ADDENDUM A

SCHEDULE OF BENEFITS AND FEES

AIMSTAFF

COVERED BENEFITS PROGRAM I-A

Monthly Premium Php 158.00

Room Accommodation Ward

Maximum Daily Room and Board Open

Maximum Benefit Limit Php 20, 000.00 / year

Hospital Confinement (Accredited Hospital)

1. Hospital Bills & Professional Fees
2. Non-emergency (non-accredited hospital in areas with no provider Php 10,000 / confinement / illness
network) Covered (80%)

Out-Patient Consultation Unlimited

1. Accredited Clinic (with 1 pre-natal & 1 post natal) Covered
2. Non-accredited clinic in areas with no provider network Covered (reimbursement)
3. Laboratory , X-ray & other diagnostic examination Php 2,000.00 / year

Out-Patient Emergency Treatment of Illness and Injury: Maximum Php 5,000.00 / year

1. Accredited Hospital Covered

2. Non-Accredited Hospital Covered
3. Medico legal cases Reimbursement only

Prescribed Take Home Medicines Not covered

Dental Services:
1. Simple tooth extraction 5 extractions
2. Prophylaxis Covered after one (1) year
3. Permanent Filling 2 permanent filling per year

Annual Physical Examination (APE):

To cover the following procedures:

1. CBC Covered after one (1) year

2. Physical Examination
3. Urinalysis
4. Chest X-ray
5. Fecalysis

Pre existing Illness Covered after one (1) year

Financial Assistance: (Death Benefit)

1. Natural Death Php 10,000.00
2. Accidental Death Php 20,000.00
3. Dismemberment due to Accident Up to Php 20,000 (as per scheduled body parts)
4. Burial expense Php 2,000.00

Conforme: ______________________ ________________________