TABLE OF BENEFITS Sample Clauses

TABLE OF BENEFITS. Description of Disablement Percentage of Sum Covered (%)

TABLE OF BENEFITS. Maximum coverage per insured, per policy year No limit In-patient benefits and limitations Coverage Hospital services 100% Hospital room and board (standard private/semi private) • In Bupa hospital network • In other hospitals, per day 100% US$1,000 Intensive care unit • In Bupa hospital network • In other hospitals, per day 100% US$3,000 Medical and nursing fees 100% Mental Health while in-patient (must be pre-approved) 100% Drugs prescribed while in-patient 100% Diagnostic procedures (pathology, lab tests, X-rays, MRI/CT/PET scan, ultrasound, and endoscopies) 100% Accommodation charges for companion of a hospitalized child, per day US$300 Out-patient benefits and limitations Coverage Ambulatory surgery 100% Physicians and specialists visits 100% Prescription drugs: • Following hospitalization or out-patient surgery (for a maximum of 6 months) • Per policy year thereafter • Out-patient or non-hospitalization (with 20% co-insurance) 100% US$2,000 US$1,000 Diagnostic procedures (pathology, lab tests, X-rays, MRI/CT/PET scan, ultrasound, and endoscopies) 100% Physical therapy and rehabilitation services (must be pre-approved) 100% Home health care (must be pre-approved) 100% Routine health checkup (all inclusive) • No deductible applies US$600 Vaccines (medically necessary) • No deductible applies • Subject to 20% of coinsurance US$1,600 Urgent Care Facilities or Walk-in Clinics in the U.S.A. Expenses derived from treatment in emergency care centers and convenience clinics in the United States of America that are necessary to treat an injury, illness or medical condition covered under the policy. • US$50 copay • No deductible applies 100% 4 | TERMS AND CONDITIONS Maternity benefits and limitations Coverage Pregnancy, maternity, and birth, per pregnancy (includes normal delivery, cesarean delivery, all pre- and post-natal treat- ment, required vitamins during pregnancy and well baby care) • 10-month waiting period • No deductible applies • Plans 1, 2 and 3 only US$7,500 Complications of pregnancy, maternity, and birth (per lifetime, per policy) • 10-month waiting period • Plans 1, 2 and 3 only • No deductible applies US$1,000,000 Provisional coverage for newborn children (for a maximum of 90 days after delivery) • Covered pregnancies only • No deductible applies US$30,000 Evacuation benefits and limitations Coverage Medical emergency evacuation: • Air ambulance • Ground ambulance • Return journey • Repatriation of mortal remains Must be pre-approved and coord...

TABLE OF BENEFITS. Type of incident Cover • Natural or Accidental Death • Accidental Total and permanent disablement • Total and permanent loss of sight in both eyes as a result of an accident • Total loss by physical severance of total and permanent loss of the following parts, as a result of an accident: a) Two limbs b) Both hands c) Arm above the elbow d) Leg above the knee 100% of the credit outstanding up to an aggregate maximum of LKR 2,000,000 per credit cardholder

TABLE OF BENEFITS. Unless otherwise stated and subject to any sub-limit as stated in any Section, the maximum liability in respect of each of the Insured Persons is shown under the Table of Benefits below:

TABLE OF BENEFITS. Maximum Weekly Indemnity Benefits Payable

TABLE OF BENEFITS. Description of Disablement Percentage of sum insured (%) BENEFIT C – Double Indemnity

TABLE OF BENEFITS. Name Group Corona Kavach Policy, Niva Bupa Health Insurance Co. Ltd. Product Type Individual/Floater Category of Benefit Indemnity/Benefit Sum Insured Rs. 50,000/- (Fifty Thousand) to 5,00,000 (Five Lakh) (in the multiples of fifty thousand) On Individual basis- SI shall apply to each individual family member On Floater basis- SI shall apply to the entire family. Policy Period Three and half months (3 ½ months), Six and half months (6 ½ months), Nine and half months (9 ½ months) including waiting periods Eligibility Policy can be availed by persons between the age of 18 Years up to 65 Years, as Proposer. Proposer with higher age can obtain policy for family, without covering self. Policy can be availed for Self and the following family members 1. Legally wedded spouse 2. Parents & Parents-in-law 3. Dependent Children (i.e natural or legally adopted) between the day 1 of age to 25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible. Hospitalization Expenses Medical Expenses of Hospitalization for Covid for a minimum period of 24 consecutive hours shall be admissible. Pre-Hospitalization For 15 days prior to the date of hospitalization/home care treatment Post Hospitalization 30 days from the date of discharge from the hospital/completion of home care treatment Sub-limits Hospital Daily Cash: 0.5% of Sum Insured per day subject to maximum of 15 days in a policy period for every insured member. Home Care Treatment: Maximum up to 14 days per incident AYUSH Medical Expenses incurred for inpatient care treatment for Covid under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems of medicines shall be covered up to sum insured during the Policy period as specified in the policy schedule. Home Care Treatment Expenses The Company shall indemnify costs of treatment incurred by the Insured person for availing treatment at home for Covid on positive diagnosis of Covid in a Government authorized diagnostic Centre maximum up to 14 days per incident, which in the normal course would require care and treatment at a hospital but is actually taken while confined at home subject to policy terms and conditions 1 BABY FOOD 2 BABY UTILITIES CHARGES 3 BEAUTY SERVICES 4 BELTS/ BRACES 5 BUDS 6 COLD PACK/HOT PACK 7 CARRY BAGS 8 EMAIL / INTERNET CHARGES 9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL) 10 LEGGINGS 11 LAUNDRY CHARGES 12 MINERAL WATER 13 SANITARY PAD 14 TELEPHONE CHARGES 15 GUEST SERVICES 1...

TABLE OF BENEFITS. The Table of Benefits referred to in this document is the Table of Benefits as listed in Section 2.

TABLE OF BENEFITS. The benefits for each medical plan are shown in the Table of Benefits. You may only claim for cover as provided for under the specific plan that you have taken out. Benefits not stated in the Table of Benefits cannot be claimed for. The information provided in the Table of Benefits is subject to the terms and conditions of membership as set out in this Plan Agreement.

TABLE OF BENEFITS. The table in this agreement that sets out the benefits covered by each plan. A trip for business and/or recreational purposes, which has a defined return date and is for a period that is no longer than the maximum duration specified for your USA cover option. If your treatment extends beyond the end of your trip's specified return date, your cover will cease at the end of the term defined in your USA cover option wording. For example, if you have selected the USA-45 option and you are on a 30-day trip to the United States of America, which becomes extended to 60 days, your cover in the United States of America will cease 45 days after your date of entry to the United States of America. A condition that has become incurable and all the treatments given are to prolong life. Surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury. The amount of premium that is attributable to the period from the date after the date of cancellation, up to the date before the next premium due date. In the event of a refund of unused premium being eligible, the unused premium amount refunded (using an annually paid plan as an example) will be the annual premium paid divided by 12 and multiplied by the number of whole calendar months remaining in the period of cover. If the plan is cancelled part way through a month, an additional amount, equal to one twelfth of the annual premium paid, multiplied by the proportion of days without cover in the calendar month of cancellation will also be paid. For example, if the annual premium for an insured person is US$3,000, the period of cover is 1st January to 31st December 2020, and the insured person leaves the plan on 27th September 2020, the unused premium will be US$775, as: -