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WIPRO

EffectiveDate:17July2016
SUMMARYOFBENEFITS

Category2 Category3 Category4 Category5


AetnaSummit
AetnaSummit5000 AetnaSummit5000 AetnaSummit5000
5000+
CategoryDescription 2AbuDhabi 3Kuwait 4Qatar 5Oman

AreaofCover CoverArea2 CoverArea2 CoverArea2 CoverArea2


Overallplanlimit
Wewillnotpayanymorethantheoverallplanlimitforanyoneormoreclaimsonanyone
1.0 ormoreofthebenefitsbelow.WhereabenefitlimitisshownasPaidinfull,thisisstill $125,000 $125,000 $125,000 $125,000
subjecttotheoverallplanlimit.Unlessstated,allbenefitlimitsshownapplyfortheplan
year.
2.0 Inpatientanddaycare(seesection26fordeductibles)
Medicalcostsincludingintensivecarecosts,theatrecosts,hospital
2.1 accommodation,medicalpractitioners'andspecialists'fees,anaesthetists'fees, Paidinfull Paidinfull Paidinfull Paidinfull
nursingfees,kidneydialysis,appliancesandprescribeddrugsanddressings.

MRI,PETandCTscans,Xrays,pathologyandotherdiagnostictestsand
2.2 Paidinfull Paidinfull Paidinfull Paidinfull
procedures.
Reconstructivesurgerytorestorenaturalfunctionorappearancewithin12months
2.3 Paidinfull Paidinfull Paidinfull Paidinfull
ofanaccidentorsurgery.
Speechandlanguagetherapyandoccupationaltherapyaspartofyourinpatient
2.4 treatment.Thisbenefitisonlyavailableifthemedicalconditioniscoveredunder Paidinfull Paidinfull Paidinfull Paidinfull
section2.1or2.3.

Medicalservicesofanurseaspartofyourinpatientordaycaretreatmentwhen
2.5 thesearereceivedinyourhomeinsteadofinhospital.Thisbenefitisonlyavailable Paidinfull Paidinfull Paidinfull Paidinfull
ifthemedicalconditioniscoveredundersection2.1or2.3.

Inpatienttreatmentneededforacutemedicalconditionsthatbeginbeforean
Paiduptoalifetimelimit Paiduptoalifetimelimit Paiduptoalifetimelimit
2.6 insuredmemberiseightdaysoldifthepregnancywastheresultofnatural Paidinfull
of$150,000 of$150,000 of$150,000
conception.
Inpatienttreatmentneededforacutemedicalconditionsthatbeginbeforean
2.7 insuredmemberiseightdaysoldifthepregnancywastheresultofassisted Paidinfull Notcovered Notcovered Notcovered
conception.
3.0 Parentaccommodation(seesection26fordeductibles)
Hospitalaccommodationcostsforaparentorlegalguardiantostaywithaninsured
3.1 childaged17orunder.Thisbenefitisonlyavailablewhenthechildisreceiving Paidinfull Paidinfull Paidinfull Paidinfull
inpatienttreatmentcoveredundersections2.1to2.4.

Ifthecostsoftheinsuredchildsinpatientadmissionarerelatedtoamedicalconditioncoveredundersections2.6,5,6,9.1,11to14,19.4or25.1,thehospitalaccommodationcostsfora
3.2
parentorlegalguardiantostaywiththeinsuredchildwillbecoveredwithinthebenefitlimitsofthesamesection.

Outpatientposthospitalisationtreatment (seesection26fordeductibles)
4.0
Foracutemedicalconditions
Outpatienttreatmentforaperiodof90daysfromthedateofdischargefollowing
eachadmissionforinpatientordaycaretreatmentrelatedtothesameacute
4.1 medicalcondition.Thisbenefitcoversmedicalpractitioners'andspecialists'fees, Paidinfull Paidinfull Paidinfull Paidinfull
surgicalprocedures,prescribeddrugsanddressings,MRI,PETandCTscans,Xrays,
pathologyandotherdiagnostictestsandprocedures.

Rehabilitation (seesection26fordeductibles)
5.0
Foracutemedicalconditionsandstabilisationofacuteepisodesofchronicmedicalconditions

Rehabilitationforamedicalconditioncoveredundersection2.1or2.3.Thisbenefit
isonlyavailableif:
youhavereceivedinpatienttreatmentforthreeormoreconsecutivedaysforthe
samemedicalcondition,and
youhavestayedinhospitalforthreeormoreconsecutivenights.

Rehabilitationmustbereferredbyamedicalpractitionerorspecialistandstart:
afteryouaredischargedfromhospitalfollowingyourinpatienttreatment,or Paidinfullforupto120 Paidinfullforupto120 Paidinfullforupto120 Paidinfullforupto120
5.1 whenyouaretransferredtoarehabilitationunitfollowingyourinpatient daysfollowingeach daysfollowingeach daysfollowingeach daysfollowingeach
treatment. admission admission admission admission

Yourfirstsessionmustbenomorethan14daysafteryouaredischargedor
transferred.

Thisbenefitcoversinpatient,daycareandoutpatientphysiotherapy,speechand
languagetherapyandoccupationaltherapy.Wewillalsopayforaccommodation
costsattherehabilitationunitwhenmedicallynecessary.
WIPRO
EffectiveDate:17July2016
SUMMARYOFBENEFITS

Category2 Category3 Category4 Category5


AetnaSummit
AetnaSummit5000 AetnaSummit5000 AetnaSummit5000
5000+
Section5.1appliesbeforeanyavailablebenefitlimitshowninsections8.1,8.2and8.3.Ifposthospitalisationoutpatientphysiotherapyisneededfollowingrehabilitation,thebenefitlimit
5.2 showninsection8.2willonlybeavailableifthenumberofdaysshowninsection5.1islessthan90days.Ifthisappliestoyou,thenumberofdaysoftreatmentavailableundersection8.2
willbe90daysminusthenumberofdaysshowninsection5.1.

6.0 Cancercare(seesection26fordeductibles)
Alltreatmentfor,orrelatedto,adiagnosedcancer.Thisincludespalliative
6.1 Paidinfull Paidinfull Paidinfull Paidinfull
treatmentandcareduringtheendstagesofacancer.
Outpatienttreatment(seesection26fordeductibles)
7.0
Foracuteandchronicmedicalconditions
7.1 Surgicalprocedures Paidinfull Paidinfull Paidinfull Paidinfull
Outpatientpreoperativetestsupto72hoursbeforeinpatientordaycare
7.2 Paidinfull Paidinfull Paidinfull Paidinfull
treatmentcoveredundersections2.1to2.3.

Medicalpractitioners'andspecialists'fees,prescribeddrugsanddressings,MRI
7.3 Paidinfull Paidinfull Paidinfull Paidinfull
scans,Xrays,pathologyanddiagnostictestsandprocedures.

Outpatienttreatmentreceivedinahospitalwhenyourmedicalconditionisan
7.4 Paidinfull Paidinfull Paidinfull Paidinfull
emergency.
7.5 Kidneydialysis Paidinfull Paidinfull Paidinfull Paidinfull
7.6 PETandCTscans Paidinfull Paidinfull Paidinfull Paidinfull
Physiotherapyandcomplementarymedicine(seesection26fordeductibles)
8.0
Foracuteandchronicmedicalconditions
8.1 Physiotherapyaspartofinpatientordaycaretreatment. Paidinfull Paidinfull Paidinfull Paidinfull

Posthospitalisationoutpatientphysiotherapyfollowingadmissionsforinpatientor
8.2 daycaretreatmentcoveredundersections2.1to2.3or2.6.Thisbenefitisavailable Paidinfull Paidinfull Paidinfull Paidinfull
foraperiodof90daysfollowingeachadmission.
Outpatientphysiotherapywhenreferredbyamedicalpractitionerorspecialist.
Furthermedicalinformationmaybeneededifyoureceivefurthertreatmentafter
8.3 Paidinfull Paidinfull Paidinfull Paidinfull
youhavecompletedthenumberofsessionsthatwerereferredbythemedical
practitionerorspecialist.

Outpatientpodiatry,osteopathicandchiropractictreatment,whenreferredbya
medicalpractitionerorspecialist.Furthermedicalinformationmaybeneededif
8.4 Nocover Nocover Nocover Nocover
youreceivefurthertreatmentafteryouhavecompletedthenumberofsessions
thatwerereferredbythemedicalpractitionerorspecialist.

OutpatienttraditionalChinesemedicine,ayurvedicmedicine,acupunctureand
8.5 homeopathictreatment.Furthermedicalinformationmaybeneededafteranyfour Nocover Nocover Nocover Nocover
sessionsforanyonemedicalcondition.
Psychiatrictreatment(seesection26fordeductibles)
9.0
Foracuteandchronicmedicalconditions
Inpatientpsychiatrictreatmentandpsychotherapy.Thisbenefitisavailableforup
9.1 Nocover Nocover Nocover Nocover
to30daysintheplanyear.
9.2 Outpatientpsychiatrictreatmentandpsychotherapy. Paidinfull Nocover Nocover Nocover
Inpatientandoutpatientpsychiatrictreatmentandpsychotherapywhenyour
9.3 Notapplicable Notapplicable Notapplicable Notapplicable
medicalconditionisanemergency.
10.0 Durablemedicalequipment(seesection26fordeductibles)

Durablemedicalequipmentincludingprostheticandorthoticsupplies.Wewillpay
for:
Itemsprescribedbyamedicalpractitionerorspecialist,whichareneededto
deliver,orfacilitatethedeliveryof,prescribeddrugsanddressings
Thepurchaseandfittingofdevicesoritemsmedicallynecessaryfortreatment,
including,butnotlimitedto,spinalsupports,orthopaedicbracesandaircastboots
Therentalorinitialpurchaseofcrutchesorawheelchairifmedicallynecessary
Theinitialpurchaseandfittingofexternalprosthesesneededfollowingsurgery,
10.1 Paidinfull Nocover Nocover Nocover
including,butnotlimitedto,artificialeyesandlimbs
Thepurchaseandfittingofmedicallynecessaryorthoticsupplies,including,but
notlimitedto,insolesandorthoticsupports

Thisbenefitdoesnotextendtosightorhearingaids,thesupply,modificationor
fittingoffurniture,oranymodificationstoyourpersonalorworkenvironment.
Coverisonlyavailableunderthisbenefitifthetreatmentiscoveredundersections
2,4,5,7to9or23.

Ifthecostsarerelatedtoamedicalconditioncoveredundersections6,11to14,22.2,22.3or25thesewillbecoveredwithinthebenefitlimitsofthesamesection.Coverunderthese
10.2
sectionsdoesnotextendtosightorhearingaids,thesupply,modificationorfittingoffurniture,oranymodificationstoyourpersonalorworkenvironment.
WIPRO
EffectiveDate:17July2016
SUMMARYOFBENEFITS

Category2 Category3 Category4 Category5


AetnaSummit
AetnaSummit5000 AetnaSummit5000 AetnaSummit5000
5000+
11.0 Congenitalabnormalities(seesection26fordeductibles)
Alltreatmentfordiagnosedcongenitalabnormalitiesandanyrelatedmedical
11.1 conditions.Thisincludespalliativetreatmentandcareduringtheendstagesofa Paidinfull Nocover Nocover Nocover
congenitalabnormalityoranyrelatedmedicalcondition.

11.2 Fororgantransplantsforcongenitalabnormalitiesandanyrelatedmedicalconditions,seesection13.

12.0 HIVorAIDS(seesection26fordeductibles)
Alltreatment,includingpalliativetreatmentandcare,fordiagnosedHIVorAIDS
12.1 Nocover Nocover Nocover Nocover
andallrelatedmedicalconditions.
Organtransplants(seesection26fordeductibles)
13.0
Foracuteandchronicmedicalconditionsandcongenitalabnormalities

13.1 Kidney,pancreas,liver,heartorlungtransplantsandanyrelatedtreatment. Paidinfull Paidinfull Paidinfull Paidinfull

14.0 Terminalcare(seesection26fordeductibles)
Palliativetreatmentandcareforamedicalconditionwhichisdiagnosedas
14.1 Paidinfull Paidinfull Paidinfull Paidinfull
terminal.
14.2 Forterminalcarerelatedtocancercare,congenitalabnormalitiesandHIVorAIDS,seesections6,11and12.

15.0 Medicalevacuation(seesection26fordeductibles)
Thecoststotransportyoutothenearestlocationwhereappropriatemedical
facilitiesareavailable,asagreedbyusandbyyourattendingmedicalpractitioner.
Thisbenefitwillonlybepaidifyourmedicalconditionisanemergencyandwe
agreeappropriatetreatmentisnotavailablelocally.
Thisbenefitextendstothecostsforemergencytreatmentyoureceiveduringthe
journey.
15.1 Whereitisnecessarytotransportyououtsideyourareaofcover,anyrelatedcosts Paidinfull Paidinfull Paidinfull Paidinfull
thatareincurredinthecountryyouareevacuatedtowillbepayableunderthe
sectionsofyourBenefitsschedulethatwouldnormallyapplywhenyouarewithin
yourareaofcover.
Coverisonlyavailableunderthisbenefitifthetreatmentiscoveredundersections
2,4,6,7,9,11to14or22andyouhavecompletedanywaitingperiodsshownin
therelevantsection.

Economyclasstravelcostsforyoutogobacktoyourcountryofresidence,oryour
15.2 Paidinfull Paidinfull Paidinfull Paidinfull
homecountry,afteryouremergencymedicalevacuationundersection15.1.
Costsofonedependantorcompanionhavingtoaccompanyyouforanemergency
medicalevacuationundersection15.1.Thisbenefitwillonlybecomeavailableif
yourmedicalconditioniscriticaloryouareexpectedtostayinhospitalforsevenor
morenights.Wewillcover:
15.3 Paidinfull Paidinfull Paidinfull Paidinfull
Costsforreturneconomyclasstravel,includingtaxitransferstoandfromthe
hotelonarrivalanddeparture
Ataxifromthehoteltothehospital,andback,onceaday
Reasonableovernightaccommodationcosts,toincludebreakfast
Thecoststotransportyoutoappropriatemedicalfacilitiestoreceivetreatment
whenyourmedicalconditionisnotanemergency.
Wewillcovercostsforreturneconomyclasstraveltoalocationofyourchoice
withinyourareaofcoverif:
15.4 weagreeappropriatetreatmentisnotavailablelocally,and Notcovered Notcovered Notcovered Notcovered
weagreeappropriatetreatmentisavailableinyourchosenlocation.
Wewillalsopayforairporttaxitransfers.
Coverisonlyavailableunderthisbenefitifthetreatmentiscoveredundersections
2or4to14.
Thecoststotransportyoutoappropriatemedicalfacilitiesfortreatmentrelatedto
yourpregnancyifthemedicalconditionisnotanemergency.
Wewillcovercostsforreturneconomyclasstraveltoalocationofyourchoice
withinyourareaofcoverif:
weagreeappropriatetreatmentisnotavailablelocally,and
15.5 Notcovered Notcovered Notcovered Notcovered
weagreeappropriatetreatmentisavailableinyourchosenlocation.
Wewillalsopayforairporttaxitransfers.
Youarelimitedtothreereturnjourneysforeachpregnancy.
Coverisonlyavailableunderthisbenefitifthetreatmentiscoveredundersection
22andyouhavecompletedanywaitingperiodsshowninsection22.
Costsformedicalevacuationsdonotextendtoairsearescue,oranymountainrescueunlessrelatedtoamedicalconditionyousufferatarecognisedskiresortorsimilarwintersports
15.6
resort.
WIPRO
EffectiveDate:17July2016
SUMMARYOFBENEFITS

Category2 Category3 Category4 Category5


AetnaSummit
AetnaSummit5000 AetnaSummit5000 AetnaSummit5000
5000+
16.0 Localambulance(seesection26fordeductibles)
Costsoftheappropriatetypeofambulanceneededtotransportyoutothenearest
availableandappropriatelocalhospitalbecauseofanemergencyorduetomedical
necessity.
16.1 Paidinfull Paidinfull Paidinfull Paidinfull
Coverisonlyavailableunderthisbenefitifthetreatmentiscoveredundersections
2,4,6,7,9,11to14,22.2or22.3andyouhavecompletedanywaitingperiods
shownintherelevantsection.
Costsforlocalambulancesdonotextendtoairsearescue,oranymountainrescueunlessrelatedtoamedicalconditionyousufferatarecognisedskiresortorsimilarwintersports
16.2
resort.
17.0 Mortalremains(seesection26fordeductibles)
Intheeventofyourdeathwewillpayreasonablecostsfor:
thetransportationofyourbodyormortalremainstoyourhomecountryoryour
countryofresidence,or
yourburialorcremationattheplaceofyourdeath.
Thisbenefitisonlyavailableifyoudieoutsideyourhomecountry.
Intheeventofburialthisbenefitwillcover:
Thecostofopeningorreopeningagrave
17.1 Anyexclusiverightofburialfee Paidinfull Paidinfull Paidinfull Paidinfull
Burialcosts
Intheeventofcremationthisbenefitwillcover:
Thecostofanydoctorscertificates
Cremationcosts,includingtheremovalofanymedicaldevicebeforethe
cremation
Thisbenefitdoesnotextendtothepurchaseofaburialplot,orfuneralcosts,
including,butnotlimitedto,flowersandthefuneraldirectorsfees.
18.0 Compassionateemergencyvisit
Costsyouhavetopayforaneconomyclassreturntravelticketfromacountry
withinyourareaofcoverforyoutovisitaclosefamilymember:
18.1 iftheirmedicalconditioniscritical,or Paidinfull Paidinfull Paidinfull Paidinfull
toattendtheirburialorcremationfollowingtheirdeath.
Youarelimitedtoonereturnjourneyintheplanyear
19.0 DentalTreatment (seesection26fordeductibles)
Outpatientdentaltreatmentforaccidentaldamagetosound,naturalteethwhen:
thetreatmentcanonlybeprovidedafteryouhavereceivedinpatienttreatment
relatedtotheaccident,and
19.1 Paidinfull Paidinfull Paidinfull Paidinfull
thetreatmentisreceivednomorethan90daysafteryouaredischargedfrom
hospitalfollowingyourrelatedinpatienttreatment.
Thisbenefitincludesthecosttosupplyandfitdentalimplants.

Outpatientdentaltreatmentforaccidentaldamagetosound,naturalteeth,except
whenthedamageiscausedthrougheating.Coverisonlyavailablewhentreatment
19.2 Paidupto$1,500 Paidupto$1,500 Paidupto$1,500 Paidupto$1,500
fortheaccidentaldamageisreceivedwithintendaysoftheaccident.Thisbenefit
alsoincludesonefollowupconsultationwithin30daysoftheaccident.
Outpatientdentaltreatmentwhenyourdentalconditionisanemergency.Where
19.3 coverisprovidedunderthisbenefit,costsarenotpayableundersections19.1or Notapplicable Notapplicable Notapplicable Notapplicable
19.2.
Routineoutpatientdentaltreatment,includingtreatmentforaccidentaldamageto
sound,naturalteethwhenthedamageiscausedthrougheating.Thisbenefit
coversdentalexaminations,scraping,cleaningandpolishing,gumtreatment,X
19.4 rays,compositefillingsandsimplenonsurgicalextractionsonly.
Coverisavailableafteryouhavehad182days'continuouscoverfromthedatethat
thebenefitwasfirstintroducedonyourplan.Thiswaitingperiodiswaivedfor
MHD.

Majorrestorativedentaltreatment,includingtreatmentforaccidentaldamageto
Paidupto$625 Paidupto$625 Paidupto$625 Paidupto$625
sound,naturalteethwhenthedamageiscausedthrougheating.Thisbenefit
covers:
Surgicalextractions,includingwisdomteeth
Rootcanaltreatment
19.5
Thecosttosupply,fitandrepaircrowns,bridgesanddentures
Xraysneededtosupportmajorrestorativedentaltreatment
Coverisavailableafteryouhavehad182days'continuouscoverfromthedatethat
thebenefitwasfirstintroducedonyourplan.Thiswaitingperiodiswaivedfor
MHD.
Orthodontictreatment.Thisbenefitcovers:
Orthodonticexaminations
Coststosupply,fitandrepairorthodonticdevicesoritems
19.6 Notcovered Notcovered Notcovered Notcovered
Xraysneededtosupportorthodontictreatment
Surgicalandnonsurgicalextractionsneededaspartofyourorthodontic
treatment
WIPRO
EffectiveDate:17July2016
SUMMARYOFBENEFITS

Category2 Category3 Category4 Category5


AetnaSummit
AetnaSummit5000 AetnaSummit5000 AetnaSummit5000
5000+
Dentalimplants.Thisbenefitcovers:
Dentalexaminationsneededfordentalimplants
19.7 Notcovered Notcovered Notcovered Notcovered
Coststosupply,fitandrepairdentalimplants
Xraysneededtosupportthefittingorrepairofdentalimplants
20.0 Opticalcare (seesection26fordeductibles)
Costsofprescription:
Contactlenses
Spectacles
Spectaclelenses
20.1 Spectacleframes Paidupto$340 Paidupto$340 Paidupto$340 Paidupto$340
Thisbenefitalsocoversthecostsofoneconsultationandsightexaminationforthe
signsorsymptoms,ormanagementof,naturalornonmedicaldegenerativesight
disorders.Thisincludes,butisnotlimitedto,myopia,hypermetropiaand
astigmatism.
Visionaids,visioncorrectionbysurgeryandhearingaids,whentreatmentis
20.2 neededforamedicalconditionthatisanemergency.Wherecoverisprovided Notapplicable Notapplicable Notapplicable Notapplicable
underthisbenefit,costsarenotpayableundersection20.1.

21.0 Wellness
Membersaged18orover:routinehealthchecksincludingcancerscreening,
21.1 cardiovascularexaminations,neurologicalexaminations,vitalsigntestsand
Notcovered Notcovered Notcovered Notcovered
vaccinations.
21.2 Membersaged17orunder:routinehealthchecksandvaccinations.
Preventativeservicesforsightandhearing:onesightexaminationandonehearing
21.3 Paidupto$250 Paidupto$250 Paidupto$250 Paidupto$250
examinationintheplanyear.
VaccinationsandInoculations
21.4 (Includingthosethataremedicallynecessaryfortravel)Applicableonlyfor PaidinFull PaidinFull PaidinFull PaidinFull
membersaged18andunder
22.0 Pregnancyandchildbirth(seesection26fordeductibles)
Costsfor:
Antenatalcheckupsforanuncomplicatedpregnancy
Antenatalvitamins
Deliverycosts,nursingfeesandhospitalaccommodationcostsforuncomplicated
childbirth
Postnatalcheckups
Thisbenefitincludescoverforpregnanciesresultingfromnaturalorassisted
conception.
Coverforantenatalcheckupsincludesnomorethan12routineantenatalvisits
duringeachpregnancyandoneroutine2Dultrasoundscanineachtrimester.Ifany
additionalantenatalvisitsorultrasoundscansaremedicallynecessary,wewillask
22.1 forfurthermedicalinformationsowecanconsidercoverundersection22.2or Paidinfull Paidupto$5,500 Paidupto$5,500 Paidupto$5,500
22.3.
Wewillpayreasonablehospitalaccommodationcostsforthenewborntostaywith
youfornomorethanfournightsimmediatelyafterchildbirth.Wewillalsopaythe
followingroutinecostsforthenewborn:
Onephysicalexamination
VitaminK,hepatitisBandBCGvaccinations
ScreeningtestsforPKU,congenitalhypothyroidismandG6PD
Onehearingexamination
Thisbenefitisonlyavailableafteryouhavehad12monthscontinuouscoverfrom
thedatethatthebenefitwasfirstintroducedonyourplan.Thiswaitingperiodis
waived for MHD
Treatmentformedicalcomplicationsofmaternitythathappenduetoamedical
conditionduringpregnancyorchildbirth,ifthepregnancyistheresultofassisted
conception.
Wewillpayreasonableaccommodationcostsforthenewborntostaywithyou
immediatelyafteracomplicatedchildbirth.Wewillalsopaythefollowingroutine
costsforthenewborn: Coveredinthebenefit Coveredinthebenefit Coveredinthebenefit Coveredinthebenefit
22.2 Onephysicalexamination limitshowninsection limitshowninsection limitshowninsection limitshowninsection
VitaminK,hepatitisBandBCGvaccinations 22.1 22.1 22.1 22.1
ScreeningtestsforPKU,congenitalhypothyroidismandG6PD
Onehearingexamination
Thisbenefitisonlyavailableafteryouhavehad12monthscontinuouscoverfrom
thedatethatthebenefitwasfirstintroducedonyourplan.Thiswaitingperiodis
waivedforMHD.
WIPRO
EffectiveDate:17July2016
SUMMARYOFBENEFITS

Category2 Category3 Category4 Category5


AetnaSummit
AetnaSummit5000 AetnaSummit5000 AetnaSummit5000
5000+
Treatmentformedicalcomplicationsofmaternitythathappenduetoamedical
conditionduringpregnancyorchildbirth,ifthepregnancyistheresultofnatural
conception.
Wewillpayreasonableaccommodationcostsforthenewborntostaywithyou
immediatelyafteracomplicatedchildbirth.Wewillalsopaythefollowingroutine
22.3 Paidinfull Paidinfull Paidinfull Paidinfull
costsforthenewborn:
Onephysicalexamination
VitaminK,hepatitisBandBCGvaccinations
ScreeningtestsforPKU,congenitalhypothyroidismandG6PD
Onehearingexamination
Thebenefitlimitsshownforsection22applyforeachpregnancy.Whereapregnancyspansmorethanoneplanyear,anybenefitpaidfortreatmentorservicesreceivedintheplanyear
whenthepregnancybeganwillbedeductedfromthebenefitlimitshowninthefollowingplanyear.
22.4 Thisbenefitdoesnotextendto3Dor4Dultrasoundscans.
Routinecostsfornewborns,asshowninsection22,areonlycoveredforthefirst30daysfrombirth.Wherethenewbornisaninsuredmember,coverforroutinecostswithinthefirst30
dayswillstillbeprovidedundersection22oftheinsuredmothersplan.
23.0 Hormonereplacementtherapy(seesection26fordeductibles)
23.1 Hormonereplacementtherapyforsymptomsofthemenopause. Covered Covered Covered Covered
24.0 HospitalCash
Paymentmadetoyouforeachnightyoustayinahospitalwhenreceivinginpatient
treatment:
ifyourinpatienttreatmentandhospitalaccommodationareprovidedfreeof
charge,and
24.1 Paidupto$55 Paidupto$55 Paidupto$55 Paidupto$55
thetreatmentorservicesreceivedwouldnormallybecoveredundersections2,
6,9,11to14,19.4or22andyouhavecompletedanywaitingperiodsshowninthe
relevantsection.
Thisbenefitispayableforupto20nightsintheplanyear.
25.0 Emergencytreatmentoutsideareaofcover(seesection26fordeductibles)
Inpatientanddaycaretreatmentwhenyourmedicalconditionisanemergencyand
25.1 Paidupto$50,000 Paidupto$50,000 Paidupto$50,000 Paidupto$50,000
youareoutsideyourareaofcover.
Outpatienttreatmentwhenyourmedicalconditionisanemergencyandyouare
25.2 Paidupto$500 Paidupto$500 Paidupto$500 Paidupto$500
outsideyourareaofcover.

Costsoftheappropriatetypeofambulanceneededtotransportyoutothenearest
25.3 availableandappropriatelocalhospital.Thisbenefitisonlyavailablewhenyour $500 $500 $500 $500
medicalconditionisanemergencyandyouareoutsideyourareaofcover.

26.0 Deductibles
Annualexcessappliestosections2,3,4,5,7,8,9,10,11,12,13,14,15,16,17,18,
19.1,19.2,23and25.Thisisthetotalexcessthatyouwillpayforanyoneormore
26.1 Notapplicable Notapplicable Notapplicable Notapplicable
claimsintheplanyear.Anadditionaldeductiblemayapplyfortreatmentor
servicesreceivedoutsideofthenetwork,seesection26.8.

Outpatientcoinsuranceonsections4,5,7,8.2,8.3,8.4,8.5,9.2,10,11,12,13,14,
20%uptoamaximumof 20%uptoamaximumof 20%uptoamaximumof
19.1,19.2,23and25.2.Thiscoinsuranceisappliedtoeachclaim.Wherea
$15perconsultwith $20foreach $20foreach $20foreach
26.2 maximumisshown,thisappliestoanyoneormoreclaimsyoumakeintheplan
Directbilling consultationwithDirect consultationwithDirect consultationwithDirect
year.Anadditionaldeductiblemayapplyfortreatmentorservicesreceivedoutside
billing billing billing
ofthenetwork,seesection26.8.
Dentalcoinsuranceonsections19.4and19.5.Thiscoinsuranceisappliedtoeach
26.3 20% 20% 20% 20%
claim.

26.4 Orthodonticcoinsuranceonsection19.6.Thiscoinsuranceisappliedtoeachclaim. Notapplicable Notapplicable Notapplicable Notapplicable

Dentalimplantscoinsuranceonsection19.7.Thiscoinsuranceisappliedtoeach
26.5 Notapplicable Notapplicable Notapplicable Notapplicable
claim.

26.6 Opticalcarecoinsuranceonsection20.1.Thiscoinsuranceisappliedtoeachclaim. 20% 20% 20% 20%

20%uptoamaximumof 20%uptoamaximumof 20%uptoamaximumof


Maternitycoinsuranceonsections22.1and22.2.Thiscoinsuranceisappliedto
$20foreach $20foreach $20foreach
26.7 eachclaim.Anadditionaldeductiblemayapplyfortreatmentorservicesreceived Notapplicable
consultationwithDirect consultationwithDirect consultationwithDirect
outsideofthenetwork,seesection26.8.
billing billing billing
WIPRO
EffectiveDate:17July2016
SUMMARYOFBENEFITS

Category2 Category3 Category4 Category5


AetnaSummit
AetnaSummit5000 AetnaSummit5000 AetnaSummit5000
5000+
Outofnetworkdeductibleonsections2,3,4,5,6,7,8,9,11,12,13,14,22and23
if:
anappropriateproviderwithinthenetworkisavailableinthelocationwhereyou
receivetreatmentorservices,butyoureceivetreatmentorservicesataprovider
outsideofthenetwork,and
thecostoftreatmentorservicesisgreaterthanthecostthatwouldhavebeen
Deductionfor Deductionfor Deductionfor Deductionfor
incurredifthetreatmentorserviceswerereceivedwithinthenetworkinthesame
26.8 reasonableand reasonableand reasonableand reasonableand
location.
customarycosts customarycosts customarycosts customarycosts
Thevalueofthedeductiblewillbethedifferencebetweenthecostofthe
treatmentorservicesreceivedandthecostthatwouldhavebeenincurredifthe
treatmentorserviceswerereceivedwithinthenetworkinthesamelocation.This
deductibleisappliedtoeachclaimbeforethedeductionofanyotherapplicable
deductibleshowninsection26.1,26.2or26.7.Thisdeductibledoesnotapplyifthe
treatmentorservicesreceivedareneededduetoanemergency.

27.0 Healthmanagementservices
Chronicconditionanddiseasemanagementtoprovidetailoredinformationand
27.1 Included Included Included Included
accesstoanursetodiscussyourhealth.

EmployeeAssistanceProgrammeonlineandtelephonicconfidentialsupport
27.2 includingcounselling,informationandguidance.LogontotheSecureMember Included Included Included Included
WebsiteorcontactourMemberServicesTeamformoreinformation.

EmployeeAssistanceProgrammeinpersonconfidentialsupportincluding
27.3 counselling,informationandguidance.LogontotheSecureMemberWebsiteor Included Included Included Included
contactourMemberServicesTeamformoreinformation.

27.4 Thecoverprovidedundersections27.2and27.3includesacombinedmaximumoffivesessionsofcounsellingineachplanyear.
28.0 red24SecurityServices
AdviceLine24/7personalsecurityinformationandadviceforallyourtravelsafety
28.1 Included Included Included Included
queries.Pleasecontactred24orvisitwww.red24.com/aetna

ActionResponse24/7internationalrescueandresponseserviceforyouina
28.2 potentiallylifethreatening,nonmedicalevent.Pleasecontactred24orvisit Included Included Included Included
www.red24.com/aetna
Circumcision
ElectiveCircumcisionThecostofmedicalproceduresfortheelectivecircumcision
Covered Covered Covered Covered
ofmalechildrenatanytimebeforetheir5thbirthday.