Table of benefits	Access Health
Annual maximum plan benefit	AED 5,500,000 | $1,500,000

Table of benefits	Access Health
Accommodation	Private room
Semi-private room hospital cash benefit	AED 200 | $55 per day cash benefit
Inpatient treatment, daypatient, operating theatre and recovery room, prescribed medicines, drugs and dressing for inpatient or daypatient treatment	100% | 90% US
Intensive care unit	100% | 90% US
Inpatient ancillary services including physical and occupational therapy as daypatient or inpatient	100% | 90% US
Surgeons’ and anaesthetists’ fees	100% | 90% US
Inpatient consultation by specialist	100% | 90% US
Emergency room	100% | 90% US
Pathology, radiology, and diagnostic tests	100% | 90% US
MRI, CT and PET scans	100% | 90% US
Private duty nursing (Policy year maximum)	AED 27,500 | $7,500
Skilled nursing (Policy year maximum)	AED 27,500 | $7,500
Home health care Maximum of 4 hours per visit by a registered home health agency at your home (Policy year maximum)	AED 27,500 | $7,500
Hospice care (Policy year maximum)	AED 36,500 | $10,000
Emergency dental treatment (as a result of accident)	100% | 90% US
Cancer treatment	100% | 90% US
Child and companion accompaniment Companion accommodation in same room due to inpatient medical necessity. Pre-approval is necessary.	100%
Prescribed hearing aids in the event of medical emergency	100%
Laser eye surgery and optical aids in the event of medical emergency	100%
MANAGED TRANSPLANT PROGRAMME
Organ transplants maximum lifetime	AED 1,800,000 | $500,000
Tissue transplants (as part of the overall organ max.)	AED 900,000 | $250,000

Transplant must be pre-certified and approved by us. Failure to comply will result in treatment not being covered by your policy.

Table of benefits	Access Health
Outpatient and ante-natal services	100% 8 visits to PHC, 3 ultra scans
Pregnancy normal delivery	90% AED 7,000 | $2,000
Complicated pregnancy	90% AED 10,000 | $3,000
Routine nursery, included under Maternity Benefits as any other treatment including room and board, physician charges.
New born cover Included in New Born Cover are premature births, congenital conditions and birth anomalies. New Born Cover is only available for a covered pregnancy.	30 days; neo-natal, screening test AED 150,000 | $40,000
Essential vaccinations and inoculations as stipulated in DHA's policies for children	100%

Table of benefits	Access Health
Overall Benefit	AED 150,000 | $40,000
Outpatient Co-pay Option	OP90 | OP80
Surgery as outpatient	OP90 90% | OP80 80%
Physican office visits and specialist fees	OP90 90% | OP80 80%
Diagnostic Services (as outpatient)	OP90 90% | OP80 80%
Physical therapy	OP90 80% | OP80 80%
Prescription medicine programme	OP90 90% | OP80 80%

Table of benefits	Access Health
Supplemental 10% co-pay on OP90 will apply	OP90 80% | OP80 70%
Occupational therapy(as outpatient)	YES - max 10 visits. Pre-authorisation required
Chiropractic services- Policy year maximum for chiropractic services Referral letter required from medical physician	YES AED 2,750 | $750
Alternative medicine including TCM, bonesetting, accupuncture, herbal medicine, homeopathy and osteopathy	YES AED 1,800 | $500

Table of benefits	Access Health
Routine Dental Maximum of 2 oral exams in one period of insurance.	80%
Diagnostic and preventive dental One full mouth X-ray every 5 years 1 Bite X-ray ever period of insurance Maximum 2 cleanings and scalings every period of insurance 1 Topical fluoride treatment (children under 19 only) Space maintenance (children under 19 only)	80%

Table of benefits	Access Health
ADULTS Per policy year	AED 1,800 | $500
Routine physical exams in connection with overall health and wellbeing	90%
Mammograms: ages 35-39 one baseline exam; ages 40-49 one exam every one or two years for asymptomatic women, but no sooner than two years after baseline; age 50 and over one exam annually; any age whenever prescribed by a physician	90%
Prostate cancer screening: one test per policy year for males age 50 or over	90%
Immunisations and vaccinations	90%
CHILD(REN)
Maximum per policy year: birth to age 12 months (up to 6 exams)	AED 1,100 | $300
Maximum per policy year: 13 months and over (1 exam per period of insurance)	AED 735 | $200
Routine medical exams	100%
Child preventive care services	100%
Hearing tests	100%

Overall policy year Wellness Benefit maximums apply to all routine and wellness benefits for adults and children

Table of benefits	Access Health
Diabetes tests Aged 30and onwards every 3 years, high risk individuals over 18 annually	100%
Annual pap smear	100%

Table of benefits	Access Health
Vision care cover	80%
Maximum per 24-month period Eye examinations including eyeglasses and contract lenses prescribed from such eye test.	AED 1,100 | $300

Table of benefits	Access Health
Operated by Assist America
Medical evacuation and assistance	100%
24/7 Emergency medical assistance hotline	Yes
Repatriation of mortal remains to home country	100%
Repatriation accompaniment	100% AED 9,200 | $2,500

Table of benefits	Access Health
All services below provided through Assist America
Compassionate visit Arrangement and payment of roundtrip transportation for family member or a friend to join a member who is traveling alone and expected to be hospitalised for more than 5 days.	Yes
Care of minor children If an injured member has minor children left unattended, we will pay for them to return home to a family member, or will arrange childcare locally or at home.	Yes
Lost luggage or document assistance We will help members locate lost luggage, documents, or personal belongings.	Yes
Interpreter and legal referrals We will refer members to interpreters and/or legal personnel, as necessary.	Yes
Emergency message transmission We will receive and transmit authorised emergency messages for members.	Yes

Table of benefits	Access Health
YourHealth App	YES
eHealth records account	YES
Telehealth from Health at Hand	YES
Life Aware services operated by Morneau Shepell	YES
Second medical opinion Offered through Assist America the Second Medical Option programme allows you to receive a documented second medical opinion on a complex, grave, or critical illness diagnosis, directly from a specialist working in a world-class medical instituion. Includes: Confirmation of diagnosis, evaluation of case where a diagnosis is not yet possible, advice on the best course of treatment, follow up on a case reported previously.	YES

Elected co-pay applies for all outpatient benefits in this section.

Table of benefits	Access Health
Mental Health Benefits
Policy year maximum for mental health benefits (inpatient and outpatient)	AED 92,000 | $25,000
Policy year mental illness, maximum 6 visits (outpatient treatment)	AED 9,200 | $2,500 per policy year

Table of benefits	Access Health
Life Aware Programme	YES

Operated by Morneau Shepell, provides assistance with the challenges faced in working and living far from your home country. Issues such as isolation and loneliness. Adaptation across culstures, coping with culture shock and addressing the personal impact of relocation. The programme also provides assistance with dealing with challenges in your professional life such as strengthening relationships, improving with communication, dealing with a difficult boss or co-worker. And many other areas where coaching and support can be of tremendous help. All sessions are naturally completely confidential.

Table of benefits	Access Health
Medical Emergency	YES

In Emergency cases as defined by PD 02-2017, when a situation in the UAE calls for immediate medical intervention by a health services provider for the resecuing of a person's life or the elimination of the danger threatening that person's life, healthcare services outside the scope of health insurance must be covered until stabilisation as a minimum.

Table of benefits	Access Health
Durable medical equipment	YES
Policy year maximum	AED 55,000 | $15,000

Table of benefits	Access Health
Chronic conditions	YES

Chronic conditions are treated like any other condition under the policy. Elected co-pay option applies for all outpatient benefits in this section.

Table of benefits	Access Health
Policy year maximum plan benefit	AED 150,000 | $40,000

A one year Waiting period is applicable for any Outpatient treatment outside UAE for a Pre-Existing Condition. If a Pre-Existing Condition is not disclosed, which is later discovered, then the insurer can take action on the policy, including termination of the policy, under non-disclosure rules.

Table of benefits	Access Health
Lump sum in case of death All causes	$5,000 | €5,000 | £5,000

Table of benefits	Access Health
MedNet Network	Gold | Silver Premium | Silver Classic

Each network is extensive with over 1,000 medical providers in the UAE and GCC. Access to other MedNet networks within the Gulf region is included. Please note that claims will not be accepted or reimbursed from providers outside of the designated network.

Cover Region 1 – Worldwide including US and and its territories.

For Cover Region 1 – Members have access to the MedNet International Network of partners in the USA. Please refer to your Policy Pack under MedNet User Guide for instructions.

Please note that Cover Region 1 is limited to 180 days in the US in any 12-month period.

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Cover Region 2 – Worldwide but excluding US and its territories.

If you are temporarily travelling outside your area of cover, for a period not exceeding 45 days in any period of cover, we will also reimburse covered treatment for inpatient emergency treatment outside your area of cover as long as you advise us of the medical emergency immediately. Reimbursement will be up to the maximum cost of the MedNet UAE network.

Increase accidental death and dismemberment (AD&D) cover

Optional benefits plan	InCare Life	InCare Premier
Option to increase cover from standard amounts to:	$100,000 | €90,000 $150,000 | €135,000 $250,000 | €225,000	$150,000 | €135,000 $250,000 | €225,000

In the event of an accidental death or dismemberment of the primary insured the insurer pays a lump sum benefit equal to the principal sum subject to a maximum benefit multiplied by a percentage as shown below.

N.B. Benefits cannot exceed two times annual salary. See rate sheet for benefit sums available.

Policy introduction

This plan is designed by Integra Global, and issued and insured by Dubai Insurance Company psc., which is licensed by the UAE Insurance Authority, registration number 4. Registered office at Dubai Insurance Company, PO Box 3027, Dubai, UAE.

YOUR cover is governed by the following documents all of which must be read together.

• The APPLICATION FORM and any associated declarations.

• The POLICY Conditions.

• The Table of Benefits.

• The Endorsements.

• The CERTIFICATE OF INSURANCE.

The purpose of this Insurance POLICY is to provide cover to Individuals and GROUPS of INSURED PERSONS who are introduced through Dubai Insurance Company to Integra Global.

This document explains the terms and conditions of YOUR POLICY including:

• the cover provided including any limitations

• how YOUR POLICY is administered

• how to make a claim

• what is not covered by YOUR POLICY

Any word explained in the Definitions section will have the same meaning throughout. Such words are shown in capital letters for ease of recognition.

A CERTIFICATE OF INSURANCE will be issued only when YOU have completed an APPLICATION FORM, this has been accepted by US and the PREMIUM has been paid. Any CERTIFICATE OF INSURANCE replaces any other Certificate previously issued to cover the same Insurance.

Any Cover not shown on YOUR selected Plan on the Table of Benefits is not provided.

Acceptance and use of the Membership Card(s) automatically implies acceptance of all the terms, conditions, limitations and EXCLUSIONS of this POLICY.

Definitions

Accident

Any sudden and unforeseen event occurring during the PERIOD OF INSRANCE, resulting in bodily injury, the cause or one of the causes of which is external to YOUR own body and occurs beyond YOUR control.

Advanced diagnostics

Magnetic Resonance Imaging (MRI), Computerised Tomography (CT) and Positron Emission Tomography (PET) scans and any similar diagnostic tests

Application form

The form and any other declarations made by YOU in respect of the status of YOUR health provided to US when applying for this POLICY.

Alternative Medicines

1. Specialist Herbal Treatment

Internal and/or external application of herbs provided or ordered by a specialist.

2. Acupuncture

Therapy of a MEDICAL CONDITION by needles or laser provided by or ordered by a licensed PHYSICIAN.

3. Chiropractic

Treatment conducted by licensed chiropractic PHYSICIAN

Active at Work

An EMPLOYEE will be considered in Active Service on any day if they are performing in the customary manner all the regular duties of their employment as performed, or where capable of being performed, on the last regularly scheduled workday.

Benefits

A BENEFIT that WE will pay under this POLICY for MEDICAL TREATMENT CHARGES incurred during the PERIOD OF INSURANCE. Only those BENEFITS stated on the Table of Benefits are covered.

Cancer

Any malignant tumour positively diagnosed with histological confirmation and characterised by the uncontrolled growth of malignant cells and invasion of tissue. The term malignant tumor includes leukemia, sarcoma and lymphoma.

Certificate of Insurance

The certificate that WE provide to YOU that shows the details of all the people covered under YOUR POLICY and details their level of cover and lists any SPECIAL TERMS and conditions.

Chemotherapy

The use of drugs, including chemotherapy drugs, hormone therapies, biological therapies, immunotherapy therapy and target therapy in the Active Treatment of Cancer carried out under the direction and control of YOUR Cancer Specialist.

Claim

Any request made by YOU for the payment of BENEFIT in respect of a course of treatment for a specific condition.

Complicated pregnancy

a. when pregnancy is not terminated conditions that require HOSPITAL CONFINEMENT, whose diagnoses are distinct from pregnancy but are adversely affected by or are caused by pregnancy, such as:

– Acute nephritis;

– nephrosis;

– Cardiac decompensation;

– missed abortion; and

b. when pregnancy is terminated by:

– Non-elective Cesarean section;

– Ectopic pregnancy that is terminated; or

– Spontaneous termination of pregnancy that occurs

– During a period of gestation in which a viable birth is not possible.

Complications of pregnancy will not include false labour; occasional spotting; PHYSICIAN prescribed rest during the period of pregnancy; morning sickness; hyperemesis gravidarum; and similar conditions associated with the management of a difficult pregnancy that do not constitute a nosologically distinct complication of pregnancy.

Congenital conditions

Any abnormality, deformity, ILLNESS or DISEASE that was present at birth, whether it was diagnosed or not and any deformity arising during the antenatal stages of pregnancy

Country of residence

The country of which YOU are a permanent resident and have spent more than 183 days in the 12 months prior to the application

Currency

The currency of this POLICY shall be the United Arab Emirates Dirham (AED)

Co-Payment

The amount YOU must pay towards Eligible Expenses covered under this Insurance POLICY. WE shall be liable for the balance of the Eligible Expenses.

Chronic Disorder

An incurable DISEASE requiring a regular, lifetime Treatment.

Day Patient

A patient who occupies a HOSPITAL bed or is charged for HOSPITAL accommodation in the course of MEDICAL TREATMENT but does not remain overnight.

Declared Condition

Any pre-existing Condition that was declared by the POLICYHOLDER in an APPLICATION FORM.

Dependent

YOUR spouse (but excluding those legally separated), and/or unmarried children, step-children, foster children and legally adopted children, who are dependent on YOU for support. Provided that such children are not less than 15 days and not more than 18 years old at the date of enrolment in the Plan, (or 24 years old provided it can be proved that the child is dependent upon the parents for financial support, and in full time education within the United Arab Emirates).

For GROUP Policies YOUR DEPENDANTS must be in the records of the EMPLOYER.

Disease

MEDICAL CONDITION/sickness/ILLNESS involving fever, pain, and/or malfunction of a bodily organ or function.

Doctor

A person who has attained a full degree(s) in the practice of medicine having attended a recognised medical school and who is licensed to practice medicine by the relevant licensing authority where the treatment is given.

Deletion Date

The day (at 12:00 noon local time), month and year on which the YOUR coverage is terminated as the result of his/her deletion at the request of the POLICYHOLDER, and/or in case his/her status as Employee or DEPENDENT no longer holds, or upon the cancellation of this Insurance POLICY.

Due Date

The date of commencement or renewal of cover as shown on the CERTIFICATE OF INSURANCE, or the date on which any subsequent installment of PREMIUM falls due.

Durable medical equipment:

equipment that is:

a) MEDICALLY NECESSARY;

b) made for and mainly used in the treatment of an injury or an ILLNESS;

c) not useful in the absence of an ILLNESS or injury;

d) made to withstand repeated use over an extended period of time;

e) suited for use in the home; and

f) used to improve a permanent MEDICAL CONDITION.

Durable medical equipment does not include: insulin pumps; glucometers; motor driven wheelchairs or beds; comfort items such as telephone arms and over-bed tables; items used to alter air quality or temperature such as air conditioners, humidifiers, dehumidifiers, and purifiers (air cleaners); disposable supplies such as exercycles, more wheels, sun or heat lamps, heating pads, bidets, toilet seats, bathtub seats, sauna baths, elevators, whirlpool baths, exercise equipment; and similar items.

Emergency Dental Treatment

Emergency MEDICAL TREATMENT necessary to restore or replace sound natural teeth lost or damaged in an ACCIDENT and for which MEDICAL TREATMENT is provided within 48 hours following the ACCIDENT.

Emergency Ward Services following Accident

Services performed in a HOSPITAL casualty ward or emergency room immediately following an ACCIDENT.

Employee

An INSURED PERSON who is ACTIVE AT WORK on a full-time basis with the EMPLOYER within UAE under a written contract of employment. Persons in casual employment with the EMPLOYER are not included. Sole Proprietors, Partners or Directors of the EMPLOYER can be included.

Employer

YOUR EMPLOYER or, in the case of non-employee GROUPS accepted by US, the Sponsoring organisation through which the plan is offered effected or administered and to whom the MASTER POLICY is issued.

Endorsement

Contractual document issued by US subsequent to this Insurance POLICY, introducing alterations to this Insurance POLICY in full conformity with its provisions.

Enrolment Date

The day (at 12:00-noon local time) month and year, from when the first Insurance POLICY became effective for a particular INSURED PERSON.

Exclusions

See Basic Exclusions

.

Full refund

The reasonable and customary cost of MEDICAL TREATMENT up to any annual or lifetime limits

.

General Outpatient Services

OUTPATIENT SERVICES provided by or ordered by a PHYSICIAN who is licensed as a General Practitioner.

Geographical Area

The Geographical Area stated in the POLICY for which the appropriate PREMIUM has been paid. MEDICAL TREATMENT for a MEDICAL CONDITION will only be reimbursed under this POLICY if the MEDICAL TREATMENT was performed in a country specified under the Geographical Area in the POLICY.

Group

Membership of a Group Plan accepted by US. It comprises a group of EMPLOYEES employed by an EMPLOYER or Members of a Trade Union or Members of any Association and their DEPENDANTS or Members of any other Institution accepted by US and considered to be a group for the purposes of this contract.

.

Hospital

Any medical institution, public or private, 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 rehabilitation centre, spa, hydro clinic, sanatorium, nursing home, or home for the aged. It must be under the constant supervision of a resident PHYSICIAN.

Hospital Services

Accommodation, nursing, operating theatres, drugs, dressings, diagnostic procedures and any other necessary services rendered by the HOSPITAL for MEDICAL TREATMENT as an IN-PATIENT.

Hospital Confinement

An uninterrupted stay for a defined period of time in a HOSPITAL at least overnight.

Hormone Therapy

Or endocrine therapy treatment, including surgery or use of drugs to slow or stop the growth of hormone-sensitive tumors by reducing or blocking the body’s ability to manufacture hormones or interfering with hormone action.

Home health care facility:

a program

a) for the care and treatment of the insured person in his home;

b) established and approved in writing by his attending PHYSICIAN; and

c) certified, by the attending PHYSICIAN, as required for the proper treatment of the injury or ILLNESS, in place of inpatient treatment in a HOSPITAL or in an extended care facility.

Hospice care services:

An agency which provides a coordinated plan of home and inpatient care to a terminally ill person and which meets all of the following tests:

a) has obtained any required state or governmental license or certificate of need;

b) provides service 24-hours-a-day, 7-days-a-week;

c) is under the direct supervision of a PHYSICIAN;

d) has a nurse coordinator who is a registered nurse (R.N.);

e) has a duly licensed social service coordinator;

f) has as its primary purpose the provision of hospice services;

g) has a full-time administrator; and

h) maintains written records of services provided to the patient.

WE must approve the hospice care program to provide a centrally administered program of palliative and support services to terminally ill persons and their families.

Terminally ill means the patient has a prognosis of two hundred and forty (240) days or less.

Illness

See DISEASE

In-Patient

A patient who occupies a HOSPITAL bed for a minimum of one night for MEDICAL TREATMENT, and which cannot be performed on an Out – of – Hospital basis.

Insured Person

(You/Your)

Any person listed as an insured person on any CERTIFICATE OF INSURANCE.

Insurer

Dubai Insurance Co. PSC – United Arab Emirates

Laboratory and X-ray Services

Laboratory testing, radiographic and nuclear medicine procedures used to diagnose and treat MEDICAL CONDITIONS. Laboratory and X-ray Services must be provided by or ordered by a PHYSICIAN.

Local Ambulance Services

The necessary medical transportation by road ambulance to a local HOSPITAL.

Master Policy

The Contract of Insurance which is issued to the EMPLOYER or POLICYHOLDER as defined.

Maternity Care

Maternity Care, where included, shall mean pre-natal, childbirth, MEDICALLY NECESSARY abortion or miscarriage, and post-natal treatment for YOU up to the limit specified and subject to any co-insurance per pregnancy.

Medical Condition

Any ILLNESS, DISEASE or injury not excluded under this POLICY.

Medical Emergency

Any MEDICAL CONDITION or serious ACCIDENT which require urgent and immediate MEDICAL TREATMENT and which are of such severity that the absence of immediate treatment at a HOSPITAL Emergency facility is medically expected to constitute a serious threat to the life, health, bodily function and/or organ of the patient.

Medical Treatment

Medical or Surgical procedures performed with the sole purpose to cure or relieve a MEDICAL CONDITION.

Medically Necessary

A service or Treatment, which, in the medical opinion of OUR appointed PHYSICIAN, is appropriate and consistent diagnosis, and which, in accordance with generally accepted medical standards could not have been omitted without adversely affecting YOUR condition or the quality of medical care rendered.

.

Medical Treatment Charges

Reasonable, customary and necessary charges for:

1. HOSPITAL SERVICES

2. OUTPATIENT SERVICES

3. POST HOSPITALISATION TREATMENT

4. EMERGENCY WARD SERVICES

5. NURSING AT HOME

6. MATERNITY CARE

7. GENERAL OUTPATIENT SERVICES

8. SPECIALIST OUTPATIENT SERVICES

Mental Health Benefits:

Psychotherapeutic treatment and psychiatric counselling and treatment for approved psychiatric diagnosis.

A PHYSICIAN, psychiatrist or a licensed clinical psychologist must provide all mental health care services. Services of a clinical psychologist must be rendered in the PROVIDER NETWORK’S office or in the outpatient department of a HOSPITAL.

Mental Health Benefits does not include:

¥ aptitude testing, educational testing and services

¥ services for conditions WE classify as emotional or personality ILLNESSES

¥ psychiatric services extending beyond the period necessary for evaluation and diagnosis of mental deficiency or retardation

¥ services for mental disorders or ILLNESSES which are not amenable to favourable modification

¥ services related to drug and alcohol abuse.

Nursing at Home

Medical services of a government licensed nurse in YOUR home when prescribed by a PHYSICIAN and related directly to a MEDICAL CONDITION for which YOU have received or are receiving treatment covered under the terms and conditions of this Insurance POLICY.

Organ Transplantation

MEDICAL TREATMENT costs incurred in respect of kidney, heart and liver transplants. This BENEFIT does not cover the cost of acquiring the organ or any expenses whatsoever incurred by the donor.

Overall Limits

Are the total aggregate BENEFITS that may be claimed in any one PERIOD OF INSURANCE by an INSURED PERSON. Such limits will be shown in the Table of Benefits in this POLICY.

Patient Services

MEDICAL TREATMENT provided to an INSURED PERSON when not a DAY PATIENT or IN PATIENT. These may include:

• GENERAL OUTPATIENT SERVICES

• SPECIALIST OUTPATIENT SERVICES

• LABORATORY AND X-RAY SERVICES

• PRESCRIBED DRUGS

Parent Accompanying Child

Charges made by a HOSPITAL for one parent to accompany a child aged 18 years or under when treated as an IN-PATIENT

Physician

Is a legally licensed medical practitioner by the law of the country where treatment is provided and who, in rendering such treatment, is practicing within the scope of his licensing and training.

Physiotherapy

Consultation and procedures conduct by physiotherapist subject to prior referral of specialist orthopedician or other Specialists.

Insurance Policy

YOUR APPLICATION FORMS, declaration, definitions, conditions, EXCLUSIONS, including the Table of Benefits, CERTIFICATE OF INSURANCE and any endorsements and the PREMIUM table.

.

Period of Insurance

The annual period of insurance from one DUE DATE to the next anniversary of the DUE DATE as specified in the CERTIFICATE OF INSURANCE.

Policy

YOUR APPLICATION FORMS, declaration, definitions, conditions, EXCLUSIONS, including the Table of Benefits, CERTIFICATE OF INSURANCE and any endorsements and the PREMIUM table.

Policyholder

This is the person or entity who owns the Insurance POLICY. If this is a GROUP POLICY the POLICYHOLDER is the EMPLOYER and if an Individual POLICY the POLICYHOLDER is the lead INSURED PERSON.

Post Hospitalisation Treatment

Is all MEDICAL TREATMENT provided within three months immediately following discharge from HOSPITAL provided by or ordered by a PHYSICIAN which directly results from a MEDICAL CONDITION for which the INSURED PERSON has been treated as an INPATIENT. Such treatment may include:

• GENERAL OUTPATIENT SERVICES

• SPECIALIST OUTPATIENT SERVICES

• LABORATORY AND X-RAY SERVICES

• PRESCRIBED DRUGS

Pre-Authorised

Planned IN-PATIENT or DAY PATIENT treatment or SPECIALIST OUTPATIENT Procedures that YOU have informed US about prior to admission or treatment that WE have checked against YOUR POLICY cover and agreed.

Prescribed Drugs

Medications whose sale and use are legally restricted to the order of a PHYSICIAN and do not include items that may be purchased without a PHYSICIAN’S prescription.

Providers

A generic term for PHYSICIANS, HOSPITALS, Clinics, Medical Centers, Pharmacies, Laboratories, PHYSIOTHERAPY Centers, and other Paramedical Institutions or Persons who are licensed to offer healthcare services.

Provider Network

Is the group of Medical Service PROVIDERS including HOSPITALS which have contracted with US to provide MEDICAL TREATMENT to YOU.

Premium

The payment required for providing coverage and to keep the Insurance POLICY in force.

Reasonable and customary charges

The average amount charged in respect of a valid services or Treatment costs, as determined by OUR experience in any particular country, area or region and substantiated by an independent third party, being a practicing Surgeon/Specialist or Government Health Department.

Reconstructive treatment

Including surgery the purpose of which in whole or in part is to restore aesthetic appearance that has become necessary as a result of the active treatment of Cancer otherwise covered under this POLICY and planned at the time of the original treatment.

Renewal date

The date shown on YOUR CERTIFICATE OF INSURANCE when YOUR POLICY will be due for renewal.

Specialist Outpatient Services

Outpatient Services provided by or ordered by a specialist or consultant to whom YOU have been referred by another PHYSICIAN.

Special terms

Any terms, conditions or EXCLUSIONS that apply to YOU and YOUR POLICY which will be shown on YOUR CERTIFICATE OF INSURANCE.

Second Opinion

Second opinion is an opinion obtained from an additional health care professional of to the same clinical standing and specialty. This opinion maybe either prior to or after the performance of a medical treatment or surgical procedure, whereby it will then confirm the diagnosis, medical necessity and/or appropriateness of the Treatment given.

Utilisation Review

OUR right, in consultation with YOUR treating PHYSICIAN, to review any course of MEDICAL TREATMENT and to recommend alternatives.

WE/US/OUR

DUBAI INSURANCE, DUBAI United Arab Emirates

Work Related Accident/Illness

Any ACCIDENT or MEDICAL CONDITION incurred as a result of an EMPLOYEES occupation.

YOU/YOUR/INSURED PERSONS/

Any person listed as an INSURED PERSON on any CERTIFICATE OF INSURANCE or listed in Staff census which YOU have given to US and which has been accepted by US.

Waiting Period

The period of time starting from YOUR first Enrolment Date during which an Exclusion is in force under a specific BENEFIT covered under this Insurance POLICY.

Waiver Date

The date of termination of the WAITING PERIOD after which an Exclusion is deleted.

Administration

Insurance Policy

The APPLICATION FORM(s) duly completed by the EMPLOYER/POLICYHOLDER, acting on behalf of himself and/or other INSURED PERSON(s) the Preamble, the Definitions, the General Terms and Conditions, the Basic Exclusions, the different options as well as any attachment (not the list of Network PROVIDERS) and endorsement to any of the aforementioned shall constitute the entire contract between US and the POLICYHOLDER. Any amendment or addition to this POLICY shall be void, unless it has been made in writing and is signed and sealed by US. No insurance intermediary has the authority to amend this POLICY or to waive any of its provisions

Insurance Policy Validity

The validity of this POLICY (in regard to each Plan selected) begins from the Effective Date and terminates on the Expiry Date as specified in the CERTIFICATE OF INSURANCE. However, each INSURED PERSON is covered under this POLICY as from his/her Enrolment date as specified in the CERTIFICATE OF INSURANCE and/or any related ENDORSEMENT up to the Expiry Date of this POLICY, or to the DELETION DATE of the INSURED PERSON, whichever is earlier.

Application

All policies are subject to the completion of the appropriate APPLICATION FORM and medical underwriting. WE retain the right to decline any application.

WE also reserve the right to withhold CLAIMS payments and/or terminate the POLICY should any details of the APPLICATION FORM be inaccurate or missing.

Applicable Scope of Coverage

a. In return for the PREMIUM due by the POLICYHOLDER to US WE undertake to cover each INSURED PERSON under a specific Plan/Program as selected by the POLICYHOLDER on the APPLICATION FORM and approved by US.

b. The applicable Scope of Coverage of a given BENEFIT included in a selected Plan/Program related to an INSURED PERSON, details OUR liability in accordance with:

1) Any specific exclusion in addition to the Basic Exclusions

2) Any SPECIAL TERMS (Substandard terms)

3) The services covered

4) The INSURED PERSON COPAYMENT when applicable

5) The limits when applicable

6) The Territory of Occurrence

7) The PROVIDER(s) used

8) The nature of care

c. OUR liability under this POLICY towards YOU relates to each BENEFIT within the Plan detailed in the CERTIFICATE OF INSURANCE. Any expenditure relating to YOUR Treatment shall be subject to assessment of the CLAIM by US.

Premiums

The PREMIUM is the gross PREMIUM. The PREMIUM due by the POLICYHOLDER to US as defined in the CERTIFICATE OF INSURANCE are payable in advance by the POLICYHOLDER according to the frequency of payment agreed upon between the POLICYHOLDER and US and as specified in the CERTIFICATE OF INSURANCE.

If no payment is made at the expiry of this grace period of 30 days this Insurance POLICY will be automatically terminated and the POLICYHOLDER will be liable for the amount due until the date of cancellation.

The coverage provided by US under this POLICY shall not commence until the first installment is fully paid. In the event the insurance PREMIUM is not paid on the DUE DATE; WE will notify the POLICYHOLDER of the amount payable within 30 days and inform the POLICTHOLDER that otherwise this POLICY will be cancelled.

During these 30 days grace period, Free access to the Network on direct billing basis shall be suspended. In the event the PREMIUM payment is paid by the POLICYHOLDER within the grace period of 30 days, Free access to the Network on direct billing basis shall be reinstated and all eligible healthcare expenses incurred during the suspended period shall be processed and reimbursed on the basis of the Mednet Network tariff and the Insurance POLICY

Group Enrolment

The POLICYHOLDER has declared in writing at the date of the initial Application that all EMPLOYEES are enrolled on a compulsory basis. In virtue of the POLICYHOLDER declaration, this Insurance Policy was underwritten and issued by US. Similarly, the POLICYHOLDER should have declared if the DEPENDENTS per Category are to be enrolled on a compulsory basis or not.

In accordance with the POLICYHOLDER declaration on the initial APPLICATION FORM, it is agreed and understood that all EMPLOYEES, without exception, are to be included under this POLICY. However, the cover becomes effective for those EMPLOYEES only who are ACTIVE AT WORK on the effective date or any other later date.

Similarly, all DEPENDANTS related to a specific Category, for which the POLICYHOLDER has declared that enrolment of DEPENDANTS is compulsory, are to be included under this POLICY. However, DEPENDANTS relating to a Category for which the POLICYHOLDER has not required or declared on the initial Application with the status of compulsory cannot be enrolled under the Insurance Policy.

It is fully agreed and understood that the enrolment rules, as stated under this article, form one of the basics of this POLICY.

Changes to cover

If YOU wish to reduce YOUR level of cover or increase YOUR CO-PAYMENT you must request this change in writing and WE will make the change at YOUR next POLICY anniversary date (not before).

If YOU wish to increase YOUR level of cover or decrease YOUR CO-PAYMENT or change YOUR area of cover you must complete a full declaration of health detailing any changes in YOUR state of health since YOU completed YOUR original APPLICATION FORM, WE reserve the right to decline such increase in YOUR cover or apply SPECIAL TERMS. The change requested will not come into effect until accepted by US in writing and any additional PREMIUM due has been received by US.

Renewing your policy

On the RENEWAL DATE of YOUR POLICY YOU may choose to renew YOUR POLICY which will be subject to the PREMIUM rates and Table of Benefits applicable at the time of renewal.

Renewal Premiums

YOUR renewal PREMIUM will be calculated on YOU and YOUR dependents ages at the date of renewal and will be notified to YOU in advance of YOUR renewal

Unpaid or late renewal premiums

WE will automatically cancel YOUR POLICY if WE do not receive the full amount of YOUR renewal PREMIUM by the DUE DATE. WE will allow YOU to reinstate YOUR POLICY without completing a new APPLICATION FORM if YOU pay the outstanding PREMIUM within 30 days of its DUE DATE.

If YOU receive MEDICAL TREATMENT during this 30 day period WE will not cover these expenses until YOUR PREMIUM has been received and YOUR POLICY reinstated.

If WE have not received YOUR renewal PREMIUM within 30 days of the DUE DATE YOU may apply to reinstate YOUR POLICY but YOU will be required to complete a declaration of health. If YOUR health has changed WE reserve the right to decline YOUR request for reinstatement or apply SPECIAL TERMS.

If YOUR renewal PREMIUM is not received within 60 days of the DUE DATE YOU will have to apply for a new POLICY and the pre-existing condition exclusion and all WAITING PERIODS will apply from the start date of YOUR new POLICY

Changing your personal details

YOU must inform US in writing of any changes to YOUR personal details such as name, address or contact details.

Death of an insured person

In the unfortunate event of the death of an INSURED PERSON cover for the remaining INSURED PERSONS may be continued upon request.

If YOU do not want to continue cover and no CLAIMS have been made any unused PREMIUM from the date of death can be refunded. In the event that a CLAIM has been made then no PREMIUM will be refunded and WE will deduct any unpaid PREMIUM, including future monthly PREMIUM up that may be due up until the next annual anniversary of YOUR start date, from any CLAIM payment.

Cancellation

WE may cancel this Insurance Policy if:

•The PREMIUM has not been paid.

•The EMPLOYER fails to observe the terms of the POLICY or fails to act with utmost good faith.

Cancellation of the Insurance Policy will automatically cancel all cover for all INSURED PERSONS insured under the Insurance Policy.

Cessation of Coverage

Cover will cease automatically if any INSURED PERSON ceases to fulfill the requirements for Eligibility.

Group Addition

Applicable Rules

The POLICYHOLDER has the right to require from US, by completing and signing an Addition/Deletion Form, accompanied with supporting documents, the addition of new INSURED PERSONS such as new employees, newly wedded spouse or new born children of an already enrolled employee on a compulsory basis.

Enrolment Date is:

The Eligibility Date is:

New Employee -The Official date of employment in accordance with the Policyholder internal rules.

New Spouse -The date of marriage

New-born child - Covered from Date of Birth.

If the request for an addition is made within 14 days following the eligibility date of an INSURED PERSON, his/her Enrolment Date will be such eligibility date. Otherwise, the Enrolment Date of an INSUED PERSON is the date on which WE accept such addition.

Conditions of Underwriting

The initial Underwriting terms as applied on the Effective Date of this POLICY shall be applied for all eligible additions, which were required within a period not exceeding 14 days from the Eligibility Date. In case an addition is required more than 14 days after the Eligibility Date, WE reserve the right to proceed with a different Underwriting terms than the ones applied on the Effective Date of this POLICY.

Applicable Premium

The PREMIUM relating to any approved addition shall be calculated on a pro-rata basis.

Deletion

The POLICYHOLDER has the right to require from US, by completing and signing an Addition/Deletion Form, the deletion of INSURED PERSONS such as deceased or terminated employees and their DEPENDANTS.

Supporting Documents

Submission by the POLICYHOLDER of supporting documents, relating to deletion requests, which are satisfactory to US, is a pre-requisite for deletion validation. Among the documents required are the Membership Cards of the particular INSURED PERSONS.

Deletion Date

The DELETION DATE of any approved deletion is the day following the date of death or termination of the EMPLOYEE/INSURED PERSON provided request for deletion is made promptly and the Membership Card is returned to US. Otherwise, the DELETION DATE is the date on which the Membership Cards is returned to US.

Liability

The POLICYHOLDER shall be the sole and fully liable party towards the PROVIDER(s) and/or US in relation with any expenses incurred by the deleted INSURED PERSONS as from the DELETION DATE.

To this effect the POLICYHOLDER should make sure that the Membership Cards of the INSURED PERSON to be deleted has been withdrawn from the INSURED PERSON and sent back to US prior to or on the DELETION DATE.

Refund of Premium

The PREMIUM refund relating to any approved deletion shall be calculated on Pro-rate basis for the period remaining after the Deletion. No refund is due as long as the INSURED PERSON’S Membership Card is not returned to US.

Fraud

If any CLAIM shall in any respect be false or fraudulent or if fraudulent means or devices are used by any INSURED PERSON or anyone acting on his behalf to obtain BENEFIT hereunder then the coverage in respect of such INSURED PERSON and their DEPENDANTS shall be cancelled immediately and all BENEFITS and PREMIUM forfeited.

If any CLAIM shall in any respect be false or fraudulent or if fraudulent means or devices are used by the EMPLOYER or anyone acting on the EMPLOYER’S behalf to obtain BENEFIT hereunder then the POLICY shall be cancelled and all BENEFITS and PREMIUM shall be forfeited.

Legal Proceedings

No Legal proceedings shall be commenced until 60 days after a CLAIM has been correctly submitted with all documentation required by US and no such action shall be brought unless commenced within 5 years from the first date of treatment.

This POLICY is governed by the Law of the United Arab Emirates and any dispute arising out this POLICY shall be settled in the Courts of Dubai.

Material Changes

WE must be advised as soon as possible of any material change effecting any INSURED PERSON. WE retain the right to alter the terms of the POLICY or cancel the POLICY in the event of material change.

Subrogation

Once the Insurance CLAIM has been paid in accordance with the current terms, the POLICYHOLDER and INSURED PERSON subrogates his/her right to US to pursue any third responsible for any Bodily Injury and transfer to US every relevant substantial and legal right. Both the POLCYHOLDER and the INSURED PERSON shall provide US with every possible assistance should WE exercise the above right of subrogation. Should the POLICYHOLDER and the INSURED PERSON breach this obligation, they shall be responsible for any losses incurred by US.

Other Insurance

WE will not pay for MEDICAL TREATMENT CHARGES if there is or may be any other insurance or indemnity that may cover those charges. If the other insurance or indemnity does not cover all MEDICAL TREATMENT CHARGES. WE will pay the balance subject to the BENFIT limits of this POLICY.

WE have full rights of Subrogation.

Payment of Benefits

WE will make payment directly to a PROVIDER of MEDICAL TREATMENT which is a member of the Mednet NETWORK subject to receiving satisfactory proof of the MEDICAL TREATMENT provided. WE will make payment to YOU for MEDICAL TREATMENT received outside the Mednet NETWORK subject to receiving satisfactory proof of the MEDICAL TREATMENT received.

Payment of Co-payment

YOU must make payment directly to any PROVIDER of MEDICAL TREATMENT for the amount of any CO_PAYMENT applicable as specified in the CERTIFICATE OF INSURANCE.

Guarantee of Renewalability

This plan is an annual contract and YOUR cover ends on the last day of the PERIOD OF INSURANCE. WE will guarantee the Renewal of the POLICY subject to review the rates and conditions at the time of the Renewal.

International healthcare plan

Eligible expenses

Eligible expenses shall be the reasonable charges for the services and supplies listed below, actually made to the insured person and, unless otherwise shown, will be considered eligible only if the expenses are:

• given for the diagnosis or treatment of illness, or accidental injury
• ordered or performed by a physician
• medically necessary; and
• usual, reasonable and customary.

You and your physician decide which services and supplies are given, but the plan only pays for covered medical expenses which we deem to be medically necessary.

A service or supply may not be medically necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may, at our discretion consider the cost of that alternative to be covered medical expenses. In this case, covered medical expenses are limited to the usual, reasonable and customary charges for that diagnostic or treatment alternative.

It is the insured person’s responsibility to keep records of what has been paid. You will not be given notification when the maximum is approaching or when the maximum is reached and claims submitted after the maximum is reached will be disallowed.

Covered medical expenses

These are expenses for certain hospital and other medical services and supplies. They must be for the treatment of an injury or disease.

The maximum benefit amount for medical expenses includes any and all other maximum benefit amounts shown in the table of benefits or added/amended by policy endorsement. Any unused portion of the maximum benefit is only payable for expenses incurred while an insured person is eligible for cover and while this policy is in force.

Hospital expenses

We will arrange and pay for the insured person’s inpatient or day case admission to the hospital and for the following covered medical expenses and services when recommended and/or approved by our medical coordinator:

• inpatient hospital services – charges made by a hospital for giving accommodation and other hospital services and supplies to a person who is confined as a full-time inpatient
• accommodation
  InCare Life – In a semi-private room and meals. All charges in excess of the allowable semi-private room and board rate are the responsibility of the insured person
  InCare Premier – accommodation applying to Premier Health members is a private room as shown in the table of benefits
• intensive care unit – when medically necessary
• inpatient ancillary services – if medically necessary for the diagnosis and treatment of the illness or injury for which the insured person is hospitalised, the following services are also covered and benefits paid for charges for:
  • • use of operating room and recovery room
    • all medicines listed in the U.S. Pharmacopoeia or national formulary
    • blood transfusion, blood plasma expanders, and all related testing, components, equipment and services
    • surgical dressings
    • machine testing
    • durable medical equipment
    • diagnostic X-ray examination
    • electric shock therapy rendered by a physician
    • radiation therapy rendered by a radiologist for proven malignancy and/or neoplastic diseases
    • respiratory therapy rendered by a physician or registered respiratory therapist
    • chemotherapy rendered by a physician
    • physical and occupational therapy rendered by a physician or registered physical or occupational therapist, which relates specifically to the physician’s written treatment plan.

  Therapy must:

  • 1. produce significant improvement in the insured person’s condition in a reasonable and predictable period of time, and
    2. be of such a level of complexity and sophistication, and/or the condition of the patient must be such that the required therapy can safely and effectively be performed only by a registered physical or occupational therapist or
    3. be necessary to the establishment of an effective maintenance programme.
  • medical/surgical benefits – charges for:
    • surgeon
    • inpatient medical treatment
    • inpatient consultation by specialist
    • emergency medical services
    • assistant surgeon
    • anesthesiologist.

Specific exclusions applying to hospital expenses

In the case of what our medical coordinator considers to be an unreasonable length of stay or unreasonable hospital charges, we reserve the right to limit payment to what our medical coordinator considers to be usual, reasonable and customary costs.

Inpatient Cash Benefit

For treatment that would have ordinarily been eligible under this policy and was received free of charge, a defined cash benefit will be paid for each night the insured person receives in-patient treatment. The benefit is available for a maximum of 30 nights.

Fitness Check

Not subject to deductible. Six month waiting period.

Where the Insured Person is aged 40 years or over, the policy will pay for one examination every 24 months up to the policy limits in the table of benefits for the cost of an examination to ascertain the potential presence of illness or disease; these may include, (but not limited to):

• vital signs, including blood pressure, cholesterol, pulse, respiration, temperature; and
• cardiovascular and neurological examinations; cancer screening including mammogram, pap smear, colon prostate.
• Specific exclusions to Fitness Check
• exams in any way related to employment
• premarital exams
• vision, hearing
• costs where the medical results and report from the examination have not been provided to us.

Human organ transplant procedures benefits

The policy will pay up to the policy limits in the table of benefits for charges for medically necessary, non- experimental transplantation of a human organ including related services, supplies, drugs and treatments. Organs covered for transplants are limited to the following: heart, lung, kidney, liver, pancreas, and cornea. Bone marrow transplants are covered only for approved diagnosis.

Benefits are only payable if the managed transplant programme is used – all transplants need to be pre-authorised.

• benefits are provided to the insured transplant recipients only. Costs related to organ donors are not covered
• transplant must be deemed necessary by two (2) independent medical or surgical consultants in the relevant medical specialty most closely related to the transplant.

Transplants resulting from or made necessary by congenital conditions are not covered under this organ transplant benefit. They are subject to the limitations and benefits applicable to the congenital condition benefit specified in this contract in accordance with the current table of benefits.

Specific exclusions applying to human organ transplant procedures

• any treatment or service which is not pre-authorised or does not use the managed transplant network
• organ transplant benefits within the first twenty-four (24) months of the insured person’s cover. This period is determined from the date of entry
• subsequent transplants if the initial transplant was not covered under this contract for any reason
• any transplant procedures and related services we deem to be experimental.

Mental health benefits (inpatient and day case)

The policy will pay up to the policy limits in the table of benefits for allowable charges in respect of psycho- therapeutic treatment and psychiatric counselling and treatment for approved psychiatric diagnosis. The relevant annual and lifetime maximum will be applied to each insured person for benefits paid for both inpatient mental health treatment in a hospital or approved facility and for mental health treatment.

• A physician or a licensed clinical psychologist or psychiatrist must provide all mental healthcare services. Services of a clinical psychologist or psychiatrist must be rendered in the provider’s office or in the outpatient department of a hospital.

Specific exclusions to mental health benefits

• aptitude testing, educational testing and services
• services for conditions we classify as emotional or personality illnesses
• psychiatric services extending beyond the period necessary for evaluation and diagnosis of mental deficiency or retardation
• services for mental disorders or illnesses which are not amenable to favourable modification
• services related to drug and alcohol abuse.

Convalescent facility expenses

We will pay for charges made by a convalescent facility for the following services and supplies. They must be furnished to a person while confined to a convalescent facility by a disease or injury. The confinement must start during a convalescent period.

• accommodation on the room basis as per the table of benefits – this includes charges for services, such as general nursing care, made in connection with room occupancy
• use of special treatment rooms
• X-ray and lab work
• physical, occupational or speech therapy
• oxygen and other gas therapy
• other medical services usually given by a convalescent facility
• medical supplies.

Benefits will be paid for up to the maximum number of days during any one convalescent period. This starts on the first day an insured person is confined in a convalescent facility if he or she:

• was confined in a hospital for at least three days in a row, while covered under this policy, for treatment of a disease or injury; and
• is confined in the facility from the date of discharge from the hospital; and
• is confined in the facility for services needed to convalesce from the condition that caused the hospital stay. These include skilled nursing and physical restorative services.

It ends when the insured person has not been confined in a hospital, convalescent facility, or other place giving nursing care for 90 days in a row.

Specific exclusions to convalescent facility expenses

• private or special nursing, or physician services
• drug addiction
• chronic brain syndrome
• alcoholism
• senility
• mental retardation
• any other mental disorder.

Hospice care expenses

We will pay up to the policy limits in the table of benefits for charges incurred in a hospice facility, hospital or convalescence facility for accommodation and other services and supplies furnished to an insured person while a full-time inpatient, for pain control and other acute and chronic symptom management, when given as a part of a hospice care programme are included as covered medical expenses. We must approve the hospice care programme to provide a centrally administered programme of palliative and support services to terminally ill persons and their families. Terminally ill means the patient has a prognosis of two hundred and forty (240) days or less. A medically supervised interdisciplinary team of professionals and volunteers provides services.

Other expenses

We will also pay for charges made by a hospice care agency for:

• part-time or intermittent nursing care by a R.N. or L.P.N. for up to eight hours in any one day
• medical social services under the direction of a physician. These include:
  • assessment of the insured person’s social, emotional and medical needs, and the home and family situation;
  • identification of the community resources which are available to the insured person; and
  • assisting the person to obtain those resources needed to meet the insured person’s assessed needs.
• psychological and dietary counselling
• consultation or case management services by a physician
• physical and occupational therapy
• part-time or intermittent home health aide services for up to eight hours in any one day. These consist mainly of caring for the person
• medical supplies, drugs and medicines prescribed by a physician.

Charges made by the providers below, but only if the provider is not a participant of a hospice care agency; and such agency retains responsibility for the care of the insured person:

• a physician for consultant or case management services
• a physical or occupational therapist
• a home healthcare agency for:
  • physical or occupational therapy;
  • part-time or intermittent home health aide services for up to eight hours in any one day; these may consist mainly of caring for the person;
  • medical supplies, drugs and medicines prescribed by a physician; and
  • psychological and dietary counselling.

Not more than policy limits as per the table of benefits will be paid for all hospice care or expenses incurred while the insured person is not confined as a full-time inpatient.

If the insured person’s condition improves and is no longer considered terminal, then the insured person is no longer eligible for hospice care.

Specific exclusions to hospice care expense

• private or special nursing, or physician services
• drug addiction
• chronic brain syndrome
• alcoholism
• senility
• mental retardation
• any other mental disorder
• charges for any day of confinement in excess of the maximum number of days for all confinements for hospice care.

Charges for:

• services not prescribed in the approved treatment plan
• chemotherapy and radiation therapy except for palliative control
• bereavement counselling
• funeral arrangements
• pastoral counselling
• financial or legal counselling. These include estate planning or the drafting of a will
• homemaker or caretaker services. These include:
  • sitter or companion services for either the person who is ill or other members of the family;
  • transportation;
  • house cleaning; and
  • maintenance of the house.
• respite care. This is care furnished during a period of time when the person’s family or usual caretaker cannot, or will not, attend to the person’s needs.

Emergency ambulance services

We will pay charges for professional ambulance services including road ambulance and air ambulance, if necessary, to transport an insured person from the place where he or she is injured or stricken by disease to the first hospital where treatment is given.

Emergency air ambulance

• covered based on medical necessity
• evacuation is provided if an insured person is involved in an accident or suffers a sudden illness and adequate medical facilities are not available locally. A medically supervised medical evacuation to the nearest facility capable of providing an adequate level of care will be co-coordinated by our emergency medical assistance provider
• repatriation of mortal remains: our emergency medical assistance provider will coordinate the necessary clearances for the return of an insured person’s mortal remains by air transport to the home country.

To comply with the terms and conditions of the policy the insured person must contact us for pre-authorisation before any costs for evacuation and assistance costs are incurred.

Specific exclusions to emergency ambulance services

Any other expenses in connection with air travel. Any costs which are not pre-authorised.

Any costs for a road ambulance if the insured person could have been transported in a private car, whether or not one was available.

Durable medical equipment

We will pay up to the policy limits in the table of benefits for costs for prosthetic devices (artificial devices replacing body parts), orthopedic braces and durable medical equipment (including wheelchairs and hospital beds) that are:

1. prescribed by a physician and
2. customarily and generally useful to a person only during an illness or injury, and
3. determined by us to be medically necessary and appropriate.

Rental fees of durable medical or surgical equipment must not exceed the allowable purchase price of the durable medical equipment.

The initial purchase of such equipment and accessories needed to operate it; this will only be covered if:

• long term use is planned; and
• the equipment cannot be rented; or
• it is likely to cost less to buy it than to rent it.

Repair or replacement of such purchased equipment and accessories: We will only cover replacement if:

• it is needed due to a change in the insured person’s physical condition; or
• it is likely to cost less to buy a replacement than to repair the existing equipment or to rent like equipment.

Specific exclusions to durable medical equipment

Charges for more than one item of equipment for the same or similar purpose. Charges in relation to artificial limbs and eyes: eye exams and eyeglasses; hearing aids; orthopedic shoes or other devices to support the feet.

Visiting nurse/home healthcare expense

We will pay up to the policy limits in the table of benefits for charges relating to visiting nurse/home health expenses if:

• the charge is made by a home healthcare agency; and
• the care is given under a home healthcare plan; and
• the care is given to a person in his or her home.

Visiting nurse/home healthcare expenses are charges for:

• part-time or intermittent care by an R.N. or by an L.P.N. if an R.N. is not available
• part-time or intermittent home health aide services for patient care
• physical, occupational and speech therapy
• the following to the extent they would have been covered under this policy if the insured person had been confined in a hospital or convalescent facility:
  • medical supplies, drugs and medicines prescribed by a physician; and
  • lab services provided by or for a home healthcare agency.

In each period of insurance there is a maximum to the number of visits covered as per the table of benefits. Each visit by a nurse or therapist is one visit. Each visit of up to four hours by a home health aide is one visit.

Specific exclusions to visiting nurse/home healthcare expense

Charges made for:

• services or supplies that are not a part of the visiting nurse/home healthcare plan
• services to an insured person by anyone who usually lives with you or is a member of your or your wife’s or husband’s family
• services of a social worker
• transportation.

Private duty nursing (inpatient service only)

We will pay up to the policy limits in the table of benefits for costs of private duty nursing by an R.N. or L.P.N. if the person’s condition requires skilled nursing care and visiting nursing care is not adequate.

This benefit is provided only when all of the following conditions are met:

• the nursing service is available and the service is prescribed by the attending physician; and
• the service is related to the condition for which hospital care and treatment are being rendered; and
• the service is medically necessary; and
• the service is approved by the hospital.

We may elect to review a case in advance and then approve benefits for this service for up to 80 hours at a time.

Specific exclusions to private duty nursing

Benefits will not be paid for private duty nursing:

• For any shifts in excess of the private duty nursing care maximum shifts. Each period of private nursing of up to eight hours will be deemed to be one private duty nursing shift.
• When it is provided as a convenience for the patient, whether or not prescribed by a physician, or when it is provided at the request of the patient or his/her family.
• When it is rendered in such special care facilities of the hospital as self-care, selective care, and intensive care units.

Benefits will not be paid for skilled nursing care for:

• a visit of more than four hours for the purpose of performing specific skilled nursing tasks
• that part or all of any nursing care that does not require the education, training and technical skills of an R.N. or L.P.N.; such as transportation, meal preparation, charting of vital signs and companionship activities; or
• any private duty nursing care, given while the person is an inpatient in a hospital or other healthcare facility; or
• care provided to help a person in the activities of daily life; such as bathing, feeding, personal grooming, dressing, getting in and out of bed or a chair, or toileting; or
• care provided solely for skilled observation except as follows:
  • more than one four hour period per day for a period of no more than 10 consecutive days following the occurrence of:
  • change in patient medication;
  • need for treatment of an emergency condition by a physician or the onset of symptoms indicating the likely need for such treatment; or
  • any service provided solely to administer oral medicines; except where applicable law requires that such medicines be administered by a R.N. or L.P.N.

Non-emergency care in an emergency room

If treatment:

• is received in the emergency room of a hospital while a person is not a full-time inpatient; and
• the treatment is not emergency care; covered medical expenses for charges made by the hospital for such treatment will not be eligible under this policy.

Hospital level care will be deemed to be required only if care:

• could not safely and adequately have been provided other than in a hospital; or
• adequate care was not available elsewhere in the area at the time and place it was needed.

Rehabilitation

Rehabilitation undertaken either as an in-patient or outpatient or in a recognised rehabilitation facility and under the direction of a specialist, including room and board, physical therapy, occupational therapy, speech therapy and prescription drugs. Treatment must begin within 30 days after the end of your treatment in hospital for a medical condition which is covered by your policy and arose as a result of the medical condition which required hospitalisation, or as a result of the treatment for that medical condition. We do not pay room and board for rehabilitation when the treatment given is solely physiotherapy.

Travel and Accommodation Costs

In the event of your treatment requiring in excess of 5 days continuous hospitalisation we will pay the reasonable costs for an immediate family member to accompany you.

Reasonable costs are:

• 1 economy return flight.
• standard hotel room in a 4* hotel or equivalent, to be determined by us.

This benefit will only be paid once per medical condition and must be pre-authorised by us.

Emergency medical assistance and evacuation

Insured persons have access to the following services, which are provided by our appointed 24-hour emergency medical assistance company.

Scope of services available

Our 24-hour emergency medical assistance company can provide the following services, subject to the policy terms and conditions, and to the table of benefits:

• pre-travel advice to the insured person with information on visas, consulates, vaccinations and foreign office travel warnings
• a 24-hour dedicated emergency telephone and assistance service, in the event of a medical emergency
• liaison with your attending doctor or hospital administration staff to obtain medical reports on your condition and treatment needs, and ongoing medical monitoring of your condition
• communication with you and/or your close relative to keep you informed at all times
• arrangement of emergency evacuation to the nearest suitable medical facilities, including medical escort, where medically necessary
• arrangement of repatriation to your home country where appropriate, by commercial flight or by air ambulance, and with medical escort, according to the attending doctors recommendations, and subject to medical necessity
• locate and arrange the dispatch of medical supplies, blood or medical equipment to the insured person’s location
• guarantee payment of emergency medical expenses to the hospital, doctor, or other service provider
• arrange for and guarantee, additional reasonable travel and accommodation costs for a relative or friend of the insured person who is reasonably required to travel to and/or remain with the sick or injured insured person.
• in the event of death of an insured person, arrangement of repatriation of human remains to their home country, or burial/cremation in their country of residence and return of their ashes to their home country

Important: pre-authorisation is required in all cases of hospitalisation and medical transportation (except for local emergency transportation), and should be obtained in advance. The contact information is on your membership card. In the event of an emergency hospitalisation or medical transportation, where you are medically incapacitated from obtaining pre-authorisation, we must be notified with 48 hours of admission or transportation.

Pre-authorisation

Medical treatment worldwide, outside the USA

No restrictions are imposed regarding the choice of physician, laboratory, hospital, clinic, etc., except that the facilities must be licensed and the treatment performed by legally qualified providers and physicians practising within the scope of their license.

Pre-authorisation is required in all cases of:

• hospitalisation,
• day case surgery,
• medical transportation (except for local emergency transportation).

You must contact us at the earliest opportunity before a scheduled hospitalisation, outpatient surgery, or medical transportation. The contact details for obtaining pre-authorisation are shown on your membership card.

In the event of an emergency hospitalisation, we must be notified within 48 hours of admission.

Failure to obtain pre-authorisation where required

In the event that you do not obtain pre-authorisation in accordance with the above requirements, we reserve the right to reduce benefits payable by 25%.

General exclusions

You are not insured, and will not be paid under any part of this policy for:

1. Services and supplies which we deem to be unnecessary for the diagnosis, care or treatment of the physical or mental condition involved. This applies even if they are prescribed, recommended or approved by the attending physician or dentist.
2. Care, treatment, services or supplies that are not prescribed, recommended and approved by the insured person’s attending physician.
3. Expenses covered under workers’ compensation or similar law or programmes.
4. Charges for services or supplies ordered or received prior to the date of entry of cover or after the termination date of cover.
5. Plastic surgery; reconstructive surgery; cosmetic surgery; or other services and supplies which improve, alter, or enhance appearance, whether or not for psychological or emotional reasons, unless required because of a non-occupational injury that occurs while covered under the policy.
6. Treatment for morbid obesity, weight control, gastric bypass or gastric stapling procedure.
7. Tobacco dependence treatment.
8. Any costs inrelation to pregnancy, infertility and/or fertility procedures and any resulting pregnancy or childbirth(s).
9. Congenital conditions
10. Charges related to in-vitro fertilisation, artificial insemination or similar procedures.
11. Travel and hotel expenses related to medical care.
12. Routine podiatry or other foot treatment not resulting from an illness or injury.
13. Hearing aids.
14. Radial keratotomy procedures (myopia surgery), lasik, or eye surgery to correct refractive error or deficiencies.
15. Dental care which is not the result of accidental injury of sound, natural teeth sustained while covered under this policy.
16. A dental surgical implant of any type.
17. 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 by whom or by which they are prescribed, recommended or performed.
18. Anything not ordered by a physician or not necessary for medical care, as well as medical and dental services that do not meet professionally recognised standards or are not considered as being necessary for proper treatment.
19. Services or supplies that we deem to be experimental or investigational. A drug, a device, a procedure or treatment will be determined to be experimental or investigational if:
    • there is insufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or
    • if required by the Food and Drug Administration, approval has not been granted for marketing; or
    • a recognised national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational or for research purposes; or
    • the written protocol or protocols used by the treating facility or the protocol or protocols of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental, investigational or for research purposes.
20. Treatment not recognised by the medical community as potentially safe and efficacious for the care and treatment of the injury or sickness; or
21. Treatment not approved for reimbursement under national medical programmes.
22. Charges which we deem to be unusual or excessive.
23. Expenses covered by a government programme such as social security, whether or not a insured person applies for reimbursement from that programme.
24. Care provided in a government hospital or medical facility for which an individual would not be charged in the absence of this cover.
25. Expenses reimbursed or reimbursable by another insurance contract or programme.
26. Missed appointments.
27. Any injury or sickness in connection with or caused by war or an act of war whether declared or undeclared, riot, civil commotion, or police action whether participating or not.
28. Donor expenses connected with organ transplant are not covered.
29. Any expense for male or female: reversal of sterilisation; sex change or implantation; or treatment for sexual transformation; sexual dysfunctions or inadequacies.
30. Charges for breast reduction or augmentation and complications arising from these procedures.
31. Personal or comfort items such as radio, television, barber or beauty services or supplies.
32. Any participation in an assault, felony or illegal act, including but not limited to injuries sustained in fights initiated by you or your dependent.
33. Any treatment for alcoholism or drug addiction.
34. Over-the-counter (OTC) drugs or supplies, which do not require a physician prescription, smoking cessation drugs, appetite suppressant, hair regenerative drugs, anti-photo aging drugs, cosmetics and beauty aids, acne drugs (retin A for cosmetic purposes), megavitamins, vitamin, prenatal vitamins prescribed or not, nutritional supplements
35. Charges made by a member of your family to look after you other than than those specified in Rehabilitation.
36. Charges relating to hypnosis or biofeedback.
37. Charges for education or special education or job training whether or not given in a facility that also provides medical or psychiatric treatment.
38. Charges for or related to services, treatment, education testing or training related to learning disabilities or development delays including but not limited to attention deficit/hyperactivity disorder (ADD/ADHD).
39. Charges for or in connection with speech therapy. This exclusion does not apply to charges for speech therapy that is expected to restore speech to a person who has lost existing speech function (the ability to express thoughts, speak words and form sentences) as the result of a disease or injury.
40. Services and supplies related to visual therapy or orthoptics.
41. Orthotics, including all equipment, devices, foot inserts, arch supports, lifts and correct shoes.
42. Diagnostic examinations or laboratory tests performed as a hospital inpatient for inconvenience or observation when these services can be safely performed as an outpatient.
43. Treatment by naturopaths, homeopaths, naturopathic or homeopathic medications or supplements and any other alternative methods of treatment we do not recognise unless specified in the table of benefits.
44. Any condition, illness, injury or emergency air services related to nuclear accident.
45. Allergy testing and treatment.
46. Elective abortions and complications thereof.
47. All services supplies and treatment related to primal therapy, rolfing, psychodrama, megavitamin therapy, carbon dioxide therapy and bioenergetics therapy.
48. All services, supplies and treatment related to cognitive therapy both inpatient and outpatient.
49. Participation in a professional sport (not including recreational or amateur participation) or any hazardous sport or activity such as (but not limited to) the following: motor sports, riding off-road on a motorbike or a quad-bike as a driver or passenger, aerial sports, scuba diving below 30 metres or where a Professional Association of Driving Instructors Certificate is not held, any sport involving animals, speed competition, skiing off-piste and racing of any form (other than on foot). If a hazardous sport or activity is not specified in this list, the insured person must contact us to ascertain if it is acceptable for insurance before cover will apply.
50. Any claim relating to:
    1. self-inflected injury (including suicide or attempted suicide); or
    2. self-exposure to peril (except in an attempt to save human life).
51. Drugs as part of an HIV/AIDS drug programme.

General conditions

Eligibility

Individuals who meet all of the following criteria are eligible for cover as an insured person:

• the individual has completed an enrolment form for cover;
• the individual has signed and returned an enrolment form to us;
• the individual resides outside of the United States of America, or any of their territories;
• the individual and/or his or her eligible dependents will not attain 69 years of age during the period of insurance; and
• we accept the individual for cover.

Dependents

You may cover your:

• wife or husband; civil union partner; or a person who has been living with you for a period of at least one year will be deemed to be your dependent spouse if they have been publicly represented as your spouse – such persons shall be deemed to be “your domestic partner” if you have completed and signed a “declaration of dependentship” and the declaration is acceptable to us
• unmarried children who are under 19 years of age.

Any other unmarried child under 23 who goes to school on a regular basis and depends solely on you for support will be covered as a dependent at the child premium rate and child benefits apply.

Your children include:

• your biological children
• your adopted children
• any other child you support whom you are legally responsible for and who lives with you in a parent-child relationship.

Date of entry

Your cover will take effect:

• on your commencement date, if by then, you have signed and returned your enrolment form, have paid the premium and we have given our written consent Additional evidence may be required including a physician’s statement and/or results of a medical examination. You will provide any additional information at your cost and is to be provided by a physician you select and we approve.

If you don’t sign and return your enrolment form by your commencement date, cover will not take effect until this has been done and we give our written consent.

Dependents

Cover for those who are dependents as of the date and premium has been received by us, your cover takes effect and will become effective on that date, if, by then we have received notification of your written request for cover of such dependents and an enrolment form has been completed for the dependents, and have given our written consent and premium has been received by us. The evidence required may include a physician’s statement and/or results of a medical examination performed by a physician approved by us. The evidence of insurability will be at no cost to us. Otherwise, cover for such a dependent will not go into effect until you submit evidence of insurability for the dependent which we agree is satisfactory and premium has been paid. The date of entry will be a date specified by us in writing.

If you require cover for a new dependent:

• who is your biological newborn child, cover of that dependent takes effect at birth subject to notification of birth within 30 days, otherwise, the addition will take effect from the date of notification; or
• other than who is your biological newborn child, cover for the dependent will not go into effect until you submit satisfactory evidence of insurability for the dependent. The date of entry will be a date specified in writing, by us. The evidence required may include a physician’s statement and/or results of a medical examination and will be at your cost.

Any dependent aged 60 or over must supply the results of a medical exam in addition to the completion of an enrolment form. The exam will be done at the dependent’s expense and performed by a physician approved by us.

Cover will only become effective if the enrolment form and medical exam results are to our satisfaction.

Each dependent must meet the eligibility requirement of this policy and all our underwriting requirements.

Residency

The insured person must reside outside the United States of America. Permanent residence in the United States of America shall be ground for termination of this policy. For purposes of this policy, we may determine that an insured person reside(s) in the United States of America in any case in which the insured person is in the United States of America for:

1. one hundred and eighty (180) or more consecutive days; or
2. more than one hundred and eighty (180) total days in any twelve (12) consecutive month period.

A full time student attending school in the United States of America may remain covered upon proof of matriculation, subject to all other eligibility requirements of this policy.

Such proof of matriculation shall be provided at time of application for cover, at each renewal during which the full-time attendance continues, or upon our request.

Cooling off period

If you cancel within the first 14 days after receiving the policy documents within the first year of insurance, we will refund your full premium, providing no claims have been made on your policy.

We reserve the right to deduct an administrative charge of US$ 30 for the costs of production and despatch of documentation.

Termination of cover

Cover under this policy terminates at the first to occur of:

• the date on which you are no longer eligible to be an insured person
• when you fail to make any required payment due to us
• the date you become a resident of the United States of America
• upon completion of any 180 day period living in the United States of America
• the end of the period of insurance in the year in which you attain the age of 69.

In any case, the cover ceases on the termination date of this policy:

• at the request of the insured person with a two-months notice before the renewal date
• or upon the next termination date of this policy after the date upon which the Master contract between Integra Global Health Limited and the Insurer is terminated.

Dependents coverage only

Coverage for an insured person’s spouse will terminate at the first to occur of:

• the date this policy terminates
• the end of the period of insurance in which such spouse is legally separated or divorced from the insured person.

Coverage for all other dependents will terminate at the first to occur of:

• the date this policy terminates
• the end of the period of insurance in which the covered dependent marries
• the end of the period of insurance in which the covered dependent ceases to be a defined dependent.

A “Dependent” will no longer be considered to be a defined dependent on the earlier to occur of:

• the date this plan no longer allows cover for Dependent
• the date of termination of the domestic partnership. In that event, you should provide the policyholder with a completed and signed declaration of termination of domestic partnership.

Premium payments

Your first premium payment for this policy is due on the commencement date shown on the certificate of insurance.

The premiums are set regarding the area of coverage and the selected plan. They are paid by the Insured person according to the selected frequency of payment.

Should the Insured person fail to pay all premiums within the month following their due date, the cover is suspended 30 days after the Insured has been served with formal notice. If, beyond that period, the Insured has not made the requested payment, the policy may be terminated without any further formality 10 days after expiry of the 30 day period.

Revision

Premiums are automatically indexed and effective on the policy anniversary date, according to the technical results and the medical costs trend. The premiums may also be revised according to the changes in the laws and regulations in force on the effective date of the policy or at the earliest, from the effective date of the new provisions.

Renewal

Your cover is renewed by tacit agreement on each anniversary date for a period of one year, unless cancelled by you by means of a registered letter sent to Integra Global Health Limited at the latest two months before the anniversary date, which is the effective date of termination.

If this policy is not renewed, it will terminate at the end of the period of insurance for which a premium has last been paid.

If you request that:

• insurance be cancelled for one or more of the insured persons; or
• that the policy be cancelled in its entirety, such insurance will cease only at the end of the period of insurance and there will be no pro rata refund of the premium. Any unpaid premium for the policy shall remain due and owing.

Physical examinations

We will have the right and opportunity to have a physician of our choice examine any person for whom certification or benefits have been requested.

This will be done at all reasonable times while certification or a claim for benefits is pending or under review. This will be done at no cost to you.

Entire contract – changes

We must approve any change in this policy, such approval must be confirmed by a policy endorsement.

Legal Action

No legal action can be brought to recover under any benefit on this policy sooner than 60 days after the required proof of claim has been furnished. No legal action can be brought to recover under any benefit after two years from the deadline for filing claims.

Fraud/non-disclosure/mis-representation

We may terminate cover by giving written notice to the insured person for misrepresentation on the enrolment form or for fraud in obtaining cover.

Termination is effective as of the commencement date under this policy and the policy becomes void from the date of commencement. We will refund all premiums paid on behalf of the insured person less benefit payments paid to or on behalf of the insured person and his dependents. If the value of the benefits paid exceeds the amount of premium paid, the insured person will pay us an amount equal to such excess.

Recovery of benefits paid

As a condition to payment of benefits under this policy for expenses incurred by an insured person due to injury or illness for which a third party may be liable:

• we shall, to the extent of benefits it has paid, be subrogated to (have the right to pursue) all rights of recovery of insured persons against:
  • such third party; or
  • a person’s insurance carrier in the event of a claim under the uninsured or underinsured auto cover provision of an auto insurance policy
• we may recover from the insured person amounts received by judgment, settlement, or otherwise from:
  • such third party or his or her insurance carrier; or
  • any other person or entity, which includes the auto insurance carrier which provides the insured person’s uninsured or underinsured auto insurance cover
• the insured person (or person authorised by law to represent the insured person if he or she is not legally capable) shall (at their own expense); execute and deliver any documents that are required; and do whatever else is necessary to secure such rights.

Assignment

Cover may be assigned only with our written consent.

Recovery of overpayment

If a benefit payment is made by us, to or on behalf of any person, which exceeds the benefit amount such person is entitled to receive in accordance with the terms of the policy, we have the right:

• to require the return of the overpayment on request; or
• to reduce by the amount of the overpayment, any future benefit payment made to or on behalf of that person or another person in his or her family.

Such right does not affect any other right of recovery we may have with respect to such overpayment.

Claims

Proof of claim

• bills identifying patient, date of treatment, cost and describing in detail the medical services performed or the medical products purchased
• doctor’s prescription for prescription drugs, laboratory tests, physical therapy and eyeglasses and contact lenses
• the original reimbursement statements from social security, government programmes, or other insurance plans.

The insured person must also answer any questions concerning the illness or accident and, in particular, provide a complete description of the illness or accident and indicate, when requested, the date when it was first identified or treated by a medical practitioner, etc.

Notice of claim and time limitation

A claim must be submitted to us in writing. It must give proof of the nature and extent of the loss. Please contact our claims administrators for a claim form.

All claims should be reported promptly. The deadline for filing a claim for any benefits is 180 days after the date of the loss causing the claim.

No action for the recovery of any claim for benefits shall be sustainable unless commenced within 180 days of the event that is at the origin of the claim. After expiration of this term, the insured person, has no rights or obligations. After termination of this policy, claims for expenses incurred while the policy was in force shall be considered if they reach us within 90 days of such termination.

Payment of benefits

All benefits are payable to you. However, we may pay any health benefits to the service provider. This will be done unless you have told us otherwise, by the time you file the claim.

Age limit

If we accept a premium for an insured person after the date such person would cease to be insured due to age, that person’s cover will terminate and premium will be refunded less any claims paid out.

If an insured person’s age is misstated and if, according to the true age, the cover provided by this policy for that person would not have been effective or would have ceased before acceptance of premium, our liability will be limited to the refund, on request, of all premiums paid for the period not covered by the policy.

Currency

Premium payments will be made to us in the respective policy’s denominated currency: USD; EUR. Or in any other major currency as agreed with us. All references in this policy to dollars and cents mean dollar and cents of lawful United States of America money. Euros and cents means the lawful currency of the European Monetary Union and Pounds and pence means the lawful currency of the United Kingdom of Great Britain.

Record of expenses

Keep complete records of the expense of each person. They will be required when a claim is made. Very important are:

• names of physicians, and others who furnish services
• dates of expenses are incurred
• copies of all bills and receipts.

Medical services

We are not responsible for the availability, quantity, quality or results of any medical treatment received by an insured person or for the failure of an insured person to obtain medical services.

Applicable law

This policy is governed by French law.

Meaning of words

Certain words and phrases used in this policy are defined below. Other words and phrases may be defined where they are used:

Accident: a sudden, unexpected and unforeseen bodily injury caused by violent, visible and external means.

Air ambulance means a vehicle medically equipped to transport ill insured persons that:

• is licensed by local, county or state regulations, and/or
• has attendants who are fully trained in emergency care, such as emergency medical technician (EMT) or paramedics.

Ambulatory surgical centre means a facility which: a)has as its primary purpose to provide elective surgical care; and b) admits and discharges a patient within the same working day; and c) is not part of a hospital. “Ambulatory surgical centre” does not include: 1) any facility whose primary purpose is the termination of pregnancy; 2. an office maintained by a physician for the practice of medicine; or 3. an office maintained by a dentist for the practice of dentistry.

Authorisation, certify and certified means that we, following advance notification of a scheduled confinement in a hospital, have acknowledged the scheduled confinement, provided the insured person with the names and addresses of hospitals that are members of the participating provider organisation, to which the insured person may have access as a insured person under the policy, and confirmed that such confinement is medically necessary.

These terms also mean that we have received notification:

1. within 48 hours of an emergency hospital confinement;
2. 48 hours before outpatient skilled nursing care; or
3. within 48 hours of an insured person being identified as a candidate for a heart, heart and lung, single lung, pancreas and kidney, or liver transplant; in advance of any hospital stay, skilled nursing care, surgery or medical care; it means we have acknowledged such notifications, and reviewed the confinement, the outpatient skilled nursing care, and/or the proposed transplant services and procedures for medical necessity, and, when applicable, provided the insured person with the names and addresses of hospitals which are members of the participating provider network.

Close relative means mother, mother-in-law, father, father-in-law, stepmother, stepfather, daughter, daughter- in-law, son, son-in-law, (including legally adopted daughter or son), stepchild, sister, sister-in-law, brother, brother-in- law, of an insured person.

Commencement date means the date your cover becomes effective under this policy.

Confinement means admission to a facility as a registered inpatient. Two or more confinements will be deemed one period of confinement unless the discharge from the readmission to the facility is separated by at least 60 days

Country of residence means the country in which you are resident and working for at least nine months of any 12 month period.

Covered medical expenses means the usual, reasonable and customary charges incurred by a insured person, while covered under this policy, for medically necessary services, treatments or supplies described under the provisions titled covered medical expenses.

Custodial care means treatment or services which could be rendered safely and reasonably by a person not medically skilled, regardless of who recommends them and where they are provided, and which are designed mainly to help the patient with daily living activities. Such activities include but are not limited to: help in walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing; preparing meals or special diets; moving the patient; acting as a companion or sitter; and supervising medication which can usually be self-administered. Custodial care includes: the provision of accommodation, nursing care, or such other care which is provided to an individual who is mentally or physically disabled and who, as determined by the individual’s attending physician, has reached the maximum level of recovery; and in the case of an institutionalised person, room and board, nursing care or such other care which is provided to an individual for whom it cannot reasonably be expected that medical or surgical treatment will enable him to live outside an institution; and rest cures, respite care and home care provided by family members. Upon receipt and review of a claim, we or an independent medical review will determine if a service or treatment is custodial care.

Date of entry means either the commencement date or the date from which an insured person’s cover become effective.

Day case means the admission of selected patients to hospital for a planned surgical procedure, returning home the same day.

Deductible means the amount of covered expenses which an insured person is responsible to pay before benefits are payable under this policy. Such amount will not be reimbursed under the policy. After the deductible amount has been paid by the insured person, benefits for covered medical expenses will be payable under this policy at the percentage rates shown on the table of benefits.

Domestic partner means a person who has been living with you for a period of at least one year. This person will be deemed to be your dependent spouse if they have been publicly represented as your spouse.

Durable medical equipment means equipment that is: a) medically necessary; b) made for and mainly used in the treatment of an injury or an illness; c) not useful in the absence of an illness or injury; d) made to withstand repeated use over an extended period of time; e) suited for use in the home; and f) used to improve a permanent medical condition. Durable medical equipment does not include: insulin pumps; glaucometers; motor driven wheelchairs or beds; comfort items such as telephone arms and over-bed tables; items used to alter air quality or temperature such as air conditioners, humidifiers, dehumidifiers, and purifiers (air cleaners); disposable supplies such as exercycles, more wheels, sun or heat lamps, heating pads, bidets, toilet seats, bathtub seats, sauna baths, elevators, whirlpool baths, exercise equipment; and similar items.

Emergency treatment means a Hospitalisation required as the result of a serious injury or the onset of a life-threatening condition that requires immediate medical or surgical care to prevent loss of life or permanent damage to the organs or systems of the body. Examples of such injuries or conditions include, but are not limited to: heart attack, stroke, poisoning, loss of breath, severe bleeding, loss of consciousness, convulsions and severe trauma.

Enrolment for life cover means, for the purpose of evaluating enrolments, such satisfactory evidence that an individual is in good health, as we require.

Evidence of insurability means a statement of health provided by a physician.

Experimental or investigative means that a medical, surgical procedure, treatment, course of treatment, equipment or drug or medicine is: a) under investigation or is limited to research; b) restricted to use in disciplined clinical efforts and scientific studies; c) not proven in an objective way to have therapeutic value or benefit; d) medically questionable with respect to effectiveness; and e) not generally accepted by the medical community. We may be contacted to determine if a particular procedure, treatment, device, drug or drug therapy is considered to be experimental or investigative.

Extended care facility means an institution that meets all of the following requirements: a) it must be operated pursuant to law; b) for US facilities, it must be approved for payment of Medicare benefits or be qualified to receive such approval if requested; c) it must be primarily engaged in providing, in addition to room and board accommodations, skilled nursing services under a licensed physician’s supervision; d) registered or licensed practical nurses must supervise 24-hours-a-day; and e) a daily record for each patient must be maintained. Extended care facility does not include any institution that is primarily a clinic; a rest home; a home for the aged; a place for alcoholics or drug addicts; a place for custodial care; or a facility for mental illness.

Home healthcare agency means an agency or organisation, or subdivision thereof, which: a) is primarily engaged in providing skilled nursing care and other therapeutic services in the insured person’s home; b) is duly licensed, if required, by the appropriate licensing facility; c) has policies established by a professional group associated with the agency or organisation, including at least one physician and one registered graduate nurse (R.N.) to govern the services provided; d) provides for full-time supervision of such services by a physician or by a registered nurse (R.N.); e) maintains a complete medical record on each patient; and f) has a full-time administrator.

Home healthcare plan means a programme: a) for the care and treatment of the insured person in his home; b) established and approved in writing by his attending physician; and c) certified, by the attending physician, as required for the proper treatment of the injury or illness, in place of inpatient treatment in a hospital or in an extended care facility.

Hospice care means an agency which provides a coordinated plan of home and inpatient care to a terminally ill person and which meets all of the following tests:

a) has obtained any required state or governmental license or certificate of need; b) provides service 24-hours-a-day, 7 days a week; c) is under the direct supervision of a physician; d. has a nurse coordinator who is a registered nurse (R.N.); e) has a duly licensed social service coordinator; f) has as its primary purpose the provision of hospice services; g) has a full-time administrator; and h) maintains written records of services provided to the patient.

Hospital means an institution which is licensed as a hospital under the laws of the jurisdiction where it is located, and: a) is primarily engaged in providing, for payment and on its own premises, inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities; b) is under the direction of a staff of physicians; c) provides 24-hour nursing service rendered or supervised by a registered graduate nurse; has facilities on its premises for major surgery (or a written contractual agreement with an accredited hospital for the performance of surgery); and for US facilities, is accredited by the joint commission on accreditation of healthcare facilities.

“Hospital” does not include a facility, or part thereof, which is principally used as: a rest or custodial care facility; nursing facility; convalescent facility; extended care facility; or facility for the aged or for the care and treatment of drug addicts or alcoholics, unless specifically provided in this policy and/or as mandated by local law. It does not mean any institution in which the insured person receives treatment for which he is not required to pay.

Illness means: a bodily disorder or infirmity; complications of pregnancy; and pregnancy.

Injury means a bodily injury that is: 1) sustained by a insured person while insured under this policy; and 2) caused by an accident directly and independently of all other causes. An insured person must begin receiving services, supplies or treatment within 72 hours from the time of accident in order for it to be considered an injury. All injuries sustained by one person in any one accident, including all related conditions and recurrent symptoms of these injuries, are considered a single injury.

Insured event means an accident or the sudden and unexpected onset of serious illness, or the sudden and unexpected death or imminent demise of a close relative, during the period of insurance within the permanent place of residence of the close relative.

Insured person means an eligible individual and his or her dependents entitled to benefit under this policy, each of whom is named or described on a completed enrolment form or subsequent notification and for whom the appropriate premium has been paid to us, and whom we have accepted for cover.

L.P.N. means a licensed practical nurse.

L.V.N. means a licensed vocational nurse.

Medical emergency means the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate attention could reasonably be expected to result: a) in placing the patient’s body in serious jeopardy; b) serious impairment to bodily functions; or c) serious dysfunction of any bodily organ or part.

Medically necessary means that a treatment, service, supply, drug or hospital or extended care facility confinement (or part of a confinement): a) is appropriate and essential to diagnose or treat the patient’s illness or injury; b) does not exceed, in scope, duration, or intensity, the level of care which is needed to provide safe, adequate, and appropriate diagnosis or treatment; c) is prescribed by a physician; d) is consistent with widely accepted professional standards of medical practice in the jurisdiction where treatment is rendered; e) is not primarily for the personal comfort or convenience of the patient, the family, physician, or other provider of care; f) is not a part of or associated with the scholastic education or vocational training of the patient; g) is not experimental or investigative; and h) in the case of inpatient care, cannot be provided safely on an outpatient basis.

The fact that a physician has prescribed, recommended, approved or provided a treatment, service, supply, or confinement does not, in itself, make it medically necessary. We may examine all conditions listed above in reviewing a claim for treatment, service, supply, drug or hospital or extended care facility confinement or part thereof.

Medicare means Title XVIII (Health Insurance Act for the Aged) of the United States Social Security Act, as added by the Social Security Amendments of 1965 as now or subsequently amended.

Medical coordinator or our medical coordinator means an organisation with a staff who performs the certification processes in conjunction with consultant physician(s) qualified or specialising in the treatment of the condition (including mental illness, alcohol or drug abuse), and arrange or approve certain medical transportation.

Nurse midwife means a person: a) certified to practice as a nurse midwife; b) and licensed by a board of nurses as a registered nurse (R.N.); and c) who has completed a programme for the preparation of nurse midwives, approved by the jurisdiction in which the person is practicing.

Out of pocket means expenses that the insured person pays towards costs.

Period of insurance means the period which is shown on your certificate of insurance.

Physician/practitioner means, with respect to any medical care and service, a person: a) certified or licensed, under the laws of the jurisdiction where treatment is rendered, as qualified to perform the particular medical or surgical service for which a claim for cover under this policy is made and who is practicing within the scope of such certification or licenser; and b) any other healthcare provider if, and as, mandated by a state’s or other jurisdiction’s law. This term does not include: 1) an intern; or 2) a person in training.

Policy means this document, including the policyholder’s enrolment, and any subsequent amendment or policy endorsement, which we issue for attachment to the policy.

Policy limit means the limit of applicable benefit shown in the table of benefits.

Policyholder: the primary insured person who has subscribed to this policy, who is responsible for paying the premium and ensuring that the policy terms and conditions are adhered to.

Preferred provider/organisation (PPO) means the hospitals, physicians, or other providers who have entered into a contractual agreement with us to provide hospital and medical services to insured persons at negotiated fees.

Reconstructive surgery means surgery which does not itself restore the function of an abnormal body structure and which is incidental to, or the result of, a previous surgery necessary due to illness, injury, or congenital defect.

Rehabilitation facility means a facility devoted to the rehabilitation of patients with various neurological, musculo-skeletal, orthopedic and other medical conditions following stabilisation of their acute medical issues.

R.N. means a registered nurse.

Scheduled hospitalisation or scheduled confinement means a hospital confinement, which has been planned in advance by an insured person’s physician for a fixed future time.

Serious illness means any sudden and detrimental alteration in health as duly diagnosed by a physician, which necessitates the close relative being admitted to a hospital bed on the advice of a physician for a minimum of three consecutive nights.

Skilled nursing care means services provided by, and which require the special skills of, a registered nurse (R.N.), Licensed practical nurse (L.P.N.), Or licensed vocational nurse (L.V.N.).

Usual, reasonable and customary charge/allowable charge means the lower of: a) the provider’s usual charge for furnishing the treatment, service or supply; or b) the charge which we determine to be the general rate charged by others who render or furnish such treatments, services or supplies to persons: 1) who reside in the same area; and 2) whose injury or illness is comparable in nature and severity. (We will determine the usual, reasonable and customary charge for a treatment, service or supply that is unusual, or not often provided in the area, or that is provided by only a small number of providers in the area. We will consider such factors as: 1) complexity; 2) degree of skill needed; 3) type of specialist required; 4) range of services or supplies provided by a facility; and 5) the prevailing charge in other areas. The term “area” means a city, a county or any greater area, which is necessary to obtain a representative cross section of similar institutions or similar treatment.)

We, us, our means MGEN.

You, your means an insured person.

Complaints procedure

We trust you will be satisfied with your policy, but in the event that you do have any cause for complaint, the most important thing for us is to help resolve your concerns as quickly as possible. Upon receipt of your complaint, we will do all we can to resolve your complaint by the end of the next business day. However, if we can’t do this, we will contact you within five working days to acknowledge your complaint and explain the next steps. Letting us know when you are unhappy with our service gives us the opportunity to put things right for you and improve our service for everybody.

You can call our claims administrators on: +(33) 184 780 368

email to: >integra@medical-administrators.com

or write to: Medical Administrators International, 37, rue Anatole France, 92532 Levallois Perret, France.

If the Insured persons are not satisfied by MAI’s response, they can send a standard letter or email to: MGEN International Benefits, 7 Square Max Hymans, 75748 Paris Cedex 15, France or clients@mgen-ib.com.

In the event of disagreement with a decision by the Insurer and having exhausted all means of appeal offered by the Insurer, the Insured person may contact the MGEN ombudsman at MGEN – Monsieur le Médiateur – 3, Square Max Hymans – 75748 Paris Cedex 1 or email mediation@mgen.fr.

The Ombudsman’s opinion is not binding on the parties in dispute and they retain the right to bring proceedings before the competent court. The Ombudsman is not authorised to give an opinion on insurance admissibility conditions. The terms and conditions of the Ombudsman’s intervention can be consulted on the website www.mgen.fr (mediation section) or obtained on request from the postal address above.

To help us resolve your complaint, please supply the following information:

• your name and membership details
• a contact telephone number
• a description of your complaint
• any relevant information relating to your complaint that we may not have already seen.

Data protection notice

We collect and maintain personal information in order to underwrite and administer the policies of insurance that we issue. All personal information is treated with the utmost confidentiality and with appropriate levels of security. We will not keep your information longer than is necessary. Your information will be protected from accidental or unauthorised disclosure. We will only reveal your information if it is allowed by law, authorised by you, to prevent fraud or in order that we can liaise with our agents in the administration of this policy.

Where personal information is collected about individuals in connection with the arranging of insurance, this information will be collected and processed in accordance with our Privacy Policy which can be viewed on our website: https://integraglobal.com/ig/privacy-policy. Alternatively, you can contact us for a copy.

You have the right to ask for a copy of any information we hold on you and to require a correction of any incorrect information held. Any inaccurate or misleading data will be corrected as soon as possible. The above principles apply whether we hold your information on paper or in electronic form.

Enquiries in relation to data held by MGEN should be directed to Data Protection, MGEN, Centre de gestion de la Verrière, Gestion CNIL, Cs 10601 La Verrière 6 bis avenue Joseph Rollo, 78321 Le Mesnil Saint Denis Cedex, France, enclosing a photocopy of both sides of a valid identity card.

Life Cover lump sum in case of death

A lump sum is paid in case of death (all causes) of an adult Insured Person depending on the plan chosen and as listed in your Table of Benefits.

Unless you have designated a particularly beneficiary, the benefit in the case of the Insured’s death is attributed by order of preference:

• to the spouse not legally separated from the Insured,
• failing him/her, to the civil union partner
• in the absence of the latter, to the Insured’s children born or to be born equally shared between them, the share of the predeceased going to his own children or to his brothers and sisters if he has no children
• in the absence of the latter, to the mother and father, equally shared between them, or to the surviving parent in the case of predecease
• in the absence of the latter, to the heirs.

The Insured can modify the above order at any time and designate any natural or legal person of his choice by sending a registered letter to the Insurer with request for acknowledgement of receipt.

When the beneficiary is specifically named, the Insured must indicate the contact details of the beneficiary so that the Insurer can use them in the event of death. Where the personal designation lapses, the above standard designation shall apply.

The designation of a beneficiary becomes irrevocable by the acceptance of the beneficiary. Acceptance by authentic deed or private deed signed by the Insured and the beneficiary must be notified to the Insurer in order to take effect.

In the case of death of an Insured and one or more designated beneficiaries during the same event without it being possible to determine the order of death, or when the beneficiary who died before the Insured, did not have time to accept the benefit of the payment, the Insured is assumed to have survived when determining the beneficiaries of the payment.

Sums due under this benefit, which are not the subject of a request for payment, are deposited to the ‘Caisse des Dépôts’ after a period of 10 years from the date on which the Insurer becomes aware of the Insured’s death. Six months prior to the transfer of the sums due to ‘Caisse des Dépôts’, the Insurer shall inform the beneficiary(s) of the transfer. For 20 years from the transfer of the sums due to the ‘Caisse des Dépôts’, the beneficiaries can approach the latter to claim their sums. The lump sum paid to natural persons is revalued “post-mortem” in accordance to a rate in accordance with French Decree.

Specific exclusions

The coverage excludes in any case:

• the consequences of a civil or non-civil war, an insurrection, a riot, an attack, a commotion or acts of terrorism, whatever the place of these events and their protagonists, except if the insured person does not take an active part in such event
• the consequences of an illness or accident intentionally provoked by the covered person, intentional self-injuries or suicide attempt, the participation in any sport as a professional.

Accidental death and disablement (AD&D)

Specific accidental death and disablement definitions

The following additional definitions apply to this section:

Annual salary means the total remuneration from your primary employer as declared. It excludes bonuses, overtime, commissions and any other financial incentives or benefits.

Bodily injury means physical injury resulting from an accident to your body resulting in your death, loss of sight or loss of limb being incurred.

Loss of hand/hands/arm/arms means loss by physical separation of a hand at or above the wrist and includes total and irrecoverable loss of use of the hand or arm.

Loss of limb means loss by physical separation of a hand at or above the wrist or of a foot at or above the ankle and includes total and irrecoverable loss of use of hand, arm, foot or leg.

Loss of foot/feet/leg/legs means loss by physical separation of a foot at or above the ankle and includes total and irrecoverable loss of use of the foot or leg.

Loss of sight of one eye means total and permanent loss of sight in one eye.

Loss of sight of both eyes eyes means total and permanent loss of sight in both eyes.

Accidental death and disablement cover

If during the period of insurance an insured person sustains bodily injury resulting from an accident we will pay to the insured person the benefit specified in the certificate of insurance attached to and forming part of this policy subject to:

1. payment of the premium specified; and
2. the terms, conditions and exclusions of this policy.

Specific accidental death and disablement exclusions

The following additional exclusions apply to this section:

1. From the insured person(’s):
   1. engaging in:
      1. riding or driving in any kind of race,
      2. horse riding,
      3. riding on a motorcycle as a driver or passenger,
      4. rock climbing or mountaineering of any type,
      5. hang-gliding, paragliding, parachuting or bungee jumping,
      6. snow skiing or snowboarding whilst away from prepared and marked runs and/or against the advice of the local ski school or local authoritative body;
      7. sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, accompanied by a certified instructor, and at depths of less than 10 meters; or
      8. aviation except when traveling by air as a fare paying passenger;
   2. bodily injury resulting from any occupation not declared to and accepted by us.
   3. being a member of the police or armed forces of any nation or international authority or a member of any reserve forces;
   4. being under the influence of alcohol or drugs, otherwise than under the direction of a registered medical practitioner provided that such direction is not for treatment for drug addiction or dependence;
2. Sickness or disease not directly resulting from bodily injury;
3. From or is traceable to or is caused by any gradually developing deterioration whatever the cause of that deterioration;
4. Work related accidents other than from normal crew activities;
5. War, hostilities (whether war be declared or not), terrorist activity, revolution, military or usurped power, civil commotion or any similar event;
6. Radiation or contamination or the effects of radiation;
7. After the expiry of the period of insurance during which the insured person attains the age of 65 years; or
8. From any injury arising more than 12 months after the accident giving rise to bodily injury.

Specific accidental death and disablement conditions

1. The insured must declare to us all facts which are likely to affect this cover. Failure to do so may prejudice a claim. If there is doubt whether or not a fact is material it should be declared to us.
2. Any benefit payable under this policy will be payable to the insured unless otherwise specified in writing and agreed by us.
3. The insured person must take all reasonable steps to avoid or minimise any claim and must avoid needless self-exposure to peril unless attempting to save human life.
4. The maximum sum payable under this policy in respect of any one accident to any one insured person shall not exceed the largest of any one benefit specified in the schedule applicable to that insured person.
5. The maximum benefit payable in respect of any one Accident resulting in bodily injury to more than one insured person shall not exceed the aggregate limit specified in the table of benefits and in any case shall not exceed two times annual salary.
6. Written notice must be given to us as soon as practicable in the event of any change in an insured person’s occupation or country of residence involving increased personal hazard. Bodily injury arising from such changed occupation will not be covered hereunder until our agreement has been obtained and any additional premium that may be required has been paid. We reserve the right to withhold such agreement.
7. Cover shall not apply where the period of insurance is less than two complete months.
8. In the event of a claim under this section notice must be sent to us as soon as practicable. The insured person will permit our own appointed medical adviser or advisers to examine them as often as may be deemed necessary.

eHealth records account in partnership with, and powered by Medelinked

The eHealth records account is available to all adults covered under our yourLife, yourFamily, premierLife and premierFamily plans. We have teamed up with Medelinked, a leading online electronic health records storage service, to keep your health records secure and accessible from anywhere, 24-hours-a-day.

The unique system enables you to build your health picture online which you can then share securely with your trusted health partners. Bringing your records together is easy, you update your known information and connect with your health providers such as your doctor, specialist or optician to request them to upload records and contribute to your health picture.

Your eHealth records account empowers you to have greater control over your health by having your information available when you need it. It enables your health providers to make more informed health decisions based on your essential medical information. All of your health plan documentation has been conveniently loaded onto your account for easy access in times when you might not have access to your member ID card or plan documents.