Page 1 - Lysis Plan- Plan Rules

LYSIS HEALTH PLAN, Plan Rules
APRIL 2012
Introduction
The cover provided shall be determined by
reading the Rules defined herein together with the
Certificate of Insurance (the Certificate) issued to
each Insured Person. Any benefit not shown in
the Certificate is not provided. Premiums will be
paid in Euros.
The Insurance is effective only after the applicant
has been accepted by the Insurer and becomes
and remains insured in accordance with the
terms, provisions and conditions set out in the
Certificate and Rules.
The legal representative of the Insured Person
shall have the right to act for an Insured Person
who is incapacitated or deceased. Benefits are
payable to the Insured Person or to the licensed
providers of medical care who provide the
medically necessary insured treatments and
services to the Insured Person.
Benefits are limited to the usual Customary and
Reasonable charges in the area where treatment
is provided.
Benefit payments are processed by claims
administrators, appointed by the Insurer, who
specialise in medical claims administration.
Definitions
The following definitions apply to the Plan:
Accident is any sudden and unforeseen event
occurring during the policy period, resulting in
bodily injury, the cause or one of the causes of
which is external to the victim’s own body and
occurs beyond the victim’s control.
Accident and Emergency Room Services are
services performed in a Hospital casualty ward
or emergency room immediately following an
Accident.
Chronic Condition Treatment means the
treatment of a chronic condition/illness which
is a disease or illness which has no known cure
and/or which is likely to continue or to keep
recurring and which needs prolonged supervision,
monitoring or treatment. Costs are only eligible
under the benefits shown on the Certificate.
Claim is defined as a course of treatment to treat a
diagnosed medical condition.
Complementary Therapies are treatments
provided by registered and properly qualified
Osteopaths, Chiropractors, Homeopaths and
Acupuncturists and must be recommended and
ordered by a Physician.
Cooling off period If cover is not required within
30 days from commencement then a full refund of
premium paid will be made, provided that notice
is given in writing and that no claim has been
filed under the policy.
Country of Residence is the country declared on
the Application Form/Certificate of Insurance as
the Country of Residence.
Customary and Reasonable Charges means the
charges that would typically be made for the
treatment provided for the location in which
the treatment is received. The Insurer will
only pay up to the charges typically made for
that treatment in that location. In the event of
a dispute, the Insurer will identify the amount
typically charged by obtaining three quotations
for the disputed treatment and will settle costs
based on an average of the three quotations.
Daycare Surgery is any surgical procedure
performed on an outpatient basis but where a
period of recovery in a Hospital is required.
Dependant is the spouse or partner of the Insured
Person, and/or unmarried children, step-children,
foster children and legally adopted children, who
are dependent on the Insured Person for support,
provided always that such children are not more
than 18 years old at the date of enrolment or
renewal of the Plan (or 24 if proof is provided that
the child is continuing in full-time education).
Deductible shall mean the portion of costs
for which the Insured Person is liable. The
Deductible will be applied as specified on
the Certificate. The Deductible shown on the
Certificate shall be reduced by 50% for covered
benefits where treatment is received in Greece,
except for treatment received in Athens and
Thessaloniki. The Deductible shown on the
Certificate may also be reduced where medical
costs can be claimed from any other provider,
including National Health Schemes/Services or
Employer sponsored health insurance schemes,
subject to authorised proof being provided of any
payments received.
Geographical Area shall mean Europe which
includes the following countries: Albania,
Andorra, Armenia, Austria, Azerbaijan, Belgium,
Bosnia and Herzegovina, Bulgaria, Croatia,
Cyprus, Czech Republic, Denmark, Estonia,
Finland, France, Georgia, Germany, Gibraltar,
Greece, Hungary, Iceland, Ireland, Italy, Latvia,
Liechtenstein, Lithuania, Luxembourg, Malta,
Monaco, Norway, Poland, Portugal, Republic of
Macedonia, Republic of Serbia and Montenegro,
Romania, San Marino, Slovak Republic, Slovenia,
Spain (including the Balaerics and Canary
Islands), Sweden, Switzerland, The Netherlands,
Turkey, Ukraine, United Kingdom and Vatican
City.
Home Country is the country of which the
Insured Person holds a passport. Where the
Insured Person holds more than one passport
the Home Country will be taken to mean the
nationality which the Insured Person has declared
on the Application Form. Dependants will be
deemed to have the same Home Country as
the Applicant.
Hospital is any institution which is legally
licensed as a medical or surgical hospital in the
country in which it is located and whose main
activities are not those of a spa, hydro clinic,
sanatorium, nursing home, or home for the aged.
It must be under the constant supervision of a
resident Physician.
Hospital Cash Benefit is an alternative cash
benefit which may be paid where treatment is
provided in a government Hospital where no
charge is made. The maximum payable is 30 days
in any one Certificate period.
Hospital Services include all medical treatment
provided to the Insured Person only when
appropriate diagnostic procedures and/or
treatments are not available on an Outpatient
basis and when admitted as a registered inpatient
to a Hospital for a period of not less than 24
hours. Pre-authorisation (as defined) is required
for all Hospital Services claims. Hospital Services
include reasonable and customary charges, in the
area where treatment is provided, for Hospital
accommodation up to the cost of a two-bedded
room, intensive care unit charges, meal charges,
all Hospital medical facilities, and all medical
treatment and medical services ordered by a
Physician. Hospital Services excludes any costs
relating to pregnancy (except ectopic pregnancy).
Insured Person is an individual who has currently
completed or whose name is included on an
Application Form for the Plan and for whom
commencement of cover has been confirmed, or
who has been issued with a Certificate.
Insurer The Insurer of the Plan is Catlin
Underwriting Agencies Limited.
Newborn Care is treatment received by a
newborn child from the date of birth until 30 days
following discharge from Hospital, provided that
an Application form has been completed for the
child within 14 days of birth and a Certificate of
Insurance has been issued for the newborn. No
other benefits are available to newborns until 30
days following discharge from Hospital when the
selected Plan benefits and Rules will apply.
LYSIS HEALTH PLAN