Employee Benefit Guide

Transcription

1 International Healthcare Plans for Qatar Employee Benefit Guide Valid from 1 st November 2012

2 Welcome to Allianz Worldwide Care Limited Thanks to a package negotiated by your company, you and your family can now depend on us to give you access to the very best care possible wherever you are in the world. We provide flexible, comprehensive and reliable international health insurance, built upon a commitment to service excellence. This guide sets out the standard benefits and rules of your group healthcare insurance policy. Please read this Employee Benefit Guide in conjunction with your Insurance Certificate, Table of Benefits and Access Card to ensure that you fully understand your level of cover. Acceptance and use of the Access Card automatically implies acceptance of all the terms, conditions, limitations and exclusions of this policy. For full details of your company s insurance contract, please contact your company s Group Scheme Manager. Allianz Worldwide Care Limited. QFC Branch address: Regus West Bay, 14th floor, Al Fardan Office Tower, PO Box 31316, Doha, Qatar. Phone: Fax: Website: Authorised by the Qatar Financial Centre Regulatory Authority. Allianz Worldwide Care Limited is incorporated in Ireland. 3

3 Table of contents Introduction 5 What you are covered for 6-27 Emergency Assistance 6 Helpline Service 6 Access Card 7 Network of clinics/hospitals and pharmacies in Qatar 7 Online Services 8 Hospital, Doctor and Health Practitioner Finder 9 Benefit limits 9 Medical necessity 10 Chronic conditions 10 Pre-existing conditions 11 Out-patient Plan deductible 11 Where you are covered 11 Your Core Plan explained 12 Other Benefits under your Core Plan 14 Your Out-patient Plan explained 23 Your Dental Plan explained 25 Your Repatriation Plan explained 25 Paying premiums and general information Paying premiums 35 Important events 35 General information 38 How to access treatment Cashless access to medical care within the Qatar network 42 How to claim for treatment outside of the Qatar network 43 How to claim for treatment taking place outside of Qatar 47 Claims for accidental death 47 Pre-authorization 48 Questions answered 53 Making a complaint 54 Definitions Additional policy terms What your healthcare cover does not pay for

4 Introduction Details of your health insurance policy. The overall purpose of this policy is to provide cover for reasonable and customary expenses incurred through the medically necessary treatment of medical conditions, illnesses and injuries as covered within the terms of the policy. This guide outlines what is covered under your policy, explains how to access medical care and provides details of the terms and conditions of your policy. For full details of your insurance cover, please read this document carefully in conjunction with your Insurance Certificate, Table of Benefits and Access Card. Acceptance and use of the Access Card automatically implies acceptance of all the terms, conditions, limitations and exclusions of this policy. 5

5 What you are covered for The following is an overview of your healthcare cover. Your Table of Benefits specifies the plan(s) selected by your company. This could be one of our standard Core Plans, which might have been chosen in combination with one of our standard Out-patient, Dental or Repatriation Plans. On the other hand, your plan may have been designed specifically for your company. This section provides an outline of the cover we provide. Please be aware that this cover is subject to our policy definitions, exclusions and limitations. If you have any queries regarding the cover provided under your plan, simply contact our Helpline for confirmation of your entitlements. Emergency Assistance In the event that you require emergency medical treatment in a hospital or clinic, you should contact our Helpline as soon as possible. Pre-authorization is not required in advance of emergency cases, however, we 6 must be advised within 48 hours of the event. For further details on pre-authorization, please refer to pages 49 to 51. Helpline Service Our team of professional, multilingual staff are available 24 hours a day, 7 days a week to handle your policy enquiries. Helpline staff has instant access to your policy details and any historical communication with us so that we can provide you with the assistance you require e.g. confirmation of cover or an update on the status of your claim. You can contact us by , phone or fax as follows: Helpline Tel: Fax: client.services@allianzworldwidecare.com Please note that only the policyholder (or an appointed representative) or the Group Scheme Manager can make changes to the policy. Security questions will be asked of all callers, in order to verify their identity.

6 A toll-free number is available to call our Helpline from Qatar. For our latest list of toll-free numbers, please visit: Please note that in some instances the toll-free numbers are not accessible from a mobile phone. In this case, please dial the Helpline number indicated in the previous page. Access Card A personalised Access Card which contains essential contact numbers is issued to every insured member. This means that you and your family are only a phone call away from help. We suggest that you keep this card with you at all times. This card aims to establish your identity and allows you to access the network of clinics, hospitals and pharmacies assigned to your healthcare plan. It is not transferable and should be returned or destroyed when membership ceases. The validity of the card is subject to continuity of membership. Network of clinics/hospitals and pharmacies in Qatar We have contractual arrangements in place with a large number of clinics/hospitals and pharmacies in Qatar. Each of these clinics/hospitals and pharmacies, upon being presented with your Access Card (plus the Pharmacy Services Claim Form, in the case of pharmacies) will provide their services and products without seeking immediate payment from you (unless the prescribed treatment is specifically excluded under your policy with us). Please note that cover provided under the following benefits is available on a reimbursement basis only i.e. you will have to pay for eligible treatment and then complete 7

7 Allianz Worldwide Care What you are covered for and submit a Claim Form for: - Routine health checks including screening for early detection of illness or disease - Prescribed glasses and contact lenses - All dental benefits covered under the Dental Plans A list of the network of medical providers is issued to you with this Employee Benefit Guide. For more information on how to access treatment, please refer to page 42 to 52. Online Services If your company has requested this facility, you can access our secure Online Services at: Simply use the login details sent to you in a letter included as part of your Membership Pack. Alternatively, if you have not already received your login details, you can access your online account by clicking the register link in the members area. Please type in your policy number, surname and date of birth, exactly as shown on your Membership Pack documents. An automated containing your login details will then be sent to the address we have on record for you (if this has been provided to us). Online Services allows you to: View and amend your personal details online (if your group is not using a collective address). Securely retrieve a lost or forgotten username and password. Download your Insurance Certificate and Employee Benefit Guide. An Access ecard can also be downloaded in PDF format. View your Table of Benefits and check how much 8

8 remains payable under each benefit limit. Confirm the status of any claims submitted to us and view claims related correspondence. For Online Services assistance, please contact our Helpline. Hospital, Doctor and Health Practitioner Finder Our Medical Provider directory is available on the website: This online directory allows you to search for hospitals, clinics, doctors and specialists on a country by country basis, with the ability to narrow down the search to specific regions and cities. Users can also search under Medical Practitioner categories e.g. Internal Medicine, as well as on specialism e.g. General Surgery, Neurosurgery or Traumatology etc. You are not restricted to using the providers listed in this directory. Benefit limits There are two kinds of benefit limits shown in the Table of Benefits. The maximum plan benefit, which applies to certain plans, is the maximum we will pay for all benefits in total, per member, per Insurance Year, under that particular plan. Some benefits also have a specific benefit limit, for example 'Nursing at home or in a convalescent home'. Specific benefit limits may be provided on a per Insurance Year basis, a per lifetime basis or on a per event basis, such as per trip, per visit or per pregnancy. In some instances we will pay a percentage of the costs for the specific benefit e.g. 65% refund, up to US$7,100. Where a specific benefit limit applies or where the term Full refund appears next to certain benefits, 9

9 Allianz Worldwide Care What you are covered for the refund is subject to the maximum plan benefit, if one applies to your plan(s). All limits are per member, per Insurance Year, unless otherwise stated in your Table of Benefits. Medical necessity their charges are reasonable and customary. By reasonable and customary we mean that the charges are in accordance with standard and generally accepted medical procedures. If a claim is deemed by us to be inappropriate, we reserve the right to reduce the amount payable by us. As an insurance company, our clients expect us to control medical costs, where possible, in order to maintain affordable health insurance premiums. To do this, our team of highly experienced medical professionals ensures that planned medical interventions are appropriate and medically necessary. By medically necessary we mean treatment that is the most appropriate type and level of service required to treat a patient's condition, illness or injury. In addition, our team of claims experts will ensure that we only reimburse medical providers where If you are uncertain whether your planned medical treatment is covered under your policy, please contact our Helpline. Chronic conditions A chronic condition is defined as a sickness, illness, disease or injury which has one or more of the following characteristics: Is recurrent in nature. Is without a known, generally recognised cure. Is not generally deemed to respond well to 10

10 treatment. Requires palliative treatment. Requires prolonged supervision or monitoring. Leads to permanent disability. Please refer to the Notes section of your Table of Benefits to confirm if chronic conditions are covered within the limits of your plan(s). Pre-existing conditions Pre-existing conditions are medical conditions or any related conditions for which one or more symptoms have been shown at some point during the five years prior to commencement of cover, irrespective of whether any medical treatment or advice was sought. Any such condition or related condition, about which you or your dependants could reasonably have been assumed to have known, will be deemed to be pre-existing. Out-patient Plan deductible An Out-patient Plan deductible is an amount payable by you in respect of any out-patient treatment, i.e. treatment that does not require admission to hospital. Please refer to your Access Card to determine the amount of deductible (if any), that applies to your out-patient benefits. Where applied, deductibles are payable per person, per Insurance Year (unless indicated otherwise in the Table of Benefits). Where you are covered Please refer to your Access Card to confirm your geographical area of cover (unless you have been advised otherwise). 11

11 Allianz Worldwide Care What you are covered for Where the necessary medical treatment for which you are covered is not available locally, you can avail of treatment in any country within your geographical area of cover. In order to seek reimbursement for medical treatment and travel expenses incurred, you will need to submit a Pre-authorization Form for approval prior to travel. Where the necessary medical treatment for which you are covered is available locally, but you choose to travel to another country within your area of cover for treatment, we will reimburse all eligible medical costs incurred within the terms of your policy; however, we will not pay for travel expenses incurred. Your Core Plan explained The following section gives a summary of the range of benefits which we offer. Please note that those available to you will be listed in your Table of Benefits. In-patient benefits You are covered for in-patient treatment under your Core Plan, subject to the limits stated on your Table of Benefits. In-patient benefits include things like hospital accommodation, anaesthesia and theatre charges, surgical fees, surgical appliances, prostheses and diagnostic tests. Please refer to your Table of Benefits for details of the in-patient benefits available to you. Pre-authorization is required in advance of all in-patient benefits listed in the Table of Benefits. In-patient psychiatry and psychotherapy Please refer to the Table of Benefits to determine if psychiatry and psychotherapy cover is included in your plan. 12

12 Accommodation costs for one parent staying in hospital with an insured child under 18 In the event of an insured child requiring hospitalization, the cost of one parent s accommodation staying with a child under 18 years of age will be covered for the duration of the admission to hospital. In the event that no suitable bed is available in the hospital, we will cover the equivalent of a three star hotel daily room rate, unless agreed otherwise between your company and us. Please refer to your Table of Benefits to determine the level of cover available under your plan. Accommodation costs for an accompanying person staying in hospital in same room in cases of critical conditions In the event of an insured member requiring hospitalization, the cost of an accompanying person staying in the same hospital room will also be covered for the duration of the insured member s admission for eligible treatment, if the insured member is in a critical condition, i.e. the condition is potentially life threatening. Please refer to your Table of Benefits to determine the level of cover available under your plan. Emergency in-patient dental treatment If cover for emergency in-patient dental treatment is included in your Table of Benefits, this provides you and your dependants with a full refund for emergency dental treatment due to a serious accident requiring hospitalization. Please note that cover under this benefit does not extend to follow-up dental treatment, dental surgery, dental prostheses, orthodontics or periodontics. If cover is provided for these benefits, it will be listed separately in your Table of Benefits. 13

13 Allianz Worldwide Care What you are covered for Other benefits under your Core Plan Your company may have included some or all of the following benefits in your plan. Please note that those available to you will be listed in your Table of Benefits. Day-care treatment If this benefit is included, cover is provided for planned day-care treatment received in a hospital or day-care facility. Please note that pre-authorization is required. Out-patient surgery day-care facility or out-patient department. Please note that pre-authorization is required. Nursing at home or in a convalescent home If cover is provided for this benefit, you will be entitled to claim for nursing received at home or in a convalescent home, if the nursing is provided immediately after or instead of hospitalization. The maximum amount available under this benefit is indicated in the Table of Benefits. Please note that pre-authorization is required. Please also note that this benefit is not payable in respect of palliative care or long term care, which, where provided, is covered under a separate benefit. Rehabilitation treatment If this benefit is included, cover is also provided for surgical procedures performed in a surgery, hospital, If cover is provided for this benefit, it is for treatment which takes place in a licensed rehabilitation facility, 14

14 immediately after the acute medical treatment ceases. The level of cover provided is indicated in the Table of Benefits. Please note that pre-authorization is required. Local ambulance If this benefit is listed in your Table of Benefits, cover is provided for ambulance transport required for an emergency or due to medical necessity, to the nearest available and appropriate hospital or licensed medical facility. The level of cover provided is indicated in the Table of Benefits. Emergency treatment outside area of cover If this benefit has been selected by your company, you and your dependants will be covered for emergencies only, which occur during business and holiday trips outside of your chosen area of cover (where relevant). Cover is provided up to a maximum period of six weeks per trip within the maximum benefit amount. You will not be covered for any curative or follow-up non-emergency treatment, even if deemed unable to travel to a country within your geographical area of cover. If you are moving outside your area of cover for more than six weeks, you should contact your company s Group Scheme Manager. Not only are you covered in the event of an accident, but you are also covered for the sudden beginning or worsening of a severe illness which results in a medical condition that presents an immediate threat to your health. To be considered as emergency treatment, and thus covered under this benefit, please remember that the medical treatment provided by a physician, medical practitioner or specialist should commence within 24 hours of the emergency event. Charges relating to maternity, 15

15 Allianz Worldwide Care What you are covered for pregnancy, childbirth or any complications of pregnancy or childbirth are excluded from this benefit. Medical evacuation This benefit provides for ambulance, helicopter or airplane transportation to the nearest appropriate medical centre (which may or may not be located in your home country), if the necessary treatment for which you are covered is not available locally or if adequately screened blood is unavailable in the event of an emergency. The medical evacuation will be carried out in the most economical way, having regard to your medical condition. Your physician should request the medical evacuation. Please note that pre-authorization is required. If medical necessity prevents the insured member from undertaking the evacuation or transportation following discharge from an in-patient episode of care, we will cover the reasonable costs of hotel accommodation up to a maximum of seven days, comprising of a private room with en-suite facilities. We do not cover costs for hotel suites, four or five star hotel accommodation or hotel accommodation for an accompanying person. Where an insured member has been evacuated to the nearest appropriate medical centre for ongoing treatment, we will also cover the reasonable cost of hotel accommodation comprising of a private room with en-suite facilities. The cost of such accommodation must be more economical than successive transportation costs to/from the nearest appropriate medical centre and the principal country of residence. Hotel accommodation for an 16

16 accompanying person is not covered. Please note that pre-authorization is required. Where adequately screened blood is not available locally, we will, where appropriate, endeavour to locate and transport screened blood and sterile transfusion equipment where this is advised by the treating physician. We will also endeavour to do this when our medical experts so advise. Neither we, nor our agents accept any liability in the event that such endeavours are unsuccessful or in the event that contaminated blood or equipment is used by the treating authority. Expenses for one person accompanying an evacuated/repatriated person If this benefit is included in your Table of Benefits, one person will be entitled to travel with the evacuated or repatriated person. If this cannot take place in the same transportation vehicle, round trip transport at economy rates will be paid for. There is a maximum amount that can be claimed under this benefit, as indicated in the Table of Benefits. Please note that hotel accommodation or other related expenses are not covered and that pre-authorization is required. Travel costs of insured family members in the event of an evacuation If this cover is provided under your plan, all insured family members will be entitled to travel with the evacuated person. If this cannot take place in the same transportation vehicle, round trip transport at economy rates will be paid for. There may be a maximum amount that can be claimed under this benefit, and if so, this will be indicated in the Table of 17

17 Allianz Worldwide Care What you are covered for Benefits. Please note that cover does not extend to hotel accommodation or other related expenses and that pre-authorization is required. Repatriation of mortal remains your Table of Benefits. Please note that preauthorization will be required. Travel costs of insured family members in the event of the repatriation of mortal remains Where covered, in the event of death we will provide a maximum benefit as indicated in the Table of Benefits, to cover the cost of transportation of the insured person s mortal remains from the principal country of residence to the country of burial. Covered expenses include, but are not limited to, expenses for embalming, a container legally appropriate for transportation, shipping costs and the necessary government authorizations. Cremation costs will only be covered in the event that this is required for legal purposes. Costs incurred by any accompanying persons are not covered unless this is listed as a specific benefit in If this benefit is provided under your plan, we will pay reasonable transportation costs for any insured family members who had been residing abroad with the deceased member, to return to the home country/chosen country of burial of the deceased. There may be a maximum amount that can be claimed under this benefit, and if so, this will be indicated in the Table of Benefits. Please note that cover does not extend to hotel accommodation or other related expenses and that pre-authorization is required. 18

18 CT, MRI, PET and CT-PET scans Routine maternity Unless agreed otherwise between your company and us, CT, MRI, PET and CT-PET scans carried out on an inpatient or out-patient basis, are fully covered within the limits of your Core Plan. Pre-authorization is not needed for CT scans; however, it is always required for MRI, PET and CT-PET scans. The level of cover provided is indicated in your Table of Benefits. Oncology If this benefit has been selected by your company, you will be covered, from the point of diagnosis, for specialist fees, diagnostic tests, radiotherapy, chemotherapy and hospital charges incurred in relation to the planning and carrying out of treatment for cancer, up to the amount specified in your Table of Benefits. Pre-authorization is required for in-patient and day-care treatment. Where covered, routine maternity refers to medically necessary costs incurred during pregnancy and childbirth, including hospital charges, specialist fees, the mother's pre- and post-natal care, midwife fees (during labour only) as well as newborn care. Any non-medically necessary caesarean sections will be covered up to the cost of a routine delivery in the same hospital, subject to any benefit limit in place. Costs related to complications of pregnancy and childbirth are not payable under routine maternity. The level of cover provided is indicated in the Table of Benefits. Please note that a benefit limit may apply, on either a per pregnancy or per Insurance Year basis. If your benefit limit is payable on a per pregnancy basis, this benefit limit will be applied to the year in which the birth takes place. Please refer to your Table of Benefits for details. Pre-authorization is required for 19

19 Allianz Worldwide Care What you are covered for in-patient treatment only. Complications of pregnancy and childbirth If this is included in your Table of Benefits, complications of pregnancy relate to the health of the mother. Only the following complications that arise during the pre-natal stages of pregnancy are covered: ectopic pregnancy, gestational diabetes, preeclampsia, miscarriage, threatened miscarriage, stillbirth and hydatidiform mole. Complications of childbirth refer only to the following conditions that arise during childbirth and that require a recognised obstetric procedure: post-partum haemorrhage and retained placental membrane. Where the insured s plan also includes a routine maternity benefit, complications of childbirth shall also refer to medically necessary caesarean sections. Please note that a benefit limit may apply. Preauthorization is required for in-patient treatment. Home delivery If this benefit has been selected by your company, a lump sum will be paid, following a home delivery, as indicated in the Table of Benefits. Cover for newborn children Unless otherwise agreed between your company and us, the following will apply: Newborn infants will be accepted for cover from birth, provided that we are notified within four weeks of the date of birth. To have a newborn added to the policy, you must ask your company to submit a request in writing to its usual contact person for membership changes. Notification of the birth after four weeks will 20

20 result in newborn children being accepted for cover from the date of such notification. In-patient treatment for multiple birth babies born as a result of medically assisted reproduction will be covered up to US$42,500 per child for the first three months following birth. Out-patient treatment is paid within the terms of the Out-patient Plan. In-patient cash benefit Emergency out-patient treatment If this benefit has been included, cover includes treatment received in a casualty ward or emergency room, following an accident or sudden illness. To be considered an emergency, the treatment must be received within 24 hours of the emergency event. You are covered up to the amount specified in your Table of Benefits. If this benefit appears in your Table of Benefits, a specified amount will be paid to you for each night you spend in hospital, up to a specified maximum number of nights per Insurance Year. The benefit is only payable where treatment is received completely free of charge and in respect of treatment that is covered within the terms of your policy. The amount payable per night will be indicated in your Table of Benefits. However, if your company also selected an Out-patient Plan for you, you will also be covered, under the terms of this plan, for out-patient treatment in excess of the emergency cover benefit limit. Emergency out-patient dental treatment If selected by your company, this cover includes treatment received in a dental surgery or hospital 21

21 Allianz Worldwide Care What you are covered for emergency room for the immediate relief of dental pain. Cover includes temporary fillings limited to three fillings per Insurance Year, and/or the repair of damage caused in an accident. The treatment must be received within 24 hours of the emergency event. Please note that cover does not extend to dental prostheses or root canal treatment. However, if your company also selected a Dental Plan for you, you will be covered, under the terms of this plan, for dental treatment in excess of the emergency cover benefit limit. Please note that cover provided under a Dental Plan is on a reimbursement basis only you will have to pay for eligible treatment and then complete and submit a Claim Form. Palliative care and long term care If this benefit is included in your Table of Benefits, we will cover the costs for ongoing treatment aimed at alleviating the physical/psychological suffering associated with progressive, incurable illness and maintaining quality of life. Please note that cover is limited to the benefit limit stated in your Table of Benefits and pre-authorization is required for long term care as well as for palliative care. Accidental death If this benefit is included in your Table of Benefits, a lump sum will be payable in the event of the accidental death of any adult members aged 18 to 70. The Table of Benefits will state the amount of the lump sum. Insured members wishing to nominate a beneficiary other than those listed in the Claims for 22

22 accidental death section of this guide (pages 47 to 48) may do so by contacting our Helpline. Your Out-patient Plan explained If your company has included out-patient treatment in your cover, the appropriate Out-patient Plan name, along with the benefits provided, will be indicated in your Table of Benefits. Your Out-patient Plan will include some or all of the following benefits: Medical practitioner fees. Prescription drugs. Specialist fees. Diagnostic tests. Vaccinations. Chiropractic treatment, osteopathy, homeopathy, Chinese herbal medicine and acupuncture. Prescribed physiotherapy, speech therapy, oculomotor therapy and occupational therapy. Routine health checks including cancer screening for early detection of illness or disease (further details provided in the following section). Infertility treatment (further details provided in the following section). Psychiatry and psychotherapy. Prescribed medical aids. Prescribed glasses and contact lenses. Please note that pre-authorization is required for occupational therapy (out-patient treatment only) unless otherwise stated. 23

23 Allianz Worldwide Care What you are covered for Routine health checks including screening for early detection of illness or disease Unless agreed otherwise between your company and us, your plan will provide cover for routine health checks, tests and examinations, performed at an appropriate age interval, for the early detection of illnesses or diseases. Tests and exams include: Cardiovascular exam. Neurological exam. Cancer screening: - Annual pap smear. - Mammogram (for women aged 50+, or earlier where a family history exists). - Prostate screening (for men aged 50+, or earlier where a family history exists). Well child test (for children up to the age of six, up to a maximum of 15 visits per lifetime). Infertility treatment Unless agreed otherwise between your company and us, your policy will provide cover for non-invasive investigations into the cause of infertility, within the limits of your Out-patient Plan, if one has been selected for you. If your Table of Benefits includes a specific benefit for infertility treatment, you will also be covered for further investigation necessary to establish the cause of infertility, such as hysterosalpingogram, laparoscopy or hysteroscopy. Please note, that in-patient treatment for multiple birth babies born as a result of medically assisted reproduction will be covered up to US$42,500 per child for the first three months following birth. Out-patient treatment is paid within the terms of the Out-patient Plan. 24

24 Your Dental Plan explained If your company selected dental cover for you, this will be indicated in your Table of Benefits along with the associated benefits and levels of refund. Please note that your Dental Plan may contain a maximum plan benefit. Dental Plans are available on a reimbursement basis only. Members must pay for dental treatment and then use the Claim Form to obtain reimbursement for eligible expenses. Your Repatriation Plan explained Medical repatriation If the necessary treatment for which you are covered is not available locally, your Repatriation Plan will enable you to return to your home country for treatment rather than to the nearest appropriate medical centre. This only applies when your home country is located within your geographical area of cover. Following completion of treatment, we will also cover the cost of the return trip, at economy rates, to your principal country of residence as long as the return journey is made within one month of completion of treatment. Pre-authorization is required. This is an optional plan and if selected by your company, it will be listed in your Table of Benefits. 25

25 Allianz Worldwide Care What you are covered for Expenses for one person accompanying a repatriated person If this cover is available under your plan, one person will be entitled to travel with the repatriated person. If this cannot take place in the same transportation vehicle, round trip transport at economy rates will be paid for. There may be a maximum amount that can be claimed under this benefit, and if so, this will be indicated in the Table of Benefits. Please note that hotel accommodation and other related expenses are not covered and that pre-authorization is required. Travel costs of insured family members in the event of a repatriation If this cover is provided under your plan, all insured family members of the repatriated person will be entitled to travel with the repatriated person. If this cannot take place in the same transportation vehicle, round trip transport at economy rates will be paid for. There may be a maximum amount that can be claimed under this benefit, and if so, this will be indicated in the Table of Benefits. Please note that cover does not extend to hotel accommodation or other related expenses and that pre-authorization is required. Travel costs of insured members to be with a family member who is at peril of death or who has died If this cover is provided under your plan, we will cover reasonable transportation costs (up to the amount specified in your Table of Benefits) so that insured family members can travel to the location of a first degree relative who is at peril of death or who 26

26 has died. Claims are to be accompanied by a death certificate or doctor s certificate and cover will be limited to one claim per lifetime of the policy. Cover does not extend to hotel accommodation or other related expenses. 27

27 What your healthcare cover does not pay for Although we cover most illnesses, expenses incurred for the following treatments, medical conditions and procedures are not covered under the policy unless they are confirmed in the Table of Benefits, in any written policy endorsement or unless agreed otherwise between your company and us. 1. Treatment outside the geographical area of cover, unless for emergencies or authorized by us. 2. Pre-existing conditions (including any pre-existing chronic conditions) are covered under this policy, unless indicated otherwise in the Table of Benefits. 3. Products classified as vitamins or minerals (except during pregnancy or to treat diagnosed, clinically significant vitamin deficiency syndromes), nutritional or dietary consultations and supplements, including, but not limited to, special infant formula and cosmetic products, even if medically recommended or prescribed or acknowledged as having therapeutic effects. 4. Products that can be purchased without a doctor s prescription. 5. Unless the Table of Benefits includes a specific benefit for infertility treatment, cover is limited to non-invasive investigations into the cause of infertility, within the limits of your Out-patient Plan. 6. Unless stated otherwise in the Table of Benefits, cover is not provided for investigations into, treatment and complications arising from sterilisation, sexual dysfunction and contraception, including insertion and removal of contraceptive devices and all other contraceptives, even if prescribed for medical reasons. The only exception is the prescribing of contraceptives for the treatment of acne, where prescribed by a dermatologist. 28

28 7. Termination of pregnancy, except in the event of danger to the life of the pregnant woman. 8. In-patient treatment for multiple birth babies born as a result of medically assisted reproduction is limited to US$42,500 per child for the first three months following birth. Out-patient treatment is paid within the terms of the Out-patient Plan. 9. Any treatment carried out by a plastic surgeon, whether or not for medical/psychological purposes and any cosmetic or aesthetic treatment to enhance your appearance, even when medically prescribed. The only exception is reconstructive surgery necessary to restore function or appearance after a disfiguring accident, or as a result of surgery for cancer, if the accident or surgery occurs during your membership of the scheme. 10. Stays in a cure centre, bath centre, spa, health resort and recovery centre, even if the stay is medically prescribed. 11. Care and/or treatment of intentionally caused diseases or self-inflicted injuries, including a suicide attempt. 12. Care and/or treatment of drug addiction or alcoholism including smoking related treatments. 13. Illnesses, accidents and the consequences thereof, as well as instances of death that are related to the misuse of alcohol or drugs by the insured person. 14. Developmental delay unless a child has not attained developmental milestones expected for a child of that age in cognitive or physical development. We do not cover conditions in 29

29 Allianz Worldwide Care What your healthcare cover does not pay for which a child is slightly or temporarily lagging in development. The developmental delay must have been quantitatively measured by qualified personnel and documented as a 12 month delay in cognitive and/or physical development. 15. We do not cover treatment for conditions such as conduct disorder, attention deficit hyperactivity disorder, autism spectrum disorder, oppositional defiant disorder, antisocial behaviour, obsessivecompulsive disorder, attachment disorders, adjustment disorders, eating disorders or treatments that encourage positive socialemotional relationships, such as communication therapies, floor time and family therapy. 16. Speech therapy is only eligible for reimbursement in the context of a diagnosed physical impairment such as, but not limited to, nasal obstruction, neurogenic impairment (e.g. lingual paresis, brain injury) or articulation disorders involving the oral structure (e.g. cleft palate). We do not pay for speech therapy related to developmental delay, dyslexia, dyspraxia or expressive language disorder. 17. Psychotherapy treatment on an in-patient or out-patient basis, is only covered where you or your dependants are initially diagnosed by a psychiatrist and referred to a clinical psychologist for further treatment. 18. Where covered, out-patient psychotherapy treatment is initially restricted to 10 sessions per condition, after which treatment must be reviewed by the referring psychiatrist. Should further sessions be required, a progress report must be submitted to us, which indicates the medical necessity for any further treatment. Costs in respect of a family therapist or counsellor are not covered. 30

30 19. Treatment for any illnesses, diseases or injuries resulting from active participation in war, riots, civil disturbances, terrorism, criminal acts or acts against any foreign hostility, whether war has been declared or not. 20. Treatment for any medical conditions arising directly or indirectly from chemical contamination, radioactivity or any nuclear material whatsoever, including the combustion of nuclear fuel. 21. Treatment of sleep disorders, including insomnia. 22. Expenses for the acquisition of an organ including, but not limited to, donor search, typing, harvesting, transport and administration costs. 23. Treatment or diagnostic procedures for injuries arising from an engagement in professional sports. 24. Any form of treatment or drug therapy which in our reasonable opinion is experimental or unproven based on generally accepted medical practice. 25. Orthomolecular treatment (please refer to Definition 1.47). 26. Consultations performed, as well as any drugs or treatments prescribed by you, your spouse, parents or children. 27. Medical practitioner fees for the completion of a Claim Form or other administration charges. 28. Home visits, unless they are necessary following the sudden onset of an acute illness, which renders the insured incapable of visiting their medical practitioner, physician or therapist. 31

31 Allianz Worldwide Care What your healthcare cover does not pay for 29. Genetic testing except for DNA tests when directly linked to an eligible amniocentesis i.e. in the case of women aged 35 or over. 30. Pre- and post-natal classes. 31. Triple/Bart s, Quadruple or Spina Bifida tests, except for women aged 35 or over. 32. Investigations into, and treatment of, obesity. 33. Investigations into, and treatment of, loss of hair and any hair replacement unless the loss of hair is due to cancer treatment. 34. Complementary treatment with the exception of those treatments indicated in the Table of Benefits. 35. Treatment required as a result of failure to seek or follow medical advice. 36. Treatment required as a result of medical error. 37. Treatment to change the refraction of one or both eyes (laser eye correction). 38. Sex change operations and related treatments. 39. Treatment in the USA is not covered if we know or suspect that cover was purchased for the purpose of travelling to the USA to receive treatment for a condition, when the symptoms of the condition were apparent to the member prior to the purchase of cover. 40. Expenses incurred because of complications directly caused by an illness, injury or treatment for which cover is excluded or limited under your plan. 41. Travel costs to and from medical facilities (including parking costs) for eligible treatment, 32

32 except any travel costs covered under local ambulance, medical evacuation and medical repatriation benefits. 42. Treatment directly related to surrogacy whether you are acting as surrogate, or are the intended parent. 43. The accidental death benefit* lump sum payment will not be made in circumstances where the death of an insured member has been caused either directly or indirectly by: 43.1 Accidents which happen while the insured member is engaged in aviation activities of any description, including entering and alighting from aircraft, other than as a fare paying passenger in a standard multi-engine aircraft operated by a recognised airline or air charter company Taking part in speed or duration tests or races of any kind Taking part in motor sports of any kind, including boating, in any boat designed to travel at a speed in excess of 30 knots Mountaineering including caving and potholing which requires the use of ropes or guides White water rafting and canoeing, scuba diving and yachting or boating outside coastal waters (12 miles or more from the coast). *Our set of standard conditions, exclusions and limitations also apply to the accidental death benefit. 44. The following treatments, medical conditions or procedures, or any adverse consequences or complications thereof, are not covered unless otherwise indicated in your Table of Benefits: 33

33 Allianz Worldwide Care What your healthcare cover does not pay for 44.1 Dental treatment, dental surgery, periodontics, orthodontics and dental prostheses with the exception of oral surgical procedures, which are covered within the overall limit of your Core Plan Out-patient treatment Emergency dental treatment Routine maternity Home delivery Prescribed glasses and contact lenses Prescribed medical aids Vaccinations Preventive treatment Routine health checks including screening for early detection of illness or disease In-patient psychiatry and psychotherapy treatment Out-patient psychiatry and psychotherapy treatment Infertility treatment Rehabilitation treatment Medical repatriation Expenses for one person accompanying an evacuated/repatriated person Travel costs of insured family members in the event of an evacuation Travel costs of insured family members in the event of a repatriation Travel costs of insured family members in the event of the repatriation of mortal remains Travel costs of insured members to be with a family member who is at peril of death or who has died Organ transplant. 34

34 Paying premiums and general information The following section provides you with general information on the payment of premiums and details other important aspects of your membership. Paying premiums Your company is responsible for the payment of premiums to us for your membership and for the membership of dependants (if applicable) covered under the Company Agreement, together with the amount of any other payments due (such as Insurance Premium Tax) that may be payable in respect of your or their membership. However, please note that you may be liable for payment of tax in respect of the premiums paid by your company. For details, please check with your company. Important events Throughout this guide, you will see references to important events such as when you start, renew or end your membership, or include other people as your dependants. This section explains exactly when, and how, these events take place. Our aim is to continuously improve our service to our members. In order to help us do this, if for any reason you cancel your membership, please let us know the reason why. Starting membership The insurance shall be valid as of the effective date shown on your Access Card. The cover will continue until the group renewal date. Generally, this is one Insurance Year unless agreed otherwise between your company and us or if you started your policy mid-year. At the end of this period, your company can renew the insurance on the basis of the policy terms and conditions applicable at that time. You will be bound by those terms. 35

35 Allianz Worldwide Care Paying premiums and general information When cover starts and ends for dependants included in your membership If any other person is included as a dependant in your membership, as agreed between your company and us, their membership start date will be stated on their Access Card. Their membership will continue for as long as you remain a member of the group scheme (and as long as any child dependants remain under the dependant age limit, as defined, unless agreed otherwise between your company and us). Cover for any child dependants under your policy will end on the day before their 18 th birthday; or on the day before their 24 th birthday, as long as they are in full time education. At that time, they may apply for cover in their own right, should they wish to do so. Adding dependants You may apply to include any of your family members under your membership as one of your dependants, provided that you are allowed to do so under the agreement between your company and us. Notification to add a dependant should be made through your company unless otherwise stated. Newborn infants will be accepted for cover from birth, provided that we are notified within four weeks of the date of birth. To have a newborn added to the policy, you must ask your company to submit a request in writing to its usual contact person for membership changes. Notification of the birth after four weeks will result in newborn children being accepted for cover from the date of such notification. In-patient treatment for multiple birth babies born as a result of medically assisted reproduction will be 36

36 covered up to US$42,500 per child for the three months following birth. Out-patient treatment will be paid within the terms of the Out-patient Plan. Changing country of residence with cover, as our plans do not comply with local laws in this country. Notification of change of residence should be made through your company unless otherwise stated. It is important that we are notified if you change your country of residence as it may impact your cover or premium, even if you are moving within your area of cover. Please note that cover in some countries is subject to local health regulations, particularly for permanent residents of that country. It is your responsibility to ensure that your healthcare cover is legally appropriate and we would recommend that you seek independent legal advice in this regard. For example if you become permanently resident in the United States, please note that we can no longer provide you Renewing membership The renewal of your membership (and that of your dependants, if applicable) is subject to your company renewing your membership under the Company Agreement. If your company renews the contract with us, you (and your dependants, if applicable) will receive a new Access Card(s) to use until the next renewal date (and any previous card versions should be destroyed or returned to us). 37

37 Allianz Worldwide Care Paying premiums and general information Ending membership Your company can end your membership or that of any of your dependants by notifying us in writing. We cannot backdate the cancellation of your membership. Your membership will automatically end: We can end a person s membership and that of all his/her dependants, if there is reasonable evidence that the person concerned has misled, or attempted to mislead us. By this, we mean giving false information or withholding pertinent information from us, or working with another party to give us false information, either intentionally or carelessly, which may influence us when deciding: At the end of the Insurance Year, if the agreement between us and your company is terminated. If your company decides to end the cover or does not renew your membership. If your company does not pay premiums or any other payment due under the Company Agreement with us. When you stop working for the company. Upon the death of the principal member. Whether you (or they) can join the scheme. What premiums your company has to pay. Whether we have to pay any claim. General information Table of Benefits The benefit limits stated in your Table of Benefits will be in US Dollars. 38