SOP Exhibits

Title:

Schedule of Operations (For Basic Medical Benefit Only)

SOP Number : HR-PB20

Annex A

SCHEDULE OF OPERATIONS
(For Basic Medical Benefit Only)

To arrive at the maximum benefit payable for a particular surgical operation, multiply the amount indicated opposite the corresponding surgical operation by THIRTY (30).

If x-ray radium or any other radioactive substance are used for treatment in place of any cutting operation listed below, the Company will, subject to all of the other provisions of Surgical Benefit, pay a benefit which is usual and customary for such treatment up to the amount provided by the Schedule of Operations for replaced cutting operation.

DESCRIPTION OF OPERATION MAXIMUM BENEFIT

ABDOMEN

Appendectomy P 50.00
Cholescystectomy 75.00
Combined Abdomino-perineal resection 100.00
Gastrectomy 100.00
Herniotomy - single 50.00
Herniotomy - bilateral 62.50
Hernia, injection method (complete process) 25.00
Intestinal resection 100.00
Pyloroplasty 50.00
Pyloroplasty with gastro-je junostomy 75.00
Splenectomy 50.00
Other cutting into abdominal cavity for
diagnostic and treatment of organs 50.00

AMPUTATION, Amputation of

Hip or shoulder 62.50
Upper arm or thigh 50.00
Leg, forearm, wrist or ankle 50.00
Finger or toe (one or more phalages) 7.50
One breast - single 50.00
One breast - radical 75.00
Both breast - radical 100.00

BLOOD TRANSFUSIONS, Blood transfusions
not included in hospital charges 12.50

CHEST

Thoracoplasty 100.00
Labectomy 100.00
Open drainage of empyema 20.00
Phrenic nerve crushing 20.00
Other cutting into thoracic cavity for diagnosis and treatment
of organs 62.50
Initial induction of pneumothorax 12.50
Refills of pneumothorax, each (limit of P100.00) 2.50
Brochoscopy or Esophagoscopy 12.50

DISLOCATIONS, Reduction and treatment of

Hip or knee joint (patella excepted) 20.00
Shoulder, elbow, ankle or wrist joint 17.50
Collar bone, lower jaw, patella 10.00
Fingers or toes 5.00
(Where open operations are performed, the limits are twice the
amount)

EXCISIONS, Excision of

Portion of vertebra or vertebrae (processes 75.00
and coccyx excepted ) or discs
Shoulder or hip joint 75.00
Knee joint 50.00
Semilunar cartillage 50.00
Elbow, wrist or ankle joint 50.00
Diseased portion of bone, including curettage (alveolar
process excepted) 25.00
Bunions - radical 12.50

EAR, NOSE AND THROAT

Mastoidectomy (one side) 50.00
Mastoidectomy (both sides) 75.00
Fenestration 100.00
Cutting operation or frontal sinus
external radical 25.00
Submucous resection or trachectomy 25.00
Initial puncture of anstrum 2.50
Subsequent openings 2.50
Any other cutting operation into nasal sinus 17.50
Tonsillectomy or adenoidectomy (either or both) 15.00
Laryngectomy 75.00
Removal of nasal polyps (one or more) 7.50

EYES

Removal of cataract 75.00
Needling of cataract 15.00
Removal of eyeball 37.50
Operation for the detached retina, glaucoma
or strabismus 100.00
Removal of foreign body from cornea or solera 2.50
Any other cutting operation into eyeball
(thorough cornea or sclera) 50.00
Any other cutting operation on eye 10.00

FRACTURES. Treatment for fractures or

Thigh, upper arm, tibia and fibula (both bones)
radius and ulna (both bones) 37.50
Vertebra or vertebrae (process excepted) 37.50
Pelvis coccyx excepted) - single or multiple 37.50
Collar bone, radius, ulna, tibia, fibula or
lower jaw (alveolar process excepted) 12.50
Shoulder blade, wrist, hand, ankle or foot 12.50
Thumb, finger, toe or ribs (single or multiple) 5.00
Coccyx or vertebral process (one or more) 7.50
Skull (non-operable) 12.50
(Skull compound fractures, the limits
one and one-half times the amount)

(Fractures requires an open operation, the limits are twice the amount).

GENITO - URINARY TRACT

Nephrectomy 100.00
Removal of stones or tumors by open operation 30.00
by crushing or cauterization through
transurethreal approach
Cystoscopy 17.50
Cystoccele and rectocele repair 12.50
Porstatectomy - 37.50
Transurethal resection 50.00
Removal by open operation
(complete procedure) 75.00
Structure or uretha -
Correction by open operation 30.00
Correction by intra-urethal cutting operation 12.50
Orchidectomy or epididymectomy 37.50
Varicole Operation 37.50
Hydrocele Operation - radical 37.50
Circumcision
Under 12 years of age 5.00
over 12 years of age 7.50
Incision of Bartholins gland 5.00
Removal of uterus and one or more appendages 75.00
Removal of uterus 50.00
Excision of fistula-recto-vaginal 50.00
Dilatation and currentage, cauterization of conization,
polypectomy, or any combination of these 12.50
Other cutting operations on uterus without abdominal approach 25.00

GOITRE

Thyroidectomy - subtotal 75.00
(one or more stages)
Ligationof thyroid arteris not followed by thyroidectomy -
one ore more at one operation 30.00
two or more stage operation 37.50
Removal of thyroid adenoma 37.50

INCISION AND DRAINAGE. Incision and draine of

Abscesses, boils, furuncles or carbuncles (one or more)
Requiring hospital confinement 12.50
Not requiring hospital confinement 5.00

JOINT

Incision into joint (tapping excepted) 12.50

LIGAMENTS AND TENDONS

Cutting operation on ligaments
and tendons 25.00
Saturing of tendons - single 17.50
Saturing of tendons - multiple 25.00

NEURO-SURGERY

Craniotomy for abscesses or tumor 100.00
Exploratory trephination -
One side 25.00
Both sides 37.50
Other cutting into cranial cavity
(drill taps excepted) 37.50
Drill taps 12.50
Cutting into spinal canal for treatment 100.00
Removal of prolapsed disc 25.00
Sympathectomy - lumbar
One side 37.50
Two sides 62.50
Other symphathectomy 37.50

PARACENTESIS. Tapping of

Abdomen, chest, bladder, eardrum, hyrocele, joint or spine 7.50

RECTUM

Hemorrhoidectomy (complete procedure) 25.00
Injection treatment for radical cure of hemorrhoids,
complete procedure 5.00
Incision of thrombosed hemorrhoid 5.00
Correction of rectal polyp or fissure 12.50
Cutting operation for prolapsed rectum 25.00
Cutting operation for fistula-in-and
Single 25.00
Multiple 37.50
Any other cutting operation 7.50

TUMORS. Removal of

Malignant tumors except of face or skin 62.50
Malignant tumors of face or skin 20.00
Benign tumors or cysts (requiring hospital confinement) 12.50
Not requiring hospital confinement 5.00
Removal of pilonidal cysts 30.00

VARICOSE VEINS

Injection treatment, complete procedure
one or both legs 20.00
Cutting operation, complete procedure
One leg 25.00
Both legs 37.50