available, by a fully completed Insurers’ claim
form signed by the treating Physician and original
supporting documentation, invoices and receipts
as soon as reasonably practicable and in any event
within 90 days of treatment.
Photocopies are not
acceptable. Any invoices/receipts received by the
Insurer or appointed claims administrator that
are more than 180 days old will not be paid.
If an Insured Person is able to claim the costs of
any medical treatment received from any other
provider, including National Health Schemes/
Services or Employer sponsored health insurance
schemes, such claims should be made prior
to submitting the claim under this Plan. An
authorized receipt for any costs paid by other
providers should be submitted with the written
notice of claim. Any covered medical treatment
costs paid by other providers will be deducted
from the Deductible due under this Plan.
The burden of proof is on the Insured Person.
When an Insured Person undergoes medical
treatment for illness, he/she can claim from the
start of the course of treatment until the time
when it is medically confirmed that treatment
is no longer necessary or until the expiry of the
Certificate period, or the termination of this
insurance, whichever is the earlier event. Where
compensation is claimed for medical treatment
received and the Insured Person subsequently
claims for a new course of treatment, which is not
in any way connected with the former treatment,
the subsequent Claim will be regarded as a new
Claim.
Upon receipt of proof of claim the Insurer will
pay up to the limits shown in the Certificate for
expenses necessarily incurred as a direct result
of the Insured Person suffering bodily injury,
sickness, disease during the valid Certificate
period.
Exclusions
The following treatment, conditions, activities,
items, and their related expenses are excluded
from the insurance and the Insurer shall not be
liable for:
• Any specific medical condition/treatment shown
on the Certificate
• Pre-Existing Conditions (as defined earlier)
• All costs incurred outside the Geographical Area
• All transportation costs occurring during trips
specifically made for the purpose of obtaining
medical treatment, including Local Ambulance
services
• Services or treatment in any long term care
facility, spa, hydro clinic, sanatorium, nursing
home or home for the aged that is not a Hospital
as defined in this Policy.
• All costs relating to home nursing.
• Routine medical examinations (including
annual routine diagnostic procedures), including
vaccinations, the issue of medical certificates
and attestations, and examinations as to
suitability for employment or travel.
• Routine eye and ear examinations, including the
cost of spectacles, contact lenses and hearing
aids.
• Treatment relating to birth defects and
congenital illnesses. Birth defects will include
hereditary conditions.
• All dental treatment.
• Tests and treatment relating to infertility.
• All abortions except where there is an immediate
threat to the life of the mother.
• All costs relating to pregnancy and childbirth,
other than ectopic pregnancy.
• Prostheses, corrective devices and medical
appliances, which are not required intra-
operatively.
• Treatment of any psychological or psychiatric
disorders, and treatment of anxiety, stress,
depression and phobic states, other than hospital
confinement, subject to 30 days maximum per
Certificate Period.
• Treatment, diagnostic procedures (including
sleep study) and Prescription Drugs for sleep
disorders, including but not restricted to sleep
apnoea, sleep related breathing problems,
snoring or insomnia.
• All elective cosmetic surgery and the
consequences thereof. The Insurer will pay
for reconstructive surgery which is required
to restore appearance/function following an
accident or illness which occurred after your
Certificate became effective and which is
required within twelve months of the accident/
illness occurring.
• Costs resulting from self-inflicted injury, suicide,
abuse of alcohol, drug addiction or abuse, and
treatment of sexually transmitted diseases.
• Acquired Immune Deficiency Syndrome (AIDS),
AIDS-related Complex Syndrome (ARCS) and
all diseases caused by and/or related to the virus
HIV positive.
• Costs resulting from racing of any form other
than on foot, and all professional sports.
• Treatment by a family member and any auto-
therapy including Prescription Drugs.
• Treatment that is not scientifically recognised,
or established practice, or unproven or
experimental, as considered by the relevant
professional body.
• Claims for treatment and/or disabilities, costs
and expenses resulting from participation in
war, riots, strikes, lockouts, civil commotion,
rebellion, revolution, insurrection, terrorism,
military or usurped power or any illegal act,
including resultant imprisonment.
• Claims resulting from the release of weapon(s)
of mass destruction (nuclear, chemical or
biological) whether such involve(s) an explosive
sequence(s) or not.
• Injury or illness while serving as a member of a
police or military force or unit.
All costs directly or indirectly caused by or
contributed to or arising from:
• ionising radiations or contamination by
radioactivity from any nuclear fuel or from
any nuclear waste from the combustion of
nuclear fuel.
• the radioactive, toxic, explosive or other
hazardous properties of any explosive nuclear
assembly or nuclear component thereof.
• Claims and costs for treatment in respect of
medical expenses incurred after the expiry date
of the Certificate.
• Costs for acquisition and implantation of
artificial heart and mono or bi-ventricular
devices.
• All costs relating to Organ Transplantation,
except as defined in the Plan Rules..
• All expenses of cryopreservation.
• All expenses of introduction or re-introduction
of living cells or living tissue, whether
autologous or provided by a donor. However,
the Insurer will pay 80% of all covered expenses
associated with and necessitated by both
autologous and donor provided bone marrow
transplants. Expenses relating to the acquisition
of transplant materials and donor’s expenses are
not covered.
• Costs in respect of Hormone Replacement
Therapy.
• Treatment for learning difficulties, hyperactivity,
attention deficit disorder, speech therapy and
developmental, social or behavioural problems.
• Contraception, sterilisation or any treatment of
sexual problems (including impotence, whatever
the cause)
All expenses relating to vitamins, minerals and
other supplements, including homeopathic
remedies, irrespective of whether these have been
prescribed or not.
APRIL 2012
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