SLB COMMUTER ENROLLMENT FORM - GoCare€¦ · transfer or hire on that status. Coverage effectively starts the day you complete the benefits enrollment form and return it to your

THE SCHLUMBERGER

INTERNATIONATIONAL HEALTH CARE PLAN

FOR COMMUTER EMPLOYEES

EMPLOYEE GUIDE

Plan Administrator

European Benefits Administrators 28, rue de Mogador 75009 Paris, France

Telephone (Switchboard) +33 1.42.81.97.00 Schlumberger Team Direct Line +33 1.42.81.98.62 Fax (General n°) +33 1.42.81.99.03 Schlumberger Team Direct Fax +33 1.42.81.98.58

E-Mail [email protected]

June 2003

TABLE OF CONTENTS

1. Overview ................................................................. 1.

2. Eligibility ................................................................. 2.

3. Changes In Coverage................................................ 3.

4. Cost To Employees ................................................. 4.

5. Medical Care Coverage ........................................... 5.

6. Treatment For Psychiatric, Mental, Nervous,

Alcohol, Drug Abuse Disorders .............................. 8.

7. Vision Care .............................................................. 9.

8. Dental Care .............................................................. 10.

9. Determining Benefit Payments ................................ 13.

10. Exclusions ............................................................... 15.

11. Controlling Costs ..................................................... 17.

12. Lifetime Maximum .................................................. 19.

13. Identification Cards ................................................. 20.

14. Coverage When Not An Active Employee ............. 20.

15. Plan Administrator .................................................. 21.

16. In An Emergency ..................................................... 21.

17. Submitting Claims ................................................... 22.

18. Medical Evacuation and Assistance ........................ 24.

19. Future of the Plan .................................................... 30.

© European Benefits 2003 SLB Int’l Health Care Plan - Commuter - Page 1

1 - OVERVIEW Schlumberger provide comprehensive health care coverage for all International Commuter employees and subsidize most of the cost of the voluntary medical coverage for family members. You automatically receive Basic Cover for yourself (“Employee Only Basic Cover”).You can elect to extend the Basic Cover to your spouse and dependent children (“Employee and Family Basic Cover”) You also can elect to upgrade the cover to the level of the Special Cover for yourself (“Employee Only Special Cover”) or for yourself and your spouse and dependent children (“Employee and Family Special Cover”). Upgrading cover and extending cover to family members is your choice and requires written instructions from you on the enrollment form. The Plan is designed to cover the employee for regular health care and medical attention in the event of illness, injury, disability and medical necessity. Coverage is worldwide and there are no restrictions on the choice of doctors, laboratories, clinics, and hospitals as long as you deal with recognized medical physicians and institutions. Please read carefully Section 11 - CONTROLLING COSTS, as a precertification procedure is required for all cases of hospitalization, convalescent facilities, outpatient surgery and inpatient psychiatric treatment, as well for dental treatment plans which cost more than $1,200. Precertification is initiated by a phone call to European Benefits Administrators. Coverage begins on the day of transfer or hire on eligible status, providing you complete the Enrollment Form. There are no waiting periods and no exclusions for pre-existing conditions.


Work-related sickness or injury should be reported to your Supervisor and medical expense claims should be sent to European Benefits Administrators indicating that the cause was work-related. Where appropriate ask your Supervisor for a copy of the work accident report which should be attached to the health care claim form. Medical evacuation and assistance benefits follow a different set of procedures than those operating for medical, psychiatric, vision, and dental care benefits. To avoid confusion between two administrative environments, the medical evacuation and assistance benefits included in the Health Care Plan are placed at the end of this guide. You will find all the relevant details in Section 18 - MEDICAL EVACUATION AND ASSISTANCE. 2 - ELIGIBILITY All International Commuter employees, their spouses, and dependent children are eligible for the health care benefits from the date of transfer or hire on that status. Coverage effectively starts the day you complete the benefits enrollment form and return it to your GeoMarket Personnel Department, provided you have been hired by that time and you returned the form within 31 days of the date of hire. Basic Cover for the employee is automatic. Employees who want to upgrade the benefits to the level of the Special Cover and/or want to extend cover to family members must clearly state their choices on the enrollment form. Eligible family members include: • spouse • unmarried children under age 19 • unmarried children between 19 and 25 years of age who are full-

time students and who attend school regularly and depend solely upon the employee's financial support


• unmarried children who are physically or mentally incapacitated and depend solely upon the employee's financial support.

Dependent children include your own children, legally adopted children, step-children, foster-children and any other child who depends on your sole financial support and who lives with you in a customary parent-child relationship. Medical and dental benefits for unmarried children who are physically or mentally incapacitated remain in force after the child reaches age 19 as long as proof of the handicap is submitted to the Plan Administrator prior to the dependent's 19th birthday and periodically thereafter at the administrator's request. 3 - CHANGES IN COVERAGE A new Enrollment Form must be filled out every time a change in coverage is requested. Requests to change the level of cover (Basic to Special or Special to Basic) will only be accepted during the Open Enrollment period which will take place annually in February and March. The change in cover becomes effective on the first day of the month following receipt and approval of the new enrollment form by the GeoMarket Personnel Department. Requests to change the extent of cover (“Employee Only” to “Employee and Family” or “Employee and Family” to “Employee Only”) can be made at any time in the year. A marriage certificate should be attached to the enrollment form when moving from “Employee Only” to “Employee and Family” status. Changes in the extent of cover becomes effective on the first day of the month following receipt and approval of the new enrollment form by the GeoMarket Personnel Department.


The only exception is a new born child, who is covered from birth, providing the employee has signed up already for Employee and Family cover or signs up within 31 days of the birth of the child. Please send a copy of the birth certificate with the first claim to European Benefits. 4 - COST TO EMPLOYEES The Company pays the entire cost of the “Employee Only Basic Cover”. The Company and employees share the costs of upgrading the benefits to the level of the Special Cover and of extending cover to spouse and dependent children. Employee contributions are made by monthly payroll deductions. Basic Cover • Employee Only: No employee contribution • Employee and Family: 1% of base salary up to a $50 Monthly maximum Special Cover • Employee Only: 1% of base salary up to a $50 Monthly maximum • Employee and Family: 2% of base salary up to a $100 Monthly maximum 5 - MEDICAL CARE COVERAGE The description of benefits in Sections 5 through 8 is written as if all International Commuter employees had chosen the Special Cover. Where differences exist between the Special Cover and the Basic Cover, the Basic Cover benefits appear in italics inside a box. If there is no box, the benefit is identical in Basic Cover and in Special Cover.


In the text which follows “insured person” means the employee only, if you are covered by “Basic Cover - Employee Only” or “Special Cover - Employee Only”. If you are covered by “Basic Cover - Employee and Family” or “Special Cover - Employee and Family”, “insured person” refers to each insured member of the family (employee, spouse, dependent children). 5. 1. Health Check-Ups International Staff employees are required to undergo a mandatory predefined physical examination (MED-TRACK) at one of the Schlumberger certified clinics around the world. The MED-TRACK physicals, which are managed by the International SOS group, are scheduled every three years, unless required more frequently by job requirements or local legislation. The Schlumberger International Health Care Plan pays 100% of the cost of the mandatory check-up. All International Commuter employees will be registered with the International SOS group for the MED-TRACK examinations. The International SOS group will coordinate the mandatory physicals by notifying each employee periodically of timing of checkups, clinic locations and procedures. All physical results will be sent to the Schlumberger Medical Department via medically confidential and secure channels. The above medical information will remain strictly confidential, accessible to employee and the Schlumberger Medical Department only. The Plan pays 100% of reasonable and customary charges for one (1) check-up (including MED-TRACK) for each insured person per calendar year. Check-ups include examination of body systems, X-ray and laboratory tests to support the examination, review by the physician of the results and consultation with the patient.


5. 2. Smoking Prevention The Plan pays 100% of reasonable and customary charges up to an annual maximum of $300 per insured person for costs of smoking prevention treatment by a doctor, participation in a recognized smoking prevention program, and smoking prevention pharmaceutical products prescribed by a physician. 5. 3. Inoculations The Plan pays 100% of reasonable and customary charges for all necessary inoculations and immunizations for all insured persons. 5. 4. Pre-Certification for Hospitalization, Outpatient Surgery, Convalescent Facilities Required in all cases of hospitalization, outpatient surgery, and convalescent facilities. Plan payments may be reduced to 60% of normal payments if the instructions in Section 11 - CONTROLLING COSTS are not followed. 5. 5. Medical Hospitalization and Outpatient Surgery The Plan pays for all insured persons 100% of reasonable and customary charges for all necessary outpatient surgery expenses and hospital expenses required for inpatient treatment including: • Room and board charges for normal private or semi-private

accommodations,

• Use of intensive care units or coronary care facilities,

• Use of operating, delivery and recovery rooms and equipment,

• Blood, plasma and oxygen,

• Diagnostic and laboratory tests, • Prescribed drugs and medicines for use in the hospital, • Electrocardiograms and fluoroscopy, • X-ray examinations, • Hospital outpatient charges for surgery,


• General nursing provided by the hospital, • Services of hospital staff, • Doctors' and surgeons' fees for diagnoses and medically necessary

inpatient treatment related to injury or illness, including second opinions,

• Physicians' charges for surgery, including anesthetists, pathologists and radiologists,

• Ambulance transportation for a hospitalization. Personal expenses, such as telephone calls and television rental, are not covered by the Plan. 5. 6. Convalescent Facilities The Plan pays for all insured persons 100% of reasonable and customary charges up to sixty (60) days per disability in a convalescent facility while recovering from a hospitalization or a major injury or disease. Registered nursing, including home health services as an alternative to confinement in a hospital, are covered on the same basis. 5. 7. Outpatient Services (except Outpatient Surgery) The Plan pays for all insured persons 90% of reasonable and customary charges for the following services: • Physician’s fees for diagnoses and medically necessary outpatient

treatment related to injury or illness

• Outpatient hospital emergency room services • Registered nursing • X-rays and laboratory tests • Prescription drugs • Chiropractors’ fees (12 sessions annual maximum per person). • Prosthestic appliances and hearing aids • Ambulance transportation not related to a hospitalization


After the amount of the eligible outpatient service charges which is not reimbursed by the Plan reaches $350, the Plan will start paying 100% of reasonable and customary costs of the remaining eligible outpatient services up to the end of the calendar year.

BASIC COVER

The Plan pays for all insured persons 80% of reasonable and customary charges for the services described above. After the amount of eligible outpatient service charges which is not reimbursed by the Plan reaches $700, the Plan will start paying 100% of reasonable and customary costs of the remaining eligible outpatient services up to the end of the calendar year.

Chiropractic fees are covered up to 8 sessions per calendar year per insured person.

Please note that the Plan pays 100% of reasonable and customary charges for treatment of work-related accident, occupational or assignment related diseases. Important note: the Plan pays 100% of reasonable and customary charges for preventive malaria treatment. 5. 8. Maternity The Plan pays for all insured persons 100% of reasonable and customary charges for inpatient and outpatient medical treatment for pregnancy and childbirth. Infertility and fertility procedures (such as birth-control products or devices, tubal ligation, vasectomy, in vitro-fertilization, etc.) are not reimbursed.


6 - TREATMENT FOR PSYCHIATRIC, MENTAL, NERVOUS, ALCOHOL, DRUG ABUSE DISORDERS Contact the Plan Administrator in advance to find out if a particular facility, practitioner, or treatment qualifies for coverage. Precertification is required for inpatient treatment (see Section 11 - CONTROLLING COSTS). 6. 1. Inpatient Treatment Medically-necessary diagnosis, evaluation and effective treatment under the supervision of a staff of physicians on an inpatient basis in a hospital or specialized medical facility is reimbursed for all insured persons at 100% of reasonable and customary charges. There is a thirty (30) day lifetime maximum per insured person. 6. 2. Outpatient Treatment Outpatient diagnosis and treatment by a physician or as part of a program of therapy prescribed and supervised by a physician is reimbursed for all insured persons at 90% of reasonable and customary charges up to a maximum reimbursement of $3,200 per person per calendar year.

BASIC COVER

Outpatient diagnosis and treatment by a physician or as part of a program of therapy prescribed and supervised by a physician is reimbursed for all insured persons at 50% of reasonable and customary charges up to a maximum reimbursement of $1,000 per person per calendar year.

Psychoanalysis is not covered.


7 - VISION CARE 7. 1. Ophthalmologist Fees and Eye Surgery Eye examinations and necessary eye surgery to repair damage to the eye are reimbursed for all insured persons at 100% of reasonable and customary charges. Radial keratotomy (myopia surgery) is covered up to a lifetime maximum of $600.

BASIC COVER

Eye examinations and necessary eye surgery to repair damage to the eye are reimbursed for all insured persons at 80% of reasonable and customary charges. Radial keratotomy or any surgery whose prime purpose is to correct defective eyesight is not covered.

7. 2. Eyeglasses and Contact Lenses 100% of the cost of eyeglasses (including frames) and contact lenses prescribed as a result of an eyeglass examination to correct defective eyesight are reimbursed for all insured persons up to an annual maximum of $400 per person. Note that where possible safety lenses should be acquired.

BASIC COVER 100% of the cost of eyeglasses (including frames) and contact lenses prescribed as a result of an eyeglass examination to correct defective eyesight are reimbursed for all insured persons up to an annual maximum of $200 per person.



8 - DENTAL CARE 8. 1. Precertification for Dental Treatment Precertification is required for any treatment plan which costs more than $1,200. (See Section 11 - CONTROLLING COSTS). 8. 2. General Dental Care The Plan pays for all insured persons 100% of reasonable and customary charges for diagnostic examinations, preventive treatment, and necessary basic care as described below: • Regular oral examinations • Regular X-rays. • Regular teeth cleaning • Fluoride applications for children under age 16 • Sealant and space maintainers for children under age 16. • Oral surgery and related anesthesia • Amalgam fillings • Extractions • Endodontic treatment (including root canal therapy) • Periodontal treatment (gum disease) • Repair of crowns, inlays, onlays, bridgework and dentures.

BASIC COVER

The Plan pays for all insured persons 90% of reasonable and customary charges for the general dental care described above.

Aesthetic treatment, experimental methods, and dentistry for cosmetic purposes are not reimbursed.


8. 3. Dental Crowns, Bridges, Dentures, Implants The Plan pays for all insured persons 100% of reasonable and customary charges up to a maximum of $500 per tooth and a maximum of $2,500 per person per calendar year for necessary supplies and services of a physician which may consist of installation or replacement of: • Fixed bridgework • Partial or full removable dentures • Crowns, inlays, onlays • Gold fillings (only to the extent that the tooth cannot be restored

with amalgam, silicate acrylic or plastic restoration) • Dental surgical implants.

BASIC COVER The Plan pays for all insured persons 50% of reasonable and customary charges up to a maximum of $400 per tooth and a maximum of $1,000 per person per calendar year for dental crowns, bridges, dentures and implants as described above.

8. 5. Orthodontic Treatment The Plan pays 90% of the cost of necessary supplies and services by a physician for orthodontic treatment for each covered dependent child up to a lifetime maximum of $2,000 per child.

BASIC COVER The Plan pays 50% of the cost of necessary supplies and services by a physician for orthodontic treatment for each covered dependent child up to a lifetime maximum of $1,000 per child.

Aesthetic treatment, experimental methods, and dentistry for cosmetic purposes are not reimbursed.



9 - DETERMINING BENEFIT PAYMENTS 9. 1. Currency of Payments Bills may be submitted in any currency. Conversion between currencies is done at the Schlumberger Foreign Currency Rate applicable on the date of medical service. Reimbursements to employees are normally made in US dollars, unless you indicate on the enrollment form that reimbursements should be made in the currency of your bank account (Euro, Pound Sterling, Singapore Dollar, etc.). 9. 2. Recognized Expenses Before payments are made, the Plan Administrator evaluates the charges of the doctor, hospital or other provider of services or supplies to determine:

• If they have been furnished by qualified providers of medical care

• If the services are medically necessary

• If the charges are reasonable.

Not all physicians charge the same fee for similar treatment or require a patient to stay the same number of days in a hospital for similar treatment. While it is not the intention of this Plan to direct you to any particular physician or group of physicians, benefits will be paid only to the extent that medical and dental services are necessary and appropriate and that charges are reasonable and customary. The Plan will pay only what is reasonable and actually incurred. Reasonable and customary costs vary by type of treatment, quality of service and equipment, area and country. The level of reimbursement may be limited to the medical rates and associated costs, as well as to the lengths of hospitalization generally prevailing and of normal standard in the areas where the patients are treated.


A charge or expense will be considered reasonable and customary if it is the lesser of:

• The charge made for it by the supplier

or

• The prevailing charge in the same area made by those of similar standing.

The Plan Administrator will determine whether a charge is reasonable by considering the complexity of the treatment involved, the degree of professional skill required, and other pertinent factors. All treatments must be received in licensed facilities and by legally qualified physicians. "Physicians" refer to a licensed medical doctor, doctor of dentistry, or psychiatrist practicing within the scope of his or her license. Coverage is provided only for any service or supply which is necessary, meaning that it is broadly accepted professionally as essential to the treatment of the disease or injury. 9. 3. Coordination of Benefits If you or your insured dependents are covered by a Government program or another group health care plan (employer, educational institution, professional association, etc.), the benefits of both plans will be coordinated in order that the combined payments do not exceed the actual covered expenses. The general rule is that one plan pays first and the second plan pays the remaining eligible expenses up to the limits in the second plan. The administrator of the second plan should receive the original copy of the first plan's reimbursement statement and photocopies of all relevant bills. The following list identifies which plan should receive the original bills and act as the "First Plan" for:


All insured persons: • government programs (Social Security, Medicare, etc.) • non-health insurance (automobile, homeowner's, liability, etc.) Spouse: • spouse's employer's plan Dependent children after a divorce (in descending order): • plan of divorced parent declared responsible for medical expenses

by a court order • plan of divorced parent with custody • plan of step-parent (divorced parent with custody has remarried). 10 - EXCLUSIONS The following services and supplies are not covered under any part of the health care coverage: • Charges for services or supplies ordered or received prior to the

effective date of coverage or after the termination of coverage. • Aesthetic treatment and cosmetic surgery, unless required by an

injury which occurs after the employee becomes covered under the Plan.

• Treatment for obesity, except when the Body Mass Index is over 35.

• Infertility and fertility procedures (such as birth control products and devices, tubal ligation, vasectomy, in-vitro-fertilization, etc. )

• Psychoanalysis. • Travel and hotel expenses related to medical care. • Radial keratotomy (myopia surgery), unless Special Cover is

elected.


• Care in a nursing home or home for the aged or custodial care.

Custodial care means care comprised of, or services and supplies including room and board, and other institutional services, which are provided to an individual, whether disabled or not, primarily to assist in the activities of daily living. Such services are considered custodial care without regard to the practitioner or provider for whom or by which they are prescribed, recommended or performed.

• Anything not ordered by a doctor or not necessary for medical care,

as well as medical and dental services that do not meet professionally recognized standards or are not considered as being necessary for proper treatment.

• Treatment that is considered experimental. • Unusual or excessive charges as determined by the Plan

Administrator. • Expenses covered by a government program such as Social

Security or Medicare, whether or not a covered person applies for reimbursement from that program.

• Care provided in a government hospital or medical facility for

which an individual would not be charged in the absence of this plan.

• Expenses reimbursed or reimbursable by another insurance contract

or program. • Missed appointments. • Expenses incurred as a result of an altercation in which the

employee or the insured person is judged to be the aggressor. The Plan is not intended to be a source of profit. The combined reimbursements should not exceed the actual costs of the medical and dental care received by you or your insured dependents.


11 - CONTROLLING COSTS Medical costs are increasing at a rate that exceeds the general rate of inflation. Your choices and those of your family have a direct impact on the amount of the annual costs of the Schlumberger Health Care Plan. You and your family can help control costs by avoiding unnecessary medical expenses. 11. 1. Practice Good Health You will feel better and health costs can be reduced if you: • Exercise regularly. • Keep down your weight, blood pressure, cholesterol, smoking and

unreasonable alcohol use. • Go for periodic health check-ups, which are particularly important

for persons over 40 years of age. • Use seat belts in automobiles and helmets on bicycles and

motorcycles. • Visit the Schlumberger websites: "HealthHub"

(www.healthhub.slb.com) and "Travel" and read the Schlumberger Guide to Personal Fitness and Better Health.

11. 2. Precertify Major Expenses and Hospitalization • Call the Plan Administrator's precertification counselors one or

two weeks before entering a hospital or convalescent facility or undergoing outpatient surgery. The telephone (and fax) number is listed on your International Health Care Plan identification card. If an emergency hospitalization occurs, the Plan Administrator must be contacted within 72 hours of admission. Failure to do so may result in a reduction of reimbursement to 60% of normal payments.


• The physician can accelerate the precertification procedure by

providing in advance by fax a report which describes in detail the diagnosis, history, planned procedures and estimated costs.

• When possible, take hospital pre-admission X-ray and laboratory tests outside the hospital before you are admitted.

• Do not enter the hospital on Friday or Saturday unless it is an emergency.

• Review your hospital bill and inform the Plan Administrator if you find errors. Nobody knows as well as you what services and supplies were actually given to you.

• Precertification is required also for dental treatment which costs more than $1,200 per treatment plan and for inpatient treatment for psychiatric, mental, nervous, alcohol, drug abuse disorders.

11. 3. Review Alternative Treatments and Solutions Alternatives exist to hospital confinement which, in certain cases, can be avoided or reduced. • When a doctor recommends hospitalization, discuss with the doctor

whether an alternative such as surgery performed on an outpatient basis, skilled nursing care, or home health care might not be advisable.

• Medically sound alternatives have been developed for certain surgical procedures. To help you make an informed choice and weigh the benefits and risks of any surgical procedure, the Plan will pay 100% of reasonable costs of a second -- even a third -- surgical opinion. Covered services include a doctor's exam, x-rays, laboratory work, and the doctor's written report.

• There are several elective (non-emergency) operations that generally have equally successful alternative medical treatment. For these operations, you are required to get a second surgical opinion. If you fail to get a second opinion which is part of the precertification procedure, the Plan may cover only 60% of normal payments.


The surgical procedures for which a second opinion is required are

: • coronary bypass • reconstruction of hip • surgery of the big toe to correct deformity (including bunion) • removal of uterus (hysterectomy) • surgery of the back (laminectomy/fusion) • removal of knee cartilage • dilation and curettage • cataract removal, eye surgery • surgical removal of hemorrhoids • removal of prostate (complete and partial) • removal of gall bladder • bone surgery of the foot • removal of all or part of the kneecap • surgical reconstruction of the nose (including sub mucous

resection) • surgery of tendon and tendon sheath of wrist and hand • removal of tonsils and/or adenoids • surgery of the breast • hernia repair • varicose vein surgery • vascular surgery • neuro surgery • removal of tumors (benign or malignant) • visceral surgery (intestine, kidney, liver, spleen etc.)

12 - LIFETIME MAXIMUM The Schlumberger International Health Care Plan will pay up to one million US dollars ($1,000,000) for each employee and for each insured dependent during the total period of coverage by the Plan. There are specific lifetime ceilings for orthodontic treatment and inpatient treatment for alcoholism, drug abuse, psychiatric, mental and nervous disorders.


13 - IDENTIFICATION CARDS After enrollment in the Schlumberger International Health Care Plan, a personalized plastic identification card will be given to you. The card can be used to assist in verifying coverage when insured persons go to a hospital, clinic or doctor's office. You may request a card from the Plan Administrator for your spouse or a dependent college student away from home. 14 - COVERAGE WHEN NOT AN ACTIVE EMPLOYEE 14. 1. Termination The Schlumberger International Health Care coverage benefits stop at the end of the last month in which the employee is on payroll. However, benefits will be paid for any covered expenses incurred while covered under the Plan, if the last claim is sent to the Plan Administrator within two months after termination of employment. 14. 2. Absences The rules which apply to health care cover during periods of absence may be found in Section 4 - SENIORITY & ABSENCES of the International Commuter Manual. 14. 3. Survivor Benefits See the Schlumberger International Staff Deferred Medical Program Participant Information Brochure. 14. 4. Conversion See the Schlumberger International Staff Deferred Medical Program Participant Information Brochure.



15 - PLAN ADMINISTRATOR The Schlumberger International Health Care Plan is administered by:

EUROPEAN BENEFITS ADMINISTRATORS 28, rue de Mogador

75009 PARIS, FRANCE

Telephone (Switchboard) +33 1.42.81.97.00 Schlumberger Team Direct Line +33 1.42.81.98.62 Fax (General n°) +33 1.42.81.99.03 Schlumberger Team Direct Fax +33 1.42.81.98.58 E-Mail [email protected]

English, French, Spanish, Portuguese, Italian, Greek, German, Dutch, Russian, Arabic, Korean, Mandarin and Cantonese speaking customer service administrators are available to assist employees and family members in resolving any problems, to handle pre-certification, and to answer any questions during normal business hours (Paris time). European Benefits Administrators accepts collect calls. Freephones or 800 numbers exist for the United States, Canada, the United Kingdom, France, Germany, Holland, Norway and Australia. 16 - IN AN EMERGENCY In an emergency, you may show your Schlumberger International Health Care Plan card to the admissions staff of a hospital and ask them to contact European Benefits Administrators by fax or collect telephone call in order to confirm coverage. This is all that needs to be done in an emergency. One of the European Benefits' customer service administrators will talk to the physicians and hospital, handle the pre-certification process, and send by fax a confirmation of coverage. When possible, payments will be made directly to the hospital.


If you do not have your identification card with you or do not remember how to locate European Benefits Administrators, you should ask the hospital to get in touch with the nearest Schlumberger representative who will, in turn, contact European Benefits Administrators. European Benefits Administrators provides a 24-hour answering service, which takes messages if a call is made outside of business hours (Paris time) or on weekends and is available to help in an emergency situation. 17 - SUBMITTING CLAIMS You should send your claim forms and original medical and dental bills directly to European Benefits Administrators. Claim forms are available from your Personnel Department and are sent to you with each reimbursement statement. Several medical and dental claims can be submitted on a single claim form by completing the appropriate sections. Each claim form has easy-to-follow instructions printed on the front. Please read and carefully follow these instructions. Procedure for Filing a Claim 1. Please avoid making a series of small claims. It makes sense to

accumulate your small medical and dental bills until you have enough to justify a significant reimbursement. Then, take the precaution of making photocopies of all documents before sending the originals to European Benefits Administrators.

2. If your spouse or children are covered by Social Security, another

government plan, or a group insurance policy, you must obtain the reimbursement to which they are entitled before submitting the claim.


In this case, enclose with your claim a copy of all medical and dental bills relating to the claim, as well as the original statement of the Social Security or other prior reimbursement.


3. Fill out both sides of the claim form and attach it to the originals of

all reimbursable bills. Bills should indicate name and date of birth of patient, date of treatment, a detailed description of medical services and the amount of charges corresponding to each category of treatment or service.

Pharmacy bills should identify the drugs purchased (name and cost

per item). Bills must specify name and address of medical provider or pharmacy. Cash receipts which do not provide this information are not acceptable.

4. A bill for eyeglasses, contact lenses, prescription drugs, laboratory

tests, physical therapy, chiropractic treatment, or home health nursing services must be accompanied by a copy of the doctor's prescription.

5. In the event of a treatment costing more than $200, you should

have the physician complete and sign Section E on the claim form.

6. Fill in the claim form carefully and mail it within twelve (12)

months of treatment to:

EUROPEAN BENEFITS ADMINISTRATORS (Schlumberger International Health Care Plan)

28, rue de Mogador 75009 PARIS

FRANCE

For claims sent by company mail, write "ATTN/EUROPEAN BENEFITS ADMINISTRATORS" on the front of the envelope.

When a claim has been processed, you will receive a statement detailing how the claim was settled, along with a new claim form. Payments can be made by bank-to-bank transfers, if European Benefits Administrators is provided with a deposit slip or other bank account identification and the currency of the bank account. When the


pre-certification procedure is followed, European Benefits Administrators pays hospitals directly.


18 - MEDICAL EVACUATION AND ASSISTANCE All insured persons are covered for this benefit. The employee is automatically covered. Spouse and dependent children are covered ONLY if the employee has elected “Employee and Family” cover. The provider of the service is Inter Partner Assistance, (AXA Assistance) in France. The service is applicable to instances of medical illness, injury or accident and should be used whenever necessary. It is important to remember, however, that the program does not cover rescue expenses for certain activities during vacations: high mountain climbing, skiing emergencies, dangerous sports, as well as evacuation in the event of transport or carrier failure, or an automobile breakdown. You should take out specific local insurance to cover these risks. In general, mothers should not be allowed to fly after six months of pregnancy. Medical evacuation can be dangerous for mother and child during the last three months of pregnancy. If, in the case of an advanced pregnancy, medical evacuation should become necessary, please review the situation carefully with Inter Partner Assistance (IPA) and European Benefits Administrators before making a final decision. Most importantly, local emergencies are best handled locally. Use your local ambulance, local hospital, local fire or police department, or the local helicopter service to remove an injured person from a Schlumberger worksite. You and the local manager can handle a local emergency better and quicker than a distant medical evacuation organization. European Benefits Administrators normally will pick up the costs of the local emergency services. The Plan covers 100% of the cost of the following services which operate 24 hours a day, every day in the year, including vacations and rest periods.


18. 1. Services Which Do Not Require Prior Approval The following four services do not require a prior approval by Schlumberger. If you need to use one or more of them, contact IPA directly by telephone at one of the numbers listed in Section 18.3. • Dispatch of Essential Medicine In case of a medical emergency IPA can dispatch any essential

medicine (prescribed by a doctor) which is not available locally. • Referral to Medical Correspondents Abroad If you are in a place where you do not know whom to turn to for

medical advice or treatment, IPA can provide a referral to a medical correspondent in the region who normally will speak English and a second language, in addition to his or her mother tongue.

• Long Distance Medical Advice If you need medical advice which you can not obtain locally, IPA

physicians can advise you and provide you with the name of a physician to consult. Medical advice by telephone is not a formal diagnosis and when necessary should be followed up with a visit to a doctor.

• Travel Information Service When you need administrative or medical information prior to a

travel departure, IPA can provide you with information on passport requirements, visas, vaccinations, taxes, custom duties, currencies, and other similar matters.

Before you turn to IPA for travel information, you should first try

to contact your Travel Department, Personnel or visit the Schlumberger Websites, "HealthHub" (www.healthhub.slb.com) and "Travel". IPA can help you with questions which are not related to your work with Schlumberger.


18. 2. Services Which Require a Prior Approval By Schlumberger or European Benefits Administrators The following six services require a prior approval by a Schlumberger Manager or by European Benefits Administrators. Follow the instructions in Section 18.3. • Medical Evacuation and Repatriation If the IPA or Schlumberger physicians decide on a medical

transport, they will organize a medical evacuation by whatever means is appropriate (ambulance, helicopter, scheduled airline flight, ambulance aircraft, etc.) to a hospital capable of stabilizing the medical condition and providing adequate treatment. The Schlumberger Health Care Plan will cover the cost of international medical evacuations only in the case of life threatening situations and only when medical facilities are not capable of managing the case of western standards. When the patient's medical condition allows it, he or she can be then medically repatriated on a regular scheduled airline flight to a hospital near his or her residence.

• Dispatch of Specialized Physicians In certain cases, when the patient's condition makes a medical

evacuation impossible, IPA can dispatch a specialist physician to make an on-site evaluation of the patient's condition, collaborate with the treating physician, and arrange for an eventual medical repatriation.

• Supervision of Local Treatment When necessary, IPA physicians can coordinate and supervise a

local medical team handling the daily treatment. • Emergency Advance of Funds for Hospital Admission Normally European Benefits Administrators handles all necessary

hospitalizations on a direct-billing basis. In an emergency, however, where a hospital requires a deposit to guarantee admission, IPA can advance the necessary funds.


• Transportation Costs of Returning Minor Children Home If dependent minor children are left unattended away from home

due to an employee's accident, illness, death, or repatriation, IPA can arrange the return home of the children, if necessary with an escort.

• Repatriation of Mortal Remains In the event of a death, IPA will handle the transport of mortal

remains to a burial plot in the Country of Residence or the Country of Origin of the insured person. If local government regulations prevent the evacuation of the body, IPA will arrange a local burial. IPA will ensure that the consulate and the undertaker carry out the necessary steps. The cost of a burial plot, coffin, and funeral arrangements remain the responsibility of the employee or family.

18. 3. What To Do When You Need a Medical Evacuation or an Assistance Service? 1. In an emergency or life threatening situation, contact immediately

your local ambulance / physicians / hospital / fire department / police department / helicopter to handle the immediate emergency. On a work location contact your local manager as quickly as possible and refer to the Schlumberger Emergency Response Plan.

2. What happens next in an emergency depends whether you are in

the field or on a work location (or traveling to or from a work location) or whether you are on vacation or at home in your home country.

3. If you are in the field, on a work location, or traveling to or from

a work location, you should do your best to contact your local Schlumberger manager, supervisor, party chief, etc. He or she in turn will telephone the Duty Person on the QHSE Emergency Response Team who will assist field location staff in handling your emergency.


Your manager will find the appropriate instructions in the Area

Emergency Response Manual. Your manager and the Emergency Response Team will make the necessary arrangements with IPA who will keep European Benefits Administrators and the Schlumberger Medical Department informed at all times.

4. If you are on vacation, traveling for private reasons, or at home

in your home country, you should telephone as soon as possible to IPA as indicated below:

INTER PARTNER ASSISTANCE First choice, telephone to: France +33.1.55.92.26.39 or, to one of the following alarm centers (second choice): USA (Chicago) +1.312.935.36.80 Brazil (Sao Paulo) +55.11.4196.81.86 Singapore +65.63.22.25.31 5. IPA will ask for the following information

• Your name • Your telephone number • Your fax number (if possible) • The Schlumberger access number: 0891300*98 • The patient's name and present location • The nature of the problem and what has been done so far.


The above information is essential. Other information which might

be helpful: the age of the patient, contact telephone and name of treating physician, home address of patient, description of emergency treatment and prescribed medicine.

6. Follow the instructions of the IPA medical team who will contact

the local doctor or hospital and make all the necessary arrangements if a medical evacuation is necessary, possible, and in the best interest of the patient.

7. Contact your Supervisor or a Schlumberger manager. If you do not

manage to reach Schlumberger or European Benefits Administrators, IPA will contact Schlumberger or European Benefits Administrators to obtain the authorization.

8. Telephone or fax European Benefits Administrators in Paris as

soon as possible, because European Benefits Administrators is responsible for all the payments which go through IPA.

+33.1.42.81.97.00 or +33.1.42.81.98.62 (telephone) +33.1.42.81.99.03 or +33.1.42.81.98.58 (fax) 9. IPA or European Benefits Administrators will pay most major bills

directly to the providers. However, if you or the patient have paid any bills or expenses, make a copy for your records and send the originals with a cover note to :

European Benefits Administrators (Schlumberger International Health Care Plan)

28, rue de Mogador 75009 Paris, France

The above instructions are written for an emergency or medical urgency which involves the services which require notifying Schlumberger or European Benefits Administrators. When you need one of the services which do not require a prior approval, telephone directly to IPA at one of the numbers indicated above.


18. 4. Medical Evacuation Exclusions Medical evacuation and repatriation services are not covered, when any of the following is the cause for asking for an evacuation or repatriation :

• Transport or carrier failure, such as an automobile breakdown.

• Cases of minor illness or injury which can be adequately treated locally and which do not prevent a person from continuing his or her travel or work.

• Cases in which a person is physically able to return to his or her country of residence as a sitting passenger and without medical escort, unless IPA physicians accept them.

• Cases in which a journey is undertaken against the advice of a treating physician (sudden aggravation of risk), as well as any journey undertaken with the intention of obtaining medical treatment abroad.

• Cases of pregnancy, unless unexpected vital complications arise which cannot be treated locally, and in nearly all cases where the mother is six (6) or more months pregnant.

• In the case a person takes part voluntarily in armed conflicts, whether civil or military, strikes, riots or rebellions.

• In the case a person participates in dangerous sports or competitions, or high mountain climbing or skiing.

• In any case where Schlumberger, European Benefits

Administrators, or IPA have not given an authorization for a service which requires prior approval.

19 - FUTURE OF THE PLAN While the Company expects to maintain its health care coverage for employees, it reserves the right to amend or terminate the coverage. Changes made to the Plan will be reflected in amendments to this Guide or by other notification to eligible employees.


Documents

SLB COMMUTER ENROLLMENT FORM - GoCare€¦ · transfer or hire on that status. Coverage effectively starts the day you complete the benefits enrollment form and return it to your