Proposed Principal Insured:

Ms. AIREE SHIMOYAMADA TEMPORAL -

Age 30, Female

Policyowner or Payor:
AIREE SHIMOYAMADA TEMPORAL

Health Care Access

Dear Airee ,

Congratulations! You have taken a vital step toward securing your health with AXA, global leader in insurance and
investment. AXA Philippines is a joint venture between two financial giants — the AXA Group, headquartered in
France, and the Metrobank Group, one of the Philippines’ largest financial institutions.

Health Care Access is designed to provide you and your family with extensive medical coverage for inpatient
treatment, along with benefits such as outpatient care and emergency care. This ensures that you have access to
the best health care anytime, anywhere in the Philippines.

Below is the benefit summary of your plan:

HEALTH PLAN BENEFITS

Plan Type Health Care Access Prime
Annual Deductible (per Insured) No deductible
Refer to Premium Breakdown Table for the detailed benefits per insured.
Benefits:
Inpatient care Outpatient care Emergency care Value-added benefits

· Inpatient hospital · Consultations · Emergencies · Longevity Health Fund

charges and · Diagnostic scans · Road ambulance · Life Insurance
accommodations transport · Accidental Death and
o Including pre/post
· Laboratory
investigations Dismemberment
outpatient Insurance
treatment · Annual Physical Exam
· Surgical procedures · Dental care
· Special Outpatient
conditions
o Dialysis
o Radiotherapy
o Chemotherapy

Based on your chosen plan specified below, your First Year Annual Premium will be PHP 109,633.41 . You can
pay semi-annually for only PHP 57,009.37, or quarterly for only PHP 29,601.03.

The succeeding pages of this proposal will provide you with more details on the benefits and features of Health
Care Access. Benefits may be subject to limits, please refer to your chosen plan’s inclusions/exclusions/ limits.
Again, thank you for your interest in Health Care Access. Please do not hesitate to contact me for any assistance
or clarification. See my details below or call the AXA Customer Care Hotline at Tel. No. +632-8-581-5292.

IGNACIO, MA KRISTINA GARCIA

211600
55024
639099226044

1/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

Premium Breakdown:
The initial Annual Premium for the 1st and 2nd Policy Year are as follows:

Issue Annual Premium in PHP Annual Premium in PHP

Insured Plan Variant
Age (1st Policy Year) (2nd Policy Year)
AIREE TEMPORAL 30 Plan 500K 29,606.00 30,709.10
ANNUAL BENEFIT LIMIT - PHP 500,000
SUBTOTAL 29,606.00 30,709.10
AISHA JRIANNAH 46,170.70 37,635.00
9 Plan 500K
TEMPORAL
ANNUAL BENEFIT LIMIT - PHP 500,000
SUBTOTAL 46,170.70 37,635.00
ALYDA JASREE 46,038.20 46,038.20
5 Plan 500K
TEMPORAL
ANNUAL BENEFIT LIMIT - PHP 500,000
SUBTOTAL 46,038.20 46,038.20

TOTAL PREMIUM 121,814.90 114,382.30

TOTAL PREMIUM
109,633.41 102,944.07
with DISCOUNT

Notes:
1. The first year premium is based on the age nearest birthday of the insured and hence subject to change
depending on the policy issuance date.
2. The Total Premium with discount reflects a 10% reduction applicable to a family of 2 or more. The level
of reduction is not guaranteed and may vary for succeeding renewal years. Such discount will also be
applied to renewal premiums as long as the policy is renewed as a family.
3. The premiums shown in this illustration are those currently in effect at the time of application.
Premiums are not guaranteed and may change according to the premiums in effect based on the
attained age at the time of renewal .

COOLING -OFF PERIOD

If you are not completely satisfied with this Policy and its Supplementary Benefits, you may return it to our Head
Office or any of our branch offices within fifteen (15) days after receipt of the Policy, together with the
membership card(s) and a written notice requesting cancellation. On such cancellation, you will be entitled to a
full refund of the initial premium paid, provided that no claims have been made.

2/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

SCHEDULE OF RENEWAL PREMIUMS

Policy Year Total Annual Premium in PHP

1 109,633.41
2 102,944.07
3 103,690.26
4 104,503.32
5 105,368.98
6 98,217.81
7 94,713.75
8 95,193.40
9 95,593.36
10 96,016.99

Notes:
1. The premiums shown in this illustration corresponds to the total premiums for all insureds specified in this proposal,
subject to the insured's eligibility.
2. Coverage for dependent Children and Siblings are renewable only until age 21. Renewal premiums for dependents at
attained age 22 and above are no longer included in this table for the family plan.
3. The Total Premium reflects a 10% discount applicable to a family of 2 or more. The level if reduction is not guaranteed and
may vary for succeeding renewal years.
4. The premiums shown in this illustration are those currently in effect at the time of application. Premiums are not
guaranteed and may change according to the premiums in effect based on the attained age at the time of renewal.

3/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

BENEFITS TABLE
We shall pay the actual medical expenses incurred from our accredited providers less any deductible and after
deducting the medical benefits from PhilHealth and any other government program, employee benefit program or
insurance policies covering the Insured, for the following covered medical benefits. All benefit amount payable by
us shall be subject to the maximum amounts specified in below Benefit Table based on each insured’s chosen
plan.
Plan 500K Plan 1M Plan 2M Plan 4M Plan 5M
OVERALL YEARLY MAXIMUM LIMIT UP TO:
Annual Inpatient Benefit Limit (ABL) PHP 500,000 PHP 1,000,000 PHP 2,000,000 PHP 4,000,000 PHP 5,000,000
Annual Outpatient Limit (AOL) PHP 25,000 PHP 50,000 PHP 75,000 PHP 100,000 PHP 125,000
Regular Private Regular Private Large Private Executive Suite Executive Suite
Room and Board Category Up to Php Up to Php Up to Php Up to Php Up to Php
4,500 4,500 6,500 15,000 15,000
All Illnesses (except those caused by
accidents, dengue fever, and rabies) 30-days waiting period for the 1st policy year, plan upgrade or plan reinstatement

A lump sum equivalent to 50% of original ABL to be paid out on the policy anniversary following
Longevity Health Fund
the 75th birthday of the Insured that may be used for medical needs
Life Insurance Up to 10% of ABL
Accidental Death and
Dismemberment Insurance Up to 10% of ABL

INPATIENT AND EMERGENCY OUTPATIENT TREATMENTS AND OUTPATIENT SURGICAL PROCEDURES IN ACCREDITED HOSPITALS
Room and Board (inpatient)
Other Hospital charges (inpatient)
Professional Fee (inpatient)
Land Ambulance Service (non-
Accredited Hospital to Accredited
Hospital or point of incident to
Accredited hospital)
Pre- and post-hospitalization
Outpatient treatment (inpatient)
SPECIAL DIAGNOSTIC PROCEDURES IN ACCREDITED HOSPITALS (PART OF THE INPATIENT BENEFIT)
Heart
Surgery/Angiography/Angiogram/
Angioplasty
Transurethral Microwave Therapy of
Prostate
Percutaneous Ultrasonic
Nephrolithotomy
Lithotripsy
Laparoscopic Procedures
Arthroscopic Procedures
Hysteroscopic Procedures
Hemorrhoidectomy Procedures
Stereotactic Brain Biopsy
Gamma Knife Surgery (Based on
Cobalt / Radiotherapy)
CT Scan
Ultrasound (except maternity cases)
Thallium Scintigraphy
2D-Echo with Doppler
24-Hour Holter Monitoring
Herniorrhaphy
Electromyography
Treadmill Stress Test
Myelogram
Video Gastroscopy
Mammography / Sonomammogram
Bone Densitometry Scan (Dexa scan)
As charged based on the allowable room and board category, up to the remaining ABL
As charged based on the allowable room and board category, up to the remaining ABL
As charged based on the allowable room and board category, up to the remaining ABL
Up to PHP 3,000 per service
As charged up to the remaining ABL - within 90 days prior to hospital admission and
90 days immediately following discharge from hospital
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL
As charged, up to the remaining ABL

4/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

Magnetic Resonance Imaging As charged, up to the remaining ABL

Nuclear Radioactive Isotope Scan As charged, up to the remaining ABL
Neuroscan As charged, up to the remaining ABL
Perfusion Scan Up to 10% of ABL, but not to exceed the remaining ABL
Positron Emitting Tomography (PET
Scan) PHP 10,000, up to the remaining ABL
Cryosurgery PHP 1,000/area, up to the remaining ABL
Organ/Tissue Transplant (excluding
donor's cost - heart, heart/valve, PHP 100,000 PHP 200,000 PHP 400,000 PHP 800,000 PHP 1,000,000
heart/lung, pancreas, per year or per year or per year or per year or per year or
pancreas/kidney, bone marrow, 20% of ABL per 20% of ABL per 20% of ABL per 20% of ABL per 20% of ABL per
parathyroid, muscular/skeletal and year, up to the year, up to the year, up to the year, up to the year, up to the
cornea transplants), max remaining ABL remaining ABL remaining ABL remaining ABL remaining ABL
Kidney Dialysis As charged, up to the remaining ABL
Chemotherapy / Radiotherapy
(including the cost of doctor
consultations, treatment, and all
charges made by the doctor in As charged, up to the remaining ABL
connection with the treatment of
cancer)
Surgical Procedures received as an
outpatient As charged, up to the remaining ABL
FDA-Approved Procedures/
Treatments not yet available under PHP 10,000, up to the remaining ABL
the Relative Value Scale (RVS)
SPECIAL INPATIENT BENEFITS IN ACCREDITED HOSPITALS - (PART OF THE INPATIENT BENEFIT)
Eye Laser Treatment (whether
Inpatient or Outpatient) for retinal
hole, retinal detachment and
glaucoma (excluding myopia or Up to 10% of ABL, but not to exceed the remaining ABL
correction of error of refraction such
as Lasik, PRK and the like)
Cataract Surgery excluding cost of
lens Up to 10% of ABL, but not to exceed the remaining ABL
Sports-related Injuries, max PHP 10,000, up to the remaining ABL
Teleconsultation Unlimited
BENEFITS/TREATMENTS IN NON-ACCREDITED HOSPITALS/CLINICS (REIMBURSEMENT BASIS ONLY)
Room and Board (inpatient) 100% of the Relative Value Scale or the equivalent benefit provided for Accredited Hospitals,
whichever is lower
Other Hospital charges (inpatient) 100% of the Relative Value Scale or the equivalent benefit provided for Accredited Hospitals,
whichever is lower
Professional Fee (inpatient) 100% of the Relative Value Scale or the equivalent benefit provided for Accredited Hospitals,
whichever is lower
Pre- and post-hospitalization 100% of the Relative Value Scale or the equivalent benefit provided for Accredited Hospitals,
Outpatient treatment (inpatient) whichever is lower
Special Diagnostic Procedures 100% of the Relative Value Scale or the equivalent benefit provided for Accredited Hospitals,
(mentioned above) whichever is lower
Special Inpatient Benefits 100% of the Relative Value Scale or the equivalent benefit provided for Accredited Hospitals,
(mentioned above) whichever is lower
OUTPATIENT TREATMENTS IN ACCREDITED HOSPITAL/CLINICS
Medical consultation during regular
clinic hours
(Referral to all accredited specialists) As charged, up to the remaining AOL

Medicines and Drugs are Excluded

Laboratory tests (excluding Allergy
Tests), x-rays and other diagnostic As charged, up to the remaining AOL
exams
PHP 1,000, up PHP 1,500 , up PHP 2,000, up PHP 2,500, up PHP 3,000, up
Allergy Testing, max to the to the to the to the to the
remaining AOL remaining AOL remaining AOL remaining AOL remaining AOL
Anti-tetanus, anti-rabies & anti-
venom vaccines As charged, up to the remaining AOL
Administration of Routine
immunization except cost of vaccines As charged, up to the remaining AOL

5/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

EMERGENCY BENEFITS
Emergency Treatment in Accredited
Hospitals As charged, up to the remaining ABL
Emergency Treatment in Local Area Per inpatient/ outpatient limits using Relative Value Scale (RVS),
without Accredited Hospitals for reimbursement up to the remaining ABL
Emergency Treatment in Non- Per inpatient/ outpatient limits using Relative Value Scale (RVS),
Accredited Hospitals for reimbursement up to the remaining ABL
Emergency Treatment outside of the Per inpatient/ outpatient limits using Relative Value Scale (RVS),
Philippines for reimbursement up to the remaining ABL
ANNUAL PHYSICAL EXAMINATION IN ACCREDITED HOSPITALS/CLINICS
Basic 7 + ECG
Basic 7 + ECG for members
for members 30 y.o. & up +
30 y.o. & up + Pap Smear for
Pap Smear for female
female members 30
Basic 7 + ECG
members 30 y.o. & up) +
for members
y.o. & up) + BUN + BUA +
30 y.o. & up +
BUN + BUA + Creatinine +
Pap Smear for
Creatinine + SGPT & SGOT +
female
SGPT & SGOT + Alkaline
members 30
Basic 7 + ECG Alkaline Phosphatase +
y.o. & up) +
for members Phosphatase + HB1AC (subject
BUN + BUA +
30 y.o. & up + HB1AC (subject to
Creatinine +
Basic 7 – Physical Examination, Pap Smear for to recommendatio
SGPT & SGOT +
Chest X-Ray, Urinalysis, Fecalysis, Basic 7 female recommendatio n) + Lipid
Alkaline
CBC, FBS, Total Cholesterol members 30 n) + Lipid Profile (Total
Phosphatase +
y.o. & up) + Profile (Total Cholesterol,
HB1AC (subject
BUN + BUA + Cholesterol, Triglyceride,
to
Creatinine Triglyceride, HDL) + Total
recommendatio
HDL) + Total Protein (A/G
n) + Lipid
Protein (A/G Ratio) +
Profile (Total
Ratio) + Electrolytes
Cholesterol,
Electrolytes Serum
Triglyceride,
Serum (Sodium,
HDL)
(Sodium, Potassium,
Potassium, Total Calcium)
Total Calcium) + T3 + T4 +
+ T3 + T4 + TSH + Whole
TSH Abdomen
Ultrasound
DENTAL SERVICES IN ACCREDITED CLINICS
Dental Examination Covered once a year
Oral prophylaxis Covered twice a year
Orthodontic consultation (braces and
malposition of teeth) Covered once a year
Pre-natal check of teeth and gums Covered once a year
Temporomandibular Joint (TMJ)
consultation (clicking of jaws) Covered once a year
Emergency dental treatment for the
relief of pain Covered once a year
Gum treatment for cases like
inflammation or bleeding Covered once a year
Temporary fillings Unlimited
Permanent fillings Covered up to 4 teeth/year
Simple extraction of unsavable tooth Covered once a year
Re-cementation of fixed bridges,
crowns, jackets, inlays/onlays Covered once a year

Notes:
1) The benefit limits are all in Philippine Pesos. Premium and eligible claims will be paid in Philippine Pesos.
2) The benefit limits are per insured person each policy year unless otherwise specified and are reduced each time the insured
person claim only by the net amount (less any deductible we have actually paid). Please refer to your Policy Contract on the full
terms and conditions applying to these benefits.
3) If the policyholder has opted for annual deductible at the time of application (please refer to the policy specifications), the annual
deductible will apply to all eligible inpatient treatment and any benefit that is arising therefrom, or associated therewith to the
inpatient treatment. Please refer to Note 4 for more details.

6/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

4) Annual Deductible is applicable to the following eligible inpatient treatment benefits and any benefit that is arising therefrom or
associated therewith to any eligible inpatient treatment:
• Daily accommodation charges • Kidney Dialysis Treatment
• Hospital charges • Radiotherapy and chemotherapy (Cancer Treatment)
• Organ Transplant • Local Road ambulance transport
• Pre- and post-hospitalization Outpatient treatment
If there is no inpatient treatment, the annual deductible will not apply. If there is an eligible inpatient treatment, the annual
deductible will apply to the inpatient treatment and the associated benefits.
5) Pre-existing condition exclusion/limitations do not apply to the following benefits: Annual Physical Exam (APE) and Routine dental
care.

Pre-existing condition(s)- refers to any medical condition which during the two (2) years preceding the policy effective date, or
reinstatement date, or plan upgrade date, whichever date is later: (i) your insured person has been diagnosed; or, (ii) for which your
insured person has received medication, advice or treatment, or, (iii) which the policyholder and/or your insured person should
reasonably, based on our appointed independent medical practitioner’s opinion, have known about; or, (iv) for which your insured
person has experienced symptoms even if your insured person has not consulted a medical practitioner. There will be a waiting
period of one (1) year for pre-existing conditions.

For avoidance of doubt, if you did have any pre-existing condition(s) before joining, please declare on the relevant Application form.
Such pre-existing condition(s) will also be subject to medical underwriting and if not disclosed they may not be covered under this
policy.

6) For qualified takeover policies, pre-existing conditions are covered from Day 1.
Takeover is defined by a transfer from a similar plan which the insured person has been covered with for at least 365 consecutive
days. The Insured’s prior plan should have similar plan limits, benefits and area of cover and the Insured should pass AXA
Philippines underwriting qualification.
7) Nontakeover plans will have an applicable waiting period of 12 consecutive months for the following acquired medical conditions
and their associated medical conditions:

1. Cancer 2. Hepatitis B 3. Hepatitis C

4. Diabetes 5. Heart Disease 6. Kidney Failure
7. High Blood Pressure 8. Chronic obstructive pulmonary
disease 9. Liver cirrhosis
10. Stroke/Cerebrovascular accident 11. Transient ischaemic attack

8) Pre-approval is required for cashless transaction and for non-emergency cases before receiving any planned Inpatient and
Outpatient treatment recommended by a medical practitioner, depending on the benefits of the insured. Policyholder should
contact us before the scheduled treatment to obtain our approval. By seeking pre-approval, we can confirm the following:
⦁ The planned treatment/s is eligible under the policy
⦁ The planned treatment/s is medically necessary
⦁ The planned treatment/s is within reasonable and customary (R&C) cost
⦁ The planned treatment/s cost falls within the remaining benefit limit of the plan

9) Premium rates of Health Care Access are not guaranteed. Subject to approval of the Insurance Commission, AXA Philippines
reserves the right to change all or any part of this policy that will be issued including the Benefits Table and/or any of the terms
and conditions.
10) Premium of Health Care Access will be adjusted based on the attained age of the Insured on each policy anniversary and
according to the prevailing premium rates at the time of renewal. You may refer to your Financial Executive/Financial Advisor or
AXA for more information on renewal premium.

7/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

ILLUSTRATION OF CASH VALUE AND LONGEVITY HEALTH FUND

Principal Insured - PHP 250,000:

End of Year Attained Age Guaranteed Longevity Fund

1 31 0
2 32 0
3 33 0
4 34 250
5 35 2,000
6 36 3,750
7 37 5,500
8 38 7,500
9 39 9,750
10 40 11,750
25 55 51,500
30 60 71,000
35 65 97,250
40 70 133,250
45 75 186,250
46 76 250,000

Dependent 1 - PHP 250,000:

End of Year Attained Age Guaranteed Longevity Fund

1 10 0
2 11 0
3 12 0
4 13 0
5 14 0
6 15 0
7 16 0
8 17 0
9 18 0
10 19 750
12 21 2,500

8/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

Dependent 2 - PHP 250,000:

End of Year Attained Age Guaranteed Longevity Fund

1 6 0
2 7 0
3 8 0
4 9 0
5 10 0
6 11 0
7 12 0
8 13 0
9 14 0
10 15 0
16 21 4,250

Coverage for dependent Children or Siblings are renewable only until age 21. Their coverage can be converted to a separate stand-
alone policy after termination for plan continuation, subject to additional premium.

Notes:
1. The Illustration of Longevity Health Fund presents the amounts payable to the Owner once he/she decides to
surrender/terminate the plan, less any loans and interest. The plan provides Guaranteed Cash Value , which can be paid
to the Owner upon termination of the policy prior to death of the insured person, less any loans and interest.
2. The Longevity Health Fund refers to the lump sum to be paid out on the policy anniversary following the 75th birthday of
the insured.
3. The Cash Values under this plan are loanable, subject to interest
4. All amounts are in Philippine Peso.

9/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

Exclusions and Limitations:

Listed below are some exclusions and limitations related to your plan. This list is not exhaustive. The complete list of
Exclusions and Limitations is detailed in the policy contract that will be issued for this product .

Exclusions and Limitations for the Medical Benefits:

· Any hospitalization, treatment or surgery which commenced one (1) year after the effective date or reinstatement date due to
any pre-existing condition that existed, happened, or occurred two (2) years before the effective date or reinstatement date, if
such condition was disclosed at the time of application.
a. Any pre-existing conditions that are not disclosed upon submission of application form for policy issuance, plan
upgrade or reinstatement, whichever is later;
· Services rendered by non-affiliated doctors/specialists, except with the prior written authorization of the company, or in emergency
cases;
· Hospital charges for routine health check-ups charges; any investigation(s) not directly related to pre-admission diagnosis except
for benefits specifically defined; any treatment which is not medically necessary, convalescence, custodial or rest care, and food
supplement and vitamins (unless used to treat a medical condition, for inpatient treatment only). Telecommunication charges,
rental of television, mini-bar consumption, room or menu upgrade above the benefits defined, administrative costs or reports of any
kinds (unless otherwise stipulated by AXA) and other medically unrelated services (such as but not limited to private nursing
services);
· Expenses related to recuperation such as but not limited to confinement in sanitarium or convalescent home, outpatient
Rehabilitation facilities, custodial, domiciliary care, and government imposed quarantines;
· Vaccines that are administered for prevention of illnesses except for anti-rabies, anti-venom, and anti-tetanus vaccines which are
administered as part of necessary emergency treatment;
· Any expenses incurred in the acquisition of organs or tissue (such as, but limited to, the cost of donor search) even if such
transplants are allowed by the terms of this policy;
· Procurement or use of eyeglasses, special braces, steel implants, buckles for retinal detachment, appliance or medical aids or
durable medical equipment or mobility aids; wheelchairs or prosthetic device (including but not limited to artificial limbs, hearing
aids, crutches, intra-ocular lens, contact lenses), unless these are specifically covered under your plan;
· Dental implants, orthodontics, periodontics, endodontics, preventative dentistry, no matter who gives the treatment;
· Investigations and treatments that are directly or indirectly related to infertility or fertility, contraception and virility/potency (such as
but not limited to erectile dysfunction), gender reassignment procedure & processes leading to or in preparation for gender
reassignment, circumcision regardless of cause or reason for this procedure;
· Any surgical treatment to correct refractive defects of the eyes such as but not limited to laser/lasik eye surgery for long or short-
sightedness or astigmatism;
· Cosmetic and/or plastic surgery and cosmetic products even if prescribed- except to treat a functional defect directly caused by
accident or illness covered herein;
· The costs of collecting donor organs or tissue or any administration costs (such as, but limited to, the cost of donor search) even if
such transplants are allowed by the terms of this policy;
· Outpatient vitamins, food supplements & traditional herbal supplements;
· All other treatments, laboratory examinations, diagnostic procedures and surgical procedures not specifically defined in this
agreement are considered not covered (example but not limited to the following: Dental Surgery, Dental X-Ray, etc.);
· Insured participating in dangerous or hazardous activities or sports including but not limited to any kind of racing (other than on
foot), martial arts, caving, scuba diving, water skiiing, bungee jumping, parachuting, hang gliding, paragliding or microgliding,
mountain and rock climbing, skiiing and snowboarding or any other such activities;
· War, invasion, act of foreign enemy, hostilities or warlike operations (whether war has been declared or not), mutiny, riot, civil
commotion, strike, civil war, rebellion, revolution, insurrections, conspiracy, military or usurped power, marital law or state of siege,
or any of the events or causes which determine the proclamation or maintenance of martial law or state of siege, seizure,
quarantine, or nationalization by or under the order of any government or public or local authority;
· Aviation or aeronautics or sea travel other than as a fare-paying passenger on licensed aircraft/vessel operated by a recognized
airline/operator;
· Congenital anomalies and any related conditions arising therefrom; Developmental delays as well as neuro-developmental
disorders such as ADHD - Attention Deficit Hyperactive Disorder, Autism, Genetic Disorders which may result in a some form of
Mental Retardation (e.g. Down Syndrome), and other conditions which may require speech/physical and other related therapies;
· Substance addiction or reactions to the use of prohibited drugs, alcoholism, anxiety disorder, psychiatric and psychological
illnesses, or related accidents or conditions arising from these conditions; treatment which arises from or is directly or indirectly
caused by a self-inflicted injury or an attempt at suicide;
· Sexually transmitted diseases, HIV and its related conditions, and AIDS-related complex;
· Pregnancy, complications due to abnormal pregnancies such as but not limited to ectopic pregnancy, tubal pregnancy, Hydatidiform
Mole, abruptio placenta, placenta previa etc., childbirth, miscarriage, and/ or abortion. Also, we will not pay for such treatment if the
pregnancy was a result of assisted means or any form of assisted conception/assisted pregnancy or elective/non-medically
necessary caesarean section;
· Treatment begun, or for which the need had arisen, during the first ninety (90) days after birth for any child conceived by artificial
means or any form of assisted conception/assisted pregnancy;
· Treatment of obesity (Body Mass Index or BMI equal to 30 or above) in any way or management including medication or
supplements for weight loss or weight improvement;
· Treatment to relieve symptoms commonly associated with any bodily change arising from any physiological or natural cause such
as aging, menopause, or puberty and which is not due to any underlying disease, illness or injury;
· All forms of alternative treatment such as, but not limited to, traditional Chinese medicine and acupuncture;
· Any claim or part of a claim in respect of which you/your insured person have to pay an excess (or deductible). In this case we will
only pay the balance of the claim after we have deducted the excess (or deductible) amount;

10/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

· Cryopreservation, or harvesting or storage of stem cells as a preventive measure against possible disease/illness/injury or
implantation or re-implantation of living cells or living tissue, whether autologous or provided by a donor;
· Experimental medical procedures or non-established medication;
· Treatment whilst staying in a hospital for more than ninety (90) continuous days for permanent neurological damage or if your
insured person is in a persistent vegetative state. We define persistent vegetative state as a condition of profound no
responsiveness, with no sign of awareness or consciousness or a functioning mind, even if the person can open their eyes and
breathe unaided, and the person does not respond to stimuli such as calling their name, or touching. This state must have
remained for at least four (4) weeks with no sign of improvement or there could be no recovery.

Exclusions and Limitations for the Accidental Death, Dismemberment, or Loss of Use Benefits:
AXA Philippines will not pay the accidental death, dismemberment, or loss of use benefits if the loss occurs as a result, directly or
indirectly, wholly or partly, from any of the following causes:
· Self-inflicted injury, suicide, or any attempt threat; or
· disease or infection (except infection which occurs through an accidental cut or wound), including infection with any Human
Immunodeficiency Virus (HIV) and/or any HIV-related illness including Acquired Immune Deficiency Syndrome (AIDS) and/or any
mutations, derivations, or variations thereof; or
· strike, riot, civil commotion, Acts of Terrorism, revolution, insurrection, declared or undeclared war or any warlike operation; or
· murder, provoked assault or participation in any brawl; or
· any violation or attempted violation of the law or resistance to arrest; or
· while the Insured person is affected by alcohol or unprescribed drug; or
· bodily or mental infirmity, hernia, ptomaines or infection other than infection occurring at the same time with or because of an
accidental cut or wound, disease or sickness of any kind; or
· poison, gas, or fumes voluntarily or involuntarily taken, atomic explosion, nuclear fission, or radioactive gas; or
· while entering, operating, servicing, or ascending from or with any aerial or marine device or conveyance except while traveling as a
passenger in an aircraft or marine transportation operated by a commercial passenger airline or shipping line on a scheduled air or
sea service over an established passenger route; or
· service in the military, naval or air force in time of declared or undeclared war or while under the orders for warlike operations or
restoration of public order; or
· while undergoing medical or surgical treatment except as a result of accidental injury; or
· when occasioned by or happening through pregnancy or childbirth; or
· while engaged in hunting, racing of any kind, martial arts, scuba diving, hang-gliding, yachting beyond five (5) kilometer of coast-
line, bungee-jumping, parachuting, sky-diving, mountaineering, and other forms of extreme sports; or
· nuclear, biological, or chemical (NBC) contamination.

This proposal is an illustration only of the key features of the recommended insurance plan. You should refer
to your Financial Executive/Financial Advisor or the Company for more information. If your application is
accepted, you will receive a policy contract which will include detailed terms, conditions and exclusions.

11/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023
 Health Care Access
for: Ms. AIREE SHIMOYAMADA TEMPORAL, 30

DECLARATIONS AND ACKNOWLEDGEMENTS

Declarations
1. I confirm having read and understood the information contained in the Benefits Table Section, Notes
Section and Exclusions and Limitations Section of this illustration.
2. It is my understanding that the total premium I am going to pay when I purchase this plan shall consist of
the Health Care Access premium shown above.
3. I confirm having read and understood the information in this illustration. My Financial Advisor/Financial
Executive fully explained to me the benefits, feature and, exclusions and limitations related to the Health
Care Access product.
Product Transparency Declaration
By signing off on the items listed below, I acknowledge that the same have been discussed with and
thoroughly explained to me.

· I understand that I am buying a health insurance product.

· I understand that certain conditions may not be payable under the plan, as illustrated in the Exclusions
and Limitations of this proposal and detailed in the Exclusions and Limitations section of the policy
contract. This includes conditions that will not be payable during the waiting periods for certain medical
conditions and their associated medical conditions.
· I agree to answer all underwriting questions in the application form truthfully and I understand that
any mis-statement of facts, whether by commission or by omission may be grounds for AXA, in its
absolute and sole discretion, to decline to pay any benefit under the policy and also, to void the policy.
· I understand that the premiums will change according to any of the insured persons’ attained ages on
renewal. The premiums shown in this proposal are those currently in effect, but the premiums may
change upon renewal of the plan and will depend on those in effect at the date of renewal.
· I understand that due to the nature of the product AXA has the right to change the premiums of the policy
at any policy anniversary.
· I also understand that AXA has the right to change all or any part of the policy to be issued from any policy
anniversary and that AXA can change all or any part of the policy including the benefits table or the policy
terms, but only for the reasons shown in the policy document, and the changes will only apply when the
policy is renewed unless AXA is obliged by law to apply any change with immediate effect.
CONFORME: These declarations and acknowledgements are made
with the knowledge of AXA representative whose
signature appears below:

Financial Advisor/Financial
Applicant/Policy Owner Date Date
Executive
Signature over Printed Name
Signature over Printed Name
General Disclaimer
All information and opinions provided are of a general nature and for information purposes only. The
information and any opinions herein are based upon sources believed to be reliable, and AXA Philippines, its
officers and directors make no representations or warranty, expressed or implied, with respect to the
correctness, completeness of the information and opinions in this document. Please carefully read the policy
and endorsements and consider the risks, charges and expenses before buying the policy. You should seek
professional advice from your financial, tax, accounting or legal consultant before buying the policy.
THIS FINANCIAL PRODUCT OF AXA PHILIPPINES IS NOT INSURED BY THE PHILIPPINE DEPOSIT
INSURANCE CORPORATION (PDIC) AND IS NOT GUARANTEED BY METROBANK OR PS BANK.

12/12
Friday, May 13, 2022
Version Number: 6.2.0 Expiry Date: 07/12/2022
Plan Code: LMB10 Date of Next Insurance Age: Principal Insured: 03/19/2023