ANNEXURE 01

Insured : Digital Mobility Solution (Pvt) Ltd

Policy Number : 23HDO4AMG001084

1 Benefit Limits
Proposed
Individual Family

Indoor / Annual Limit 300,000 400,000

Indoor / Per Event Limit 300,000 400,000

3 Main Limits under the benefit

Existing Benefit
Individual Family
Indoor / Annual Limit 300,000 400,000
Indoor / Per Event limit 300,000 400,000
A. Hospital/Nursing home maintenance charges,
including admission fees

B. For Specialized services, i.e. tests/ Surgeon's, Within Indoor Limit

Doctor's charges/ Emergency transport by an ambulance up
to 2-trips maximum/ All other expenses including operational
expenses, cost of drugs, medical expenses

C. Maximum Room Charges 20,000 20,000

D. Intensive care unit (ICU) charges per day 20,000 20,000

E. Cost of prescribed drugs, medical tests, scans and x-rays whilst being an in-patient
Within Indoor Limit
on Non-Paying Government Hospital ward

F. Non-paying ward of a government hospital per day payment, maximum up to 30 days

5,000 5,000
G. Birth of twins (Cash grant)
N/A 20,000
H. Emergency Traveling (Subject to Bill Being Submitted)
20,000 20,000
I. 1. Spectacle Once a year - Employee Only (“Spectacle Bills accepted only from a
specialist consultant Eye Surgeon or Ophthalmologists only”)
20,000 20,000

I. 2. Dental Test & Treatments(Filling & Extractions Only) for all Members

4 Other Benefits
A. Maternity Benefit (Applicable only for Family Units)

a.) Normal child birth covered, Within Indoor Limit

b) Any abnormal Childbirth such as Elective caesarean, Emergency caesarean, forceps, vacuum delivery are covered,

c) Unforeseen pregnancy-related ailments, complications, sub fertility and in fertility (Excluding IVF/IUI treatments) are covered within annual

d) The cover is extended to include miscarriage/Abortions recommended by a practicing gynecologist (Life Threatening abortions). Excluding
voluntary abortions.

B. Cover for Ayurveda treatment accepted provided treatment is from

Siddhalepa Hospital Mt Lavinia

Wickramarachchi Ayurvedic Hospital
Sugatha Rasayanagaraya - Horana
Pilapitiya Ayurvedic Hospital
Any National Ayurvedic Hospital or any hospital registered under Department of Ayurveda, or any practitioner
registered under Department of Ayurveda

C. Expenses relating to Cataract surgeries are covered within indoor limit & lenses are limited to LKR 60,000/-(per eye) for All members.

D. Cover for OPD /day surgeries (surgeries available with-out hospitalization) with in indoor limit, done by a general surgeon.
 Expenses incurred due to below mentioned tests are reimbursed under indoor limit on the recommendation of the
E.
doctor without being admitted to the hospital.

I. MRI VI. C T SCAN XI ECHO TEST XV ECG & EEG

II. ENDOSCOPY VII. CYSTOSACOPY XII PET SCAN XVI DEXA SCAN
III. COLONOSCOPY VIII. LAPAROSCOPY XIII BIOPSY TEST XVII.US SCAN
IV. BRONCHOSCOPY IX. AND ALL THE INVESTIGATIONS DONE WITH INSERTION OF CAMERA TO THE BODY
V. SIGMOIDOSCOPY X. MAMMOGRAM XIV SCREENING TESTS XVIII.TREADMIL TEST

F. Pre & Post hospitalization related treatments, medicines, tests are covered up to a maximum of 30 Days (Pre 30 days/ Post 30 days)

G. Pre-existing / RecurrinG, Chronic Diseases and Womb Related ailments are covered under the policy

H. Cover is extended to include wisdom tooth removals within Indoor Limit

H. Dentures & repair or replacement of natural teeth is covered at an event of an accident under Indoor Limit

J. Physiotherapy treatments prescribed by a specialist due to an illness or accident is covered under Indoor Limit

K. Homeopathy treatment covered under indoor limit

L. Vitamins & Vaccination prescribe by a specialist for an ailment whiles been hospitalized are covered under Indoor limit

M. Cover is extended to include “infection by Acquired Immune Deficiency Syndrome(AIDS) or Aids Related Complex(ARC)” within the Indoor limit.

N. Cover is extended to cover congenital Diseases with in Indoor limit

O. Cover for Expenses incurred whilst hospitalized due to epidemic, Pandemics and outbreak of diseases within indoor limit

Medical camp will be organized by HNBGI for employees under below mention test,
P. Full blood count, • Fasting blood sugar • Urine Full report • Total cholesterol • Serum Creatinine • SGPT • Physical Exam (Examination of Blood
pressure/ pulse, Cardiovascular, Respiratory, Abdominal, Vision, and Nervous Systems)

Q. Jaw bone diseases are covered under Indoor limit

R. Laser & Lasik treatment cover under Indoor benefit

S. Psychiatric treatments whiles been hospitalized are covered under indoor limit

T. Cost of Sleep apnea under investigations covered only for employee under indoor limit maximum up to per event & aggregate LKR 200,000/-

Dental surgeries due to an ailment or accident including repair or replacement of injured sound unfilled natural teeth & surgeries done for jaw bone
U. diseases under Indoor Limit

V. Critical Illness Cover

39 illnesses on a floater basis for, on first come first serve basis (Cover will be provide for all members)

: Per Employee/per event 250,000.00

: For All other Members /per event 250,000.00
: In Aggregate 1,000,000.00

1.) Cancer, 2.) Myocardial Infarction 3.) Stroke,

4.) Coronary Artery Surgery, 5.) Renal Failure, 6.) Major Organ Transplant,
7.) Paralysis, 8.) Blindness, 9.) Heart Valve Surgery,
10.) Multiple Sclerosis, 11.) Surgery for a Disease of the Aorta, 12.) Alzheimer’s Disease,
13.) Apallic Syndrome, 14.) Aplastic Anemia, 15.) Chronic Liver Disease,
16.) Chronic Lung Disease, 17.) Coma, 18.) Deafness,
19.) Encephalitis, 20.) Fulminant Viral Hepatitis, 21.) Major Head Trauma,
22.) Loss of Speech, 23.) Major Burns 24.) Motor Neuron Disease,
25.) Muscular Dystrophy, 26.) Pulmonary Arterial Hypertension, 27.) Parkinson’s Disease,
28.) Poliomyelitis 29.) Angioplasty 30.) Amyotrophic Lateral Sclerosis
31.) Benign Brain Tumor 32.) Primary Cardiomyopathy 33.)Loss of Limbs
34.)Medullary Cystic Disease 35.)Necrotizing Fasciitis 36.)Systemic Lupus Erythematosus
37.)Terminal Illness 38.)Loss of Independent Existence [before age 65] 39.)Severe Rheumatic Arthritis

Special Conditions Applicable - Critical Illness Cover

A. Covered Hospitalization expenses only

B. This quotation is subject to changes depending on the age, occupation, number of members in the group, etc.

C. Age limit 1 year to 70 years (Employees covered under surgical & hospitalization insurance policy only)

D. Term of cover: One year & yearly renewable thereafter

Warranted that benefits under this policy with regard to reimbursement of the cost of hospitalization become payable subject to the primary health
policy(ies) with the company paying first and exhausted and in respect of named illness(es),during the policy period and up to the limit under this policy.
 Conditions
a. Geographical limits - Worldwide cover on reimbursement basis

b. Policy excess Nil

c. Policy Waiting period

for Illnesses Nil
for Accidental Nil
for Maternity Nil

d. Exclusive Package for Cooperate entering in first time for Medical Insurance

e. Age limit
Primary insured (Employee) Spouse from 18 years to 75 years

Children = from day 01 to 25 years (Unmarried & Unemployed children only)

New borns will be covered from day one, provided inclusion should be submitted within two months

Parent age up to 80 year only (for Parents above age 71 to 75, 25% premium loading & age 76 to 80, 35% premium Loading)

f. Premium Calculation for New Inclusions and Deletions

For mid term inclusions, premium will be charged as follows.

For First 6 months – 100% premium will be charge
For next 3 months – 75% premium will be charge
For last 3 months – 50% premium will be charge
Refunds for deletions will be done prorate basis subject to no-claims

Up grading’s under the policy is allowed within the first two month from the commencement of the policy subject to

g. Claim Document Submission Period

Duration
Within the policy period 90 days
Previous Claims after renewing the policy 30 days
Previous Claims after policy is not renewed with HNBGI 15 days

Hospitalization Bills are only accepted from PHSRC (Private Health Services Regulatory Council) registered
h.
private medical institutions.

i. Cash less facility

Claims will be settled directly to selected hospitals via service provider, MOBIZZ;
Premium payment - 75% to be paid on firm order to activate the cashless facility, balance amount subject to Premium
Payment Warranty

Reimbursement under this policy shall only be considered on submission of all original paid bills, prescriptions
j.
along with the doctor seal & ailment.

k. The VAT component will be honored by the Insurance Company with the Indoor Limit.

Costs incurred in respect of medical equipment, medical accessories, devices, prosthesis and apparatus are
l.
not covered under the policy.

m. Any expenses related to hospitalization due to medical checkups are excluded under the policy

Yours Faithfully
HNB General Insurance Limited

Non Motor Department