joining or at any renewal date/review date, will be accepted for cover. Children will not be accepted for cover, unless on a policy with a legal parent or guardian and subject to the same level of cover applying to all parties. 4. Acceptance clause: We are entitled to refuse to accept an application from any person without giving a reason. We maintain the right to ask you to provide proof of age and/or state of health of any person included in your application. 5. Compliance with policy terms and conditions: We shall not be liable under this policy in the event of any failure by an insured person to comply with its terms and conditions, except where the circumstances of any claim are unconnected with such failure and no fraud is involved. 6. Change of risk: The principal member must inform us as soon as reasonably possible of any material changes relating to any insured person that affect information given in connection with the application for cover under this policy. Any medical condition or related condition for which you have received treatment, had symptoms of, to the best of your knowledge existed or you sought advice for prior to your date of entry must be declared on your application or prior to acceptance for inclusion in the plan (this does not apply to insured persons who were included in the plan prior to 1st June 2007). However, this does not apply after acceptance. We reserve the right to alter the policy terms or cancel cover for an insured person following a change of risk; e.g., change to a hazardous occupation. 7. Policy duration and premiums: a) The policy is in force for the period of cover noted in your Schedule of Cover and is renewable subject to the terms provided at the time of each renewal date/review date. b) The premium payable may be changed by us from time to time. If you move to a higher age band, the premium will increase at the next renewal date/review date as applicable. However, this policy will not be subject to any alteration of premium rates generally introduced until the next renewal date/review date. c) All premiums are payable in advance of any cover under this policy being provided. 8. Break in cover: Where there is a break in cover, for whatever reason, we reserve the right to request a new application to be submitted subject to full underwriting and eligibility requirements. 9. Alterations: a) We may alter the terms and conditions of this policy at any renewal date/review date. A copy of the current policy terms will be sent to you at such time. You may cancel your policy within 15 days following any renewal date/review date and provided you have not made a claim we will refund your premium. We will give you reasonable notice of such alterations. We will send details of such alterations to the address we have for you. However, the alterations will take effect even if you do not receive them for any reason. b) No alteration or amendment to the policy terms will be valid unless it is in writing from us. 19

20 10. Waiver: Waiver by us in any instance of any term or condition of this policy will not prevent us from relying on such term or condition in other instances. 11. Grace period/non-payment of premium: In the event of any non-payment of premium, we shall be entitled to cancel this policy. We may at our discretion reinstate the cover if the premium is subsequently paid. We allow the principal member up to 31 days following the renewal date of the policy to make all payments of premiums due before this clause is invoked, subject to our right to cancel the policy in accordance with the cancellation provisions hereof. 12. Reinstatement: Provided that an application is received by us and we accept a reinstatement of a policy, it shall constitute a full reinstatement and all terms and conditions of the policy will be continuous as if the policy had continuously remained in force. 13. Cancellation: Whilst we shall not cancel this policy because of eligible claims made by any insured person, we may at any time terminate an insured person s cover if he/she or the principal member has at any time: a) Misled us by misstatement. b) Knowingly claimed benefits for any purpose other than as are provided for under this policy. c) Agreed to any attempt by a third party to obtain an unreasonable pecuniary advantage to our detriment. d) Otherwise failed to observe the terms and conditions of this policy or failed to act with utmost good faith. Notification of such cancellation will be sent to the principal member, at his/her last known address, by certified mail. The effective date of the cancellation shall be 15 days after the serving of such notice. Furthermore, we will be able to cancel this policy if you have changed your country of residence; the cover ends upon the next renewal date/review date. If there is any other reason why we would be required to cancel your policy, we would provide you with thirty (30) days notice via certified mail. If we are required to cancel your policy for any of the above reasons, a pro-rata premium refund will be provided to you, which shall be calculated from the date cancellation is affected. If the policy is cancelled by the principal member at any time other than following the renewal date/review date, a prorate premium refund will be provided to you, which shall be calculated from the date cancellation is affected. 14. Applicable Law: The law applicable to the policy shall be the laws of Jamaica. All actions at law arising from or out of this policy will be brought and maintained in Jamaica. The principal member under this policy consents to jurisdiction in Jamaica for all actions arising from or out of this policy. 15. Other insurance: If there is any other insurance covering any of the same benefits, you must disclose or ensure that the relevant insured person discloses the same to us and we shall not be liable to pay or contribute more than our rateable proportion. 16. Fraudulent/Unfounded claims: If any claim under this policy is in any respect fraudulent or unfounded, all benefits paid and/or payable in relation to that claim shall be forfeited and (if appropriate) recoverable. In addition, all cover in respect of the insured person shall be cancelled void from the commencement date with refund of premiums. 17. Liability: Our liability for benefits shall cease immediately upon termination of cover under the policy for whatever reason, including, without limitation, non-renewal and non-payment of premium. Treatment received prior to termination of cover for eligible benefits but not paid by the termination of cover will be paid after the termination of cover if the claim is received up to 180 days after termination of cover. 18. Entire contract changes: The policy, including the endorsements and attached papers, Schedule of Cover and application form constitutes the entire contract of insurance and cannot be changed by anyone other than by an executive of the underwriter. Such approval must be endorsed or attached to the policy or the Schedule of Cover. No agent can change this policy or waive its terms. 20

21 19. Time Limits: After three (3) years from the date of issue of this policy, no misstatement except fraudulent misstatements made by the applicant in the application shall be used to void the policy or deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such a 3 year period except for those medical conditions specifically excluded or endorsed to the policy. 20. Payment of claims: In the event that claims are payable where: a) A claimant is deceased; all payments will be paid to a designated beneficiary (if recorded) or to the estate. b) A claimant is a minor; the payment can be made to the legal parent or guardian. c) Any accounts, which are due to the account in respect of any hospital, nursing or medical services, these may, at our discretion and unless you request otherwise upon submission of such proof of your claim, be paid directly to the hospital or person rendering such services. 21. Legal actions: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished. 21

22 Exclusions This policy does not cover expenses arising from: 1. All medical expense charges associated with or resulting directly or indirectly from or related to the following pre-existing major medical conditions, cancer, heart, lung, orthopaedic or psychiatric related conditions are excluded until 24 months after the enrolment date (date of entry), and that all other medical expense charges associated with or resulting from or related to all pre-existing conditions, except those mentioned above, are covered 12 months after the enrolment date (applicable, to new enrolees joining on or after June 1, 2010). 2. Treatment, including auto therapy (self-administered), which we determine on medical advice, is either experimental or unproven. 3. Chronic supportive treatment of renal failure, including dialysis. We will however pay for the cost of the renal dialysis incurred: a) immediately pre- and post-operatively b) in connection with acute secondary failure when dialysis is part of intensive care 4. Auto therapy or treatment administered by a relative. 5. Birth injuries, genetic deformities and hereditary medical conditions. 6. Convalescence 7. Treatment received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a medical facility or nursing home attached to such establishments or a medical facility where the medical facility has effectively become the insured person s home or permanent abode or where admission is arranged wholly or partly for domestic or social reasons. 8. Cosmetic treatment or treatment for weight loss or weight problems whether or not for psychological purposes and any associated treatment costs consequent of cosmetic surgery or arising as a result of an eating disorder or weight problem. 9. Alternative medicines including, but not limited to, chiropodists, optometrists, lactation examiners and podiatrists. Cover is extended to include acupuncturists, chiropractors, homeopaths and osteopaths who are fully trained and legally qualified and permitted to practice by the relevant authorities in the country in which treatment is received. 10. Costs incurred in connection with locating a replacement organ or any costs incurred for removal of the organ from the donor, transportation costs of same and all associated administration costs. 11. Any second or subsequent medical opinions from a physician or specialist physician for the same medical condition unless it has been authorised by us in writing. 12. Voluntary caesarean section costs. 13. Pregnancy terminations on non- medical grounds, antenatal classes and midwifery costs when not associated with delivery or a recognised medical condition, and costs associated with amniocentesis (or associated/similar procedure). 14. Treatment directly or indirectly arising from or required in connection with male and female birth control, infertility, contraception, sterilisation (or its reversal) and any form of assisted reproduction or any complication or pregnancy arising as a result of assisted pregnancy or fertility treatment. 15. Treatment of impotence or any related condition or consequence thereof. 16. Treatment directly or indirectly associated with a sex change. 17. Venereal disease or any other sexually transmitted diseases or any related condition including HIV/AIDS. 18. Any corrective surgery in respect of any non-medical or natural degenerative eye defects. Cover is extended to include treatment for your eyesight if it is needed as a result of an injury or acute condition. 19. Normal hearing tests, provision of hearing aids or non-medical / natural degenerative hearing defects. 20. Removal of fat or other surplus tissue from any part of the body whether or not it is carried out for medical or psychological reasons or any related condition. 21. Costs in respect of a psychotherapist, psychologist, family therapist or bereavement counselor. 22. Treatment for learning difficulties in children, hyperactivity, attention deficit disorder, speech therapy (except as covered under Global 1 Benefit 12a) or any developmental and behavioural problems. 22

23 23. Suicide or attempted suicide, wilful self inflicted bodily injury or illness or injury sustained directly or indirectly as a result of the insured person committing a criminal offence. 24. Travel and accommodation costs unless specifically agreed by us in writing prior to travel. No travel and accommodation costs are payable where treatment is obtained solely as an outpatient. 25. Costs and expenses incurred where an insured person has travelled against medical advice. 26. Treatment and expenses directly or indirectly arising from or required as a consequence of: war, invasion, acts of foreign enemy hostilities (whether or not war is declared), civil war, rebellion, revolution, insurrection or military or usurped power, mutiny, riot, strike, martial law or state of siege or attempted overthrow of government or any act of terrorism, unless the insured person sustains bodily injury whilst being an innocent bystander resulting from an act of terrorism only up to a maximum of US$50,000 per insured person, per incident. 27. Regardless of any contributory clause(s), this insurance does not cover treatment of a medical condition which is in any way caused or contributed to by an act of terrorism involving the use or release or the threat thereof of any nuclear weapon or device or chemical or biological agent. 28. Treatment directly or indirectly arising from or required as a result of chemical contamination or contamination by radioactivity from any nuclear material whatsoever or from the combustion of nuclear fuel, asbestosis or any related condition. 29. Treatment received in connection with insomnia, sleep disorders, sleep apnea, fatigue, jet lag or work related stress or any related condition. 30. Dietary supplements and substances, which are available naturally, including but not limited to, vitamins, minerals and organic substances. 31. Treatment required due to medical malpractice. 32. Home visits by a physician, specialist physician or qualified nurse unless specifically agreed by us in writing prior to consultation. 33. Any treatment not prescribed recommended or approved by your attending physician or specialist physician. 34. Costs for treatment that you are not legally obliged to pay. 35. Costs, as determined by us, to be for custodial care. 36. Chronic brain syndrome or dementia. 37. Any pregnancy or complications of pregnancy whatsoever incurred in the first 10 months following the commencement date of this benefit or the date of entry, whichever is the later. 38. Treatment for alcoholism, drug or substance abuse or any addictive condition of any kind and any injury or illness arising from such abuse or addiction. 23

24 Claims Procedures Important Please ensure that any and all costs for non emergency inpatient/day-patient treatment and mri and ct scans are precertified by us, in writing (fax/ /letter) before any planned treatment is undertaken. Notification of any elective non-emergency inpatient/day-patient treatment should be notified to us as soon as reasonably possible. To obtain assistance from the international member service centre, please use the contact details shown on your member ID card. You will need to provide your name, policy number, telephone and/or fax number, location and medical condition. In any given situation, if you are unsure what to do, contact the international member service centre. Claims paid in a local currency will be converted at the rate of exchange quoted on based on the date of treatment. To safeguard you against the possibility of being faced with expenses which are not covered under your policy, we developed the following procedures: Planned Inpatient and Day-patient Treatment: In the event of a planned admission on an inpatient or day-patient basis to a medical facility, take the following steps: Payment of all expenses incurred by the enrolled person will only be reimbursed at 50 percent of the negotiated fees for an in-network Aetna provider and 50 percent of the reasonable and customary fees for an out-of-network provider unless you follow these procedures: Contact the International Member Service Centre (toll-free) as soon as reasonably possible prior to admission, giving full details of the condition, proposed treatment (including dates and name of procedure (if known), name of the specialist physician and details of the medical facility. (The telephone number is on your member ID card.) The International Member Service Centre will advise you if they have sufficient information to confirm the enrolled person s cover. If not, they will advise you what further information is required. The International Member Service Centre will verbally confirm the enrolled person s cover and will dispatch written confirmation to you. The International Member Service Centre will attempt at all times to make arrangements with the medical facility for all eligible bills to be settled directly when using a preferred care provider. Where this has been arranged, you should send the original claim form and the unpaid invoices (if given to you by the medical facility) to the Aetna International claims department. Inpatient, routine checkup or outpatient treatment undertaken out of the preferred provider network in the USA will be subject to reasonable and customary charges as detailed in this handbook unless there are no provider facilities available or where unforeseen circumstances prevent you from attending a preferred provider facility. We would however recommend that whenever possible you attend a preferred provider facility for any treatment required. Benefits will be subject to the policy deductible. Emergency Admissions: In the event of emergency admissions, you should call the International Member Service Centre as soon as possible prior to or immediately following an inpatient admission. Failure to do so may result in the reimbursement of only 50 percent of any eligible claims. Please do not delay in obtaining treatment. 24

25 Treatment in the USA: Outpatient Treatment within the Preferred Provider Network: We have arranged a preferred provider network, enabling you to obtain out patient treatment at a wide number of selected medical centres where all eligible treatment charges will be paid directly by us. Outpatient procedures are covered in full, subject to its eligibility and the deductible depending on the plan chosen outside of Jamaica. When seeking outpatient treatment at any of the participating centres, (please refer to the Aetna International preferred provider network list), it is important that you present your membership card to the medical centre before your treatment begins in order to ensure that you are not asked to settle any treatment costs yourself other than the applicable ones. Present membership card to the medical centre when you arrive Have a second form of identification available should it be required by the reception staff Check the claim form that the medical centre will provide you with after your treatment and sign it to confirm that you have received the treatment stated Settle any charges made by the medical centre, which relate to either not-covered items or in-eligible treatment that you may have received In the event that the facility requires settlement for eligible treatment, please have the facility contact us to confirm benefits IMPORTANT: Please remember that your membership card should not be used to obtain any treatment which falls under the exclusions of your policy. Please note that the preferred provider network does not include dental practitioners, therefore you can receive dental treatment within the USA at a facility of your choice. Treatment in the USA: Outpatient Treatment Outside of the Preferred Provider Network: Outpatient treatment received at a medical facility, which is not a member of our preferred provider network, will need to be settled directly by you prior to completion of your treatment. You will need to complete a claim form and have your treating physician complete the relevant sections at this time. This along with fully itemized receipts for the treatment received should be sent to your local Aetna office for assessment. When submitting any claims and any other documents pertaining to the claim, please note that you will be subject to reasonable and customary charges. The first page of the claim form has been completed in full by you for each new medical condition treated. The declaration must be signed by the insured person and dated to enable the claim to be validated. Original paid receipts and any other documents pertaining to the claim (or other proof of payment) for all treatment for which you are making a claim are attached to the completed claim form. Where applicable laboratory tests results and/or X-rays were provided, please include the test results with your claim. The diagnosis needs to be listed on the claim form. General Claims Information: All documents and materials (including but not limited to original accounts, certificates and X-rays), which are required by us to support a claim, shall be provided without expense to us, including if requested, a medical report from your medical practitioner and any details of your medical history prior to any claim being made. In cases where medical information is required by us for consideration of a claim but is not available, it will be your responsibility to obtain such information from your medical practitioner at your own cost. All claim forms should be sent to your local Aetna office centre, whose address can be found on the claim form. Claims may only be made for treatment given during a valid period of cover and benefits will be available only for expenditure incurred prior to expiration or termination of such cover. It is your responsibility to provide us, without delay, written notification of any claim or right of action against a third party arising out of any circumstances which gave rise to a claim under this policy and you must continue to keep us informed in writing, and to take all steps reasonably required in making a claim upon that other party. To the extent permissible under the laws of your country of residence, we shall be entitled to take legal action in your name for our own benefit and claim for indemnity or damages or otherwise which relates to any benefits and costs paid or payable under this policy. We shall have full discretion in the conduct of any proceedings and in the settlement of any such claim. We reserve the right to reject any claim that is not submitted within 180 days of the date treatment took place. Preauthorisation does not guarantee payment of benefits which at all times must be subject to what is defined in the member handbook. Please note: you will need to submit a claim form for each new condition. 25

26 How to make a claim To ensure that you receive the best possible service, we have compiled the following procedures that should be followed in the event of medical or dental treatment being required by you or one of your dependents. Please read these carefully as your deductible and/or coinsurance may apply. PLEASE NOTE THAT FAILURE TO PREAUTHORISE REQUIRED TREATMENTS WILL RESULT IN A 50% PENALTY. Benefits will be subject to the policy deductible. Please note: Calls may be recorded for quality and training purposes. All claims are subject to the policy terms and conditions as outlined in your member handbook. Treatment in Jamaica Step 1: If you are planning any inpatient or routine treatment in Jamaica, call the International Service Centre for preauthorisation. Step 2: We will request a precertification form (PCMF) from the treating specialist in order to confirm cover prior to your scheduled treatment. A PCMF will be required for each new condition. In some cases further medical reports may be required. non-preferred provider treatment in the Usa Step 1: If you are planning any inpatient or routine treatment with a non-preferred provider, call the International Service Centre for preauthorisation. Step 2: You will need to take along a claim form for completion by your treating specialist, pay for your treatment and send this to our member services office along with fully itemized receipts. Treatment costs will be subject to reasonable and customary charges. PreFerred provider treatment in the Usa Step 1: If you are planning any inpatient or routine treatment within the USA provider network, call the International Service Centre for preauthorisation. Step 2: Once cover is confirmed, precertification will be placed with your chosen USA preferred provider. This ensures, where possible, all eligible costs will be settled directly with the relevant hospital and/or treating specialist. treatment WorLdWide excluding the Usa and Jamaica Step 1: If you are planning any inpatient or routine treatment outside Jamaica or the USA, call the International Service Centre for preauthorisation. Step 2: We will require a precertification medical form (PCMF) to be provided by the hospital or specialist in order to assess cover for the Step 3: When cover is confirmed, we will negotiate with the hospital to try and put in place a Guarantee of Payment for your admission. All eligible costs will be settled directly with the hospital at reasonable and customary charges. 26

27 Guarantee of Payment/ Precertifications: The below information/documents are required in order to process guarantee of payments and precertifications in a timely manner: Diagnosis Treatment for which the approval is being requested Date of service/date of planned surgery Provider s name and contact person Provider s phone and fax number or Medical records/medical notes Cost estimate ROMIF (Release of medical information form) PCMF (Precertification medical form) Complaints Procedure: Our aim is at all times to provide a first class standard of service. However, there may be occasions when you feel that this objective has not been achieved. Should you have any complaints regarding this insurance policy, please contact in writing: Aetna International P.O. Box Tampa, FL USA TF T F E Aetnainternationalcomplaints&[email protected] These requests may take up to two business days to approve once we receive all of the required information. However, we will try to expedite it, when requested. Some cases may take longer to approve based on the types of request; for example, translations of medical records, transplants, etc. All claims should be sent to: Aetna International P.O. Box Tampa, FL USA TF T F E [email protected] 27

28 Stay connected to Aetna International Visit Follow Like Health insurance plans and programs are underwritten by Aetna Life & Casualty (Bermuda) Ltd., and administered by Goodhealth Worldwide (Global) Limited. Aetna International is a U.S. and European Union registered trademark of Aetna Inc. Aetna is a trademark of Aetna Inc. and is protected throughout the world by trademark registrations and treaties. Aetna does not provide care or guarantee access to health services. Not all health services are covered. Health information programmes provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. See plan documents for a complete description of benefits, exclusions, limitations and conditions of cover. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna International plans, refer to Aetna Inc LAC (5/13)