Common use of TABLE OF BENEFITS Clause in Contracts

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% Adult Routine health checkup (all inclusive) • No deductible applies US$600 Pediatric Health check-up, max. per policy year • 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 coordinated by USA Medical Services. US$125,000 100% 100% 100% Other benefits and limitations Coverage Cancer treatment (chemotherapy/radiation therapy) 100% End-stage renal failure (dialysis) 100% Transplant procedures (lifetime maximum per diagnosis) US$600,000 Congenital and/or hereditary disorders: • Diagnosed before the age of 18 (lifetime maximum) • Diagnosed on or after the age of 18 US$1,000,000 100% Prosthetic limbs (lifetime maximum US$120,000) US$30,000 Special treatments (prosthesis, implants, appliances and orthotic devices, durable medical equipment, radiation therapy, chemotherapy, and highly specialized drugs) 100% Emergency room (with or without admission) 100% Emergency dental coverage 100% Hospice/terminal care 100% Complementary therapist (maximum 20 visits/sessions) 100% Custodial care after Alzheimer’s diagnosis US$5,000 per lifetime SUPPLEMENTARY OPTION WITH THE PURCHASE OF RIDER (not automatically included) Optional coverage benefits and limitations Coverage Maternity and perinatal complications rider (per rider) Additional coverage for complications not related to congen- ital or hereditary disorders • 10-month waiting period after effective date of rider • Plans 4, 5 and 6 only US$500,000 POLICY CONDITIONS | 5 POLICY CONDITIONS IN-PATIENT BENEFITS AND LIMITATIONS

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% Adult Routine health checkup (all inclusive) • No deductible applies US$600 Pediatric Health check-up, max. per policy year • 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 coordinated by USA Medical Services. US$125,000 100% 100% 100% Other benefits and limitations Coverage Cancer treatment (chemotherapy/radiation therapy) 100% End-stage renal failure (dialysis) 100% Transplant procedures (lifetime maximum per diagnosis) US$600,000 Congenital and/or hereditary disorders: • Diagnosed before the age of 18 (lifetime maximum) • Diagnosed on or after the age of 18 US$1,000,000 100% Prosthetic limbs (lifetime maximum US$120,000) US$30,000 Special treatments (prosthesis, implants, appliances and orthotic devices, durable medical equipment, radiation therapy, chemotherapy, and highly specialized drugs) 100% Emergency room (with or without admission) 100% Emergency dental coverage 100% Hospice/terminal care 100% Complementary therapist (maximum 20 visits/sessions) 100% Custodial care after Alzheimer’s diagnosis US$5,000 per lifetime SUPPLEMENTARY OPTION WITH THE PURCHASE OF RIDER (not automatically included) Optional coverage benefits and limitations Coverage Maternity and perinatal complications rider (per rider) Additional coverage for complications not related to congen- ital or hereditary disorders • 10-month waiting period after effective date of rider • Plans 4, 5 and 6 only US$500,000 POLICY CONDITIONS | 5 POLICY CONDITIONS IN-PATIENT BENEFITS AND LIMITATIONS

TABLE OF BENEFITS. If the insured does not contact USA Medical Services before their treatment, the insurer cannot make a direct payment to the pro- vider. The insurer will then reimburse the policyholder in accordance with the usual, customary, and reasonable fees for that geographical area. • Any diagnostic or therapeutic procedure, treat- ment, or benefit is covered only if resulting from a condition covered under this policy. • Insureds are asked to notify USA Medical Services prior to beginning any treatment. • All benefits are subject to any applicable deductible, unless otherwise stated. • 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 and, solely with respect to the insurer, where otherwise prohibited by the laws in the United Kingdom and/or Denmark. Please contact USA Medical Services for more information about this restriction. 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 2,000 Intensive care unit • In Bupa hospital network • In other hospitals, per day 100% US$3,000 4,000 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$300 400 Guest meals, per day US$50 BENEFITS | 3 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$3,000 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% Adult Routine health checkup (all inclusive) • No deductible applies US$600 Pediatric Health check-up, max. per policy year • No deductible applies US$600 1,000 Vaccines (medically necessaryrequired) • No deductible applies • Subject to 20% of coinsurance US$1,600 80% Urgent Care Facilities or Walk-in Clinics in the U.S.A. Expenses derived from treatment in emergency care centers and convenience conve- nience 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, required vitamins during pregnancy, and all pre- and post-post- natal treat- ment, required vitamins during pregnancy and well baby caretreatment) • 10-month waiting period • No deductible applies • Plans 1, 2 and 3 only US$7,500 Complications 10,000 Well baby care (max. 5 visits within 6 months of pregnancy, maternity, and birth (per lifetime, per policydelivery) • 10-month waiting period • Plans 1, 2 and 3 only • No deductible applies US$1,000,000 100% Provisional coverage for newborn children (for a maximum of 90 days after delivery) • Covered pregnancies only • No deductible applies US$30,000 50,000 Complications of pregnancy, maternity, and birth • 10-month waiting period • Plans 1, 2 and 3 only • No deductible applies 100% Evacuation benefits and limitations Coverage Medical emergency evacuation: • Air ambulance • Ground ambulance • Return journey • Repatriation of mortal remains Must be pre-approved and coordinated by USA Medical Services. US$125,000 100% 100% 100% 100% 4 | TERMS AND CONDITIONS Other benefits and limitations Coverage Cancer treatment (chemotherapy/radiation therapy) 100% End-stage renal failure (dialysis) 100% Transplant procedures (lifetime maximum per diagnosis) US$600,000 750,000 Congenital and/or hereditary disorders: • Diagnosed before the age of 18 (lifetime maximum) • Diagnosed on or after the age of 18 US$1,000,000 disorders 100% Prosthetic limbs (lifetime maximum US$120,000) US$30,000 Special treatments (prosthesis, implants, appliances and orthotic devices, durable medical equipment, radiation therapy, chemotherapy, and highly specialized drugs) 100% Emergency room (with or without admission) 100% Emergency dental coverage 100% Hospice/terminal care 100% Complementary therapist (maximum 20 80 visits/sessions) 100% Custodial care after Alzheimer’s diagnosis US$5,000 per lifetime Prescribed dietician guidance (max. 4 visits) 100% SUPPLEMENTARY OPTION WITH THE PURCHASE OF RIDER (not automatically included) Optional coverage benefits and limitations Coverage Maternity and perinatal complications rider (per rider) Additional coverage for maternity and/or perinatal complications not related to congen- ital congenital or hereditary disorders • 10-month waiting period after effective date of rider • Plans 4, 5 and 6 only US$500,000 POLICY CONDITIONS | 5 POLICY CONDITIONS IN-PATIENT BENEFITS AND LIMITATIONS

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 2,000 Intensive care unit • In Bupa hospital network • In other hospitals, per day 100% US$3,000 4,000 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$300 400 Guest meals, per day US$50 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$3,000 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% Adult Routine health checkup (all inclusive) • No deductible applies US$600 Pediatric Health check-up, max. per policy year • No deductible applies US$600 1,000 Vaccines (medically necessaryrequired) • No deductible applies • Subject to 20% of coinsurance US$1,600 80% 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, required vitamins during pregnancy, and all pre- and post-natal treat- ment, required vitamins during pregnancy and well baby caretreatment) • 10-month waiting period • No deductible applies • Plans 1, 2 and 3 only US$7,500 Complications 10,000 Well baby care (max. 5 visits within 6 months of pregnancy, maternity, and birth (per lifetime, per policydelivery) • 10-month waiting period • Plans 1, 2 and 3 only • No deductible applies US$1,000,000 100% Provisional coverage for newborn children (for a maximum of 90 days after delivery) • Covered pregnancies only • No deductible applies US$30,000 50,000 Complications of pregnancy, maternity, and birth • 10-month waiting period • Plans 1, 2 and 3 only • No deductible applies 100% Evacuation benefits and limitations Coverage Medical emergency evacuation: • Air ambulance • Ground ambulance • Return journey • Repatriation of mortal remains Must be pre-approved and coordinated by USA Medical Services. US$125,000 100% 100% 100% 100% Other benefits and limitations Coverage Cancer treatment (chemotherapy/radiation therapy) 100% End-stage renal failure (dialysis) 100% Transplant procedures (lifetime maximum per diagnosis) US$600,000 750,000 Congenital and/or hereditary disorders: • Diagnosed before the age of 18 (lifetime maximum) • Diagnosed on or after the age of 18 US$1,000,000 disorders 100% Prosthetic limbs (lifetime maximum US$120,000) US$30,000 Special treatments (prosthesis, implants, appliances and orthotic devices, durable medical equipment, radiation therapy, chemotherapychemo- therapy, and highly specialized drugs) 100% Emergency room (with or without admission) 100% Emergency dental coverage 100% Hospice/terminal care 100% Complementary therapist (maximum 20 80 visits/sessions) 100% Custodial care after Alzheimer’s diagnosis US$5,000 per lifetime Prescribed dietician guidance (max. 4 visits) 100% SUPPLEMENTARY OPTION WITH THE PURCHASE OF RIDER (not automatically included) Optional coverage benefits and limitations Coverage Maternity and perinatal complications rider (per rider) Additional coverage for maternity and/or perinatal complications not related to congen- ital congenital or hereditary disorders • 10-month waiting period after effective date of rider • Plans 4, 5 and 6 only US$500,000 POLICY CONDITIONS | 5 POLICY CONDITIONS IN-PATIENT BENEFITS AND LIMITATIONS