Common use of BUPA WORLDWIDE Clause in Contracts

BUPA WORLDWIDE. BENEFITS See applicable sections of the policy for details, limitations, and restrictions. Unless otherwise stated herein, insureds under this policy are not required to obtain treatment from the preferred provider network. Maximum coverage is five million dollars ($5,000,000) per insured, per lifetime for all covered medical and hospital charges, while the policy is in force, subject to the limitations herein. The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction. SCHEDULE OF BENEFITS BENEFITS Coverage (per Insured) Maximum benefit Preferred Provider Network Non-Preferred Provider Network Standard private or semi-private hospital room and board No limit $800 per day Intensive care room and board No limit $2,000 per day The following maximum benefits apply to all Providers: Maternity care (except plans C Plus, D and E) (no deductible or coinsurance applies) $4,000 Newborn coverage (no deductible or coinsurance applies) $25,000 Congenital and hereditary disorders: Manifested before age 18 (per Insured, per lifetime) Manifested on or after age 18 (per Insured, per lifetime) $250,000 $5,000,000 Organ transplant (per Insured, per lifetime) $500,000 Air ambulance transportation (per Insured, per lifetime) $100,000 Ground ambulance transportation (per incident) $1,000 Companion of hospitalized child (per admission) $1,000 Repatriation of mortal remains $5,000 DEDUCTIBLE All insureds under the policy have Insured's deductible for the following policy year.

BUPA WORLDWIDE. BENEFITS • See applicable sections of the policy for details, limitations, and restrictions. • Unless otherwise stated herein, insureds under this policy are not required to obtain treatment from the preferred provider network. • Maximum coverage is five million dollars ($5,000,000) per insured, per lifetime for all covered medical and hospital charges, while the policy is in force, subject to the limitations herein. • The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction. SCHEDULE OF BENEFITS BENEFITS Coverage (per Insured) Maximum benefit Preferred Provider Network Non-Preferred Provider Network Standard private or semi-private hospital room and board No limit $800 per day Intensive care room and board No limit $2,000 per day The following maximum benefits apply to all Providers: Maternity care (except plans C Plus, D and E) (no deductible or coinsurance applies) $4,000 Newborn coverage (no deductible or coinsurance applies) $25,000 Congenital and hereditary disorders: • Manifested before age 18 (per Insured, per lifetime) • Manifested on or after age 18 (per Insured, per lifetime) $250,000 $5,000,000 Organ transplant (per Insured, per lifetime) $500,000 BENEFITS The following maximum benefits apply to all Providers: Air ambulance transportation (per Insured, per lifetime) $100,000 Ground ambulance transportation (per incident) $1,000 Companion of hospitalized child (per admission) $1,000 Repatriation of mortal remains $5,000 DEDUCTIBLE • All insureds under the policy have Insured's an in-country and an out-of-country deductible responsibility per policy year according to the plan selected by the Policyholder. When applicable, the corresponding deductible amount the insured submits claims or requests for reimbursement for eligible expenses that occurred during the first nine (9) months of the policy year, the benefit will be reversed, and the insured will be responsible for the following policy year's deductible. is applied per Insured, per policy year COINSURANCE before benefits are paid or xxxx- bursed to the insured. All deductible • The Insured is responsible for twenty amounts paid accumulate towards the corresponding maximum deductible per policy, which is equivalent to the sum of two individual deductibles. All insureds under the policy contribute percent (20%) of approved charges for the first five thousand dollars ($5,000) after satisfaction of the applicable deductible (except plans C Plus, D and E). to meeting the in-country and out- • One (1) coinsurance per Insured, per of-country maximum amounts of the policy year.