Summary of Coverage - Covered Medical Services

The following general summary of covered medical services may vary according to the state in which the insured obtains coverage:

• Covered charges incurred for: office, inpatient and emergency room visits, including treatment rendered during such visits; surgical services, including necessary post operative care following inpatient or outpatient surgery; services of an assistant surgeon, when we determine the services of an assistant are required to perform the surgery; anesthesia services.

• Covered charges incurred for: room, board and routine nursing services that are generally provided to all persons while confined in a hospital. If the covered person is confined in a private room, only charges up to the average semi-private rate of the hospital are covered; inpatient medical care and treatment provided in a hospital; outpatient medical care and treatment provided by a hospital, freestanding ambulatory surgical center or freestanding urgent care center; medical care and treatment provided in an emergency room.

• Covered charges incurred for outpatient x-ray, radioactive treatment and laboratory services including one screening mammographic exam per calendar year for a covered female, age 35 or over.

• Covered charges incurred for the first 30 days of confinement in a rehabilitation or skilled nursing facility for the covered person per calendar year.

• Covered charges incurred for the first 40 home health care visits for the covered person per calendar year.

• Covered charges incurred for professional ground or air ambulance service to the nearest hospital that is able to treat the illness or injury.

• Covered charges incurred for treatment and diagnosis of vertebrae, disc, spine, back, neck and adjacent tissues. The maximum amount we will pay is limited to $750 for the covered person per calendar year. The $750 maximum does not apply to covered charges incurred for hospital confinements, surgery, anesthesia, drugs, laboratory services, x-rays, MRIs or EMGs.

• Covered charges incurred for rental (not to exceed the purchase price) of one basic manual wheelchair, one basic hospital bed, one pair of basic crutches, the initial permanent basic artificial limb or eye and oxygen and the basic equipment needed to administer oxygen; and the initial external breast prosthesis needed because of the medically necessary surgical removal of all or part of the breast, provided the surgical removal was done while the covered person was covered under the plan. Charges for repairs to, replacement of, maintenance of, or enhancement of the whole or parts of such items are NOT covered.

• Covered charges incurred for reconstructive surgery required due to an illness which commenced or an injury which occurred while the covered person is insured under the plan.

• Covered charges incurred for surgical treatment of temporomandibular joint (TMJ) or craniomandibular joint (CMJ) dysfunction, provided the charges are for services included in a dental treatment plan authorized by Fortis prior to the surgery; charges for nonsurgical treatment of TMJ or CMJ. The maximum amount we will pay for surgical and non-surgical treatment combined is limited to $1,000 for the covered person during his or her lifetime.

• Covered charges incurred for the following complications of pregnancy: missed abortion (miscarriage); spontaneous, incomplete or complete abortion (miscarriage); ectopic pregnancy; spontaneous premature delivery of a nonviable fetus; and other medical conditions whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy such as acute pyelonephritis, renal failure, diabetes, cardiac decompensation, malignancy, chronic hypertension and phlebitis.

• Covered charges incurred for the covered person’s medical evacuation to his or her home country or to a facility operated pursuant to the laws of his or her home country for the care and treatment of illness or injury, should the covered person by admitted as an inpatient to a hospital as a result of illness or injury. The maximum amount we will pay for medical evacuation of the covered person during his or her lifetime is limited to $10,000.

• Covered charges incurred for repatriation of the covered person’s remains to his or her home country or country of regular domicile should the covered person die while insured under this plan, provided treatment of the illness or injury would have been covered under this plan had the person not died. The maximum amount we will pay for repatriation of the covered person’s remains is limited to $10,000.

• Covered charges incurred for the following organ transplants: lung(s), heart, heart/lung, liver, kidney, cornea, skin, or allogeneic autologous bone marrow and /or stem cell rescue for acute leukemia in remission, neuroblastoma, advanced Hodgkin’s disease, chronicmyelogenous leukemia, or severe aplastic anemia. The maximum amount we will pay for any and all organ transplants is limited to $100,000 for the covered person during his or her lifetime.

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