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TOTAL

OVERSEAS

Pesetas

Euros

Pesetas

Euros

OVERALL LIMIT

15,000,000

90,151.82

5,000,000

30,050.61

A.     Hospital Treatment

12,000,000

72,121.45

4,000,000

24,040.48

B.     Non-Hospital Treatment

3,000,000

18,030.36

1,000,000

6,010.12

AMOUNT INSURED

PESETAS

EUROS

A.     HOSPITAL TREATMENT

A.1.     In-patient (total per day)

32,000

192.32

A.2.     UVI/ICU (per day)

53,000

318.54

A.3.     Medical fees per procedure (including surgeon, assistant and anesthetist fees)

e

e

-  Minor and outpatient surgery (Group 0, OMC classification) (total per operation)

50,000

300.51

-  Minor and outpatient surgery (Group 1, OMC classification) (total per operation)

60,000

360.61

-  Minor and outpatient surgery (Group 2, OMC classification) (total per operation)

75,000

450,76

-  media surgery (Group 3, OMC classification) (total per operation)

250,000

1,502,53

-  media surgery (Group 4, OMC classification) (total per operation)

350,000

2,103.54

-  Major surgery (Group 5, OMC classification) (total per operation)

450,000

2,704.55

-  Major surgery (Group 6, OMC classification) (total per operation)

550,000

3,305.57

-  Major surgery (Group 7, OMC classification) (total per operation)

650,000

3,906,58

-  Grand surgery (Group 5, OMC classification) (total per operation)

900,000

5,409,11

A.4.     Brain sterotaxic surgery (all costs included) (total per year and policyholder)

1,000,000

6,010.12

A.5.     Medical fees for consultation (total per day)

15,000

90.15

B.     NON HOSPITAL TREATMENT

PESETAS

EUROS

B.1.     Medical consultation:

Primary healthcare (total per consultation)

7,000

42.07

Specialised healthcare (total per consultation)

15,000

90.15

B.2.     Ambulance (total per policyholder and year)

100,000

601,01

B.3.     Dentistry (only extractions, cures and dental cleaning) (total per policyholder and year)

40,000

240.40

B.4.     Special domiciliary care and domiciliary services

150,000

901.52

B.5.     Chiropody (unlimited)

B.6.     Diagnostic tests (total per policyholder and year)

150,000

901.52

Clinical analysis (total per procedure)

10,000

60.10

Clinical analysis (total per policyholder and year)

25,000

150.25

Conventional radiology (total per procedure)

10,000

60.10

Conventional radiology (total per policyholder and year)

25,000

150.25

Ecography (total per procedure)

8,000

48.08

Ecography (total per policyholder and year)

20,000

120.20

Bilateral Mammography (total per procedure)

10,000

60.10

Bilateral Mammography (total per policyholder and year)

10,000

60.10

Bilateral CAT scan (total per procedure)

16,000

96.16

Bilateral CAT scan (total per policyholder and year)

32,000

192.32

Bilateral NMR (total per procedure)

30,000

180.30

Bilateral NMR (total per policyholder and year)

60,000

360.61

Densitometry (total per procedure)

12,000

72.12

Densitometry (total per policyholder and year)

12,000

72.12

Holter (total per procedure)

15,000

90.15

Holter (total per policyholder and year)

30,000

180.30

Ergometry (total per procedure)

10,000

60.10

Ergometry (total per policyholder and year)

20,000

120.20

Echocardiogram (total per procedure)

10,000

60.10

Echocardiogram (total per policyholder and year)

20,000

120.20

B.7.     Special treatments

Linear accelerator (total per policyholder and year)

300,000

1,803.04

Cobalt bomb (total per policyholder and year)

200,000

1,202.02

Chemotherapy (total per policyholder and year)

300,000

1,803.04

Renal Lithotripsy (total per policyholder and year)

160,000

961.62

Dialysis (all included) (total per procedure)

16,000

96.16

C.     REHABILITATION (total per policyholder and year)

100,000

601.01

§         For psychiatry, “A” and “B” guarantees will have a global maximum limit of Ptas 150,000 / € 901.52 per year and policyholder and the maximum period for psychiatric hospitali sa tion will be 50 days per policyholder a year

• Diagnostic tests, special domiciliary care and chiropody included in guarantee “B” will exclusively be undertaken via the medical services recommended by the Insurer whenever these services are provided in Spain
• Expenditure originated by the policyholder for the use of medical and/or hospital services in Spain which have been recommended by the Insurer will not be taken into consideration to calculate the insured capital limit set forth under this Policy
• Should the Insurer not pay the hospital expenditure described in guarantee “A”, the Insurer would pay a subsidy of Ptas 12,500 / € 75.13 per each day in hospital with a maximum limit of 90 days per policyholder and year (this subsidy does not apply to psychiatric hospitali sa tion). (Rough translation)