VALUE ACCESS GUARANTEE SCHEDULE OF INSURED BENEFITS Option 4 Waiting Period after Coverage Effective date:   Injury 0 Days Illness 30 Days Doctors Office Visit Indemnity Benefit (Paid per Visit): $75 Maximum Visits per Calendar Year per Individual 5 Maximum Visits per Calendar Year per Family (This benefit is not subject to the Preexisting Conditions Limitation) 10 Preventive Care Indemnity Benefit:   Maximum 1 Visit per Calendar Year per Individual $75 Daily In-Hospital Indemnity Benefit:   Paid for each day of hospital confinement $1,500 Maximum number of days per confinement 30 days Daily Hospital Intensive Care Unit Confinement Indemnity   Benefit: Not paid in addition to the Daily In-Hospital Indemnity $1,500 Maximum number of days per confinement per Individual 30 days Surgery Indemnity Benefit:   The surgery benefit is based on multiplying the Payment Factor for the procedure listed in the Surgical Schedule, by the Surgical Procedure Unit. Up to $7,500 Surgical Procedure Units: 50 Maximum Surgical Sessions per Calendar Year per Individual 2 Anesthesia Indemnity Benefit:   Payment is based on a Percentage of the Surgical Indemnity Benefit 20% Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit for each day of testing: $150 Maximum number of Testing Days per Calendar Year per Individual 5 Emergency Room Indemnity Benefit:   Maximum 1 Visit per Calendar Year per Individual $150 Ambulance Benefit Indemnity Benefit:   Maximum 1 Visit per Calendar Year per Individual $100