oC SCHEDULE OF BENEFITS MARINE BENEFITS MEDICAL PLAN WWW. MARINEBENEFITS. NOTN Membership Eiigibilty Src em ame aa) Peas bertu) 1. Employees 18 to 65 years old 2. Spouse 18 (or local legal age) to 65 Pegi ey Ue PAN UAL Room and Board according to ype of enrolment Maximum period of cover (per cause or per aiment } 12 Months Lifetime limit Usp 200,000 Maximum limit per annum USD 100,000 Covered for semi private room only vioes of Physician, Surgeon and Specialist, Inpatient Me: Diagnostic procedures and ICU treatment Covered Transplants Covered excluding cost of securing donor tissue/organ Delivery Covered t-Natal consultation Covered Pro-Natal laboratory work-ups Covered Tmo Na) * Benefit is not payable unt the Insured Person has had continuous cover under the Marine Benefits Medica Plan fora least 365 days. monitoring devices, wheelchairs, crutches and casts and bandages: Consultation including specialists evaluation Covered Fist aid treatment of injury or thes Covered sie an see ese) — Laboratory examinations and all other relevant diagnostic procedures | Covered COutpationt surgical procedures Covered Nursing Care ~ up to six months Covered Ouipatient Mecications and outpatient medical appiances incuding |. CoveredSm ea ame aaa) EES peri el Tag Emergency care services Covered Emergency cae senioes in Non-accredted hospitals in the Covered absence of accreditag host et Unavallably of semi pvt room during emergency continent Covered for board dtference and incremental cr room category isnot avalable cost of upgrade to next tavalable room category. ergent Ambulance conduction (sutace) Covered Emergency care servis in medical aces in foreign terres Not Goveres while on official business trip NV oe Re UNL Percutaneous Adrenalectomy, Laparoscopic procedures, Heart Surgery Angiopiasty Cover New Diagnoste Procedures Covered Speech Therapy Covered Dialysis Covered Chemotherapy Covered Radiotherapy Covered Physica Therapy Covered ‘Al sophisticated lagnostc modalities or methods of reaiment for which, there are No comparable conventional of rational equvalet or Covered counterparts, V. OTHER FEATURES Congenital nesses, Covered for employes Vaccines Antistetanus , Ant-rabies, Ant-venom vaccines coed Dental Benefits Not Covered Work related ilnesses/injuries Mental disordersErmer Pm amen agi) CES Cteetc orn Congenital bith defects Not covered Vision Not covered 1. Injuries sickness brought about by political unrest, riot, strike, military and paramilitary activities, including fraternity violence. Some Not Covered 2. Injuries and sickness brought about by professional sporting ac- tivities and sports classified as "extreme" sports-e.g. mountaineering, ‘mountain climbing parachuting and the like Not Covered 3. Injuries and sickness due to substance abuse such as recreational/ ilict drugs, alcoho! and including non prescription drugs ©.g. vita- mins, herbal drugs Not Covered 4. Injuries ang sickness due to sexually transmitted disease such as AIDS, Hep B ete Not Covered 5. Unprescribed medical treatment and any medical services outside of network or not approved by underwriters Not Covered 6 Reproductive and family planning medical services Not Covered 7. Dermatological cosmetic medical services and routine medical diagnostic procedures for employment or travel purposes. Not Covered 8. Self inflicted bodily harm while sane or insane Not Covered 9. Medical treatment and diagnostics not accepted in current medical diagnostics and treatment protocols Not Covered 10. Any medical treatment directly or indirectly inked to an lines or accident that first manifests itself whilst the employee is signed on board a vessel - including any periods spent off vessel during a voyage — by the Assured, Not Covered 11, Expenses for sex change, hearing aids, leaming disabilities and self enhancement e.g, weight control, podiatric care and custodial rest care Not Covered