Health Insurance Guide

Transcription

1 UNIDO NPPP Health Insurance Guide Valid from 1 st January 2013 Welcome to Allianz You can depend on Allianz, to give you access to the best care possible wherever you are in the world. Your insurance is backed by the resources and expertise of the Allianz Group, one of the leading integrated financial services providers worldwide, providing you with a service that is fast, flexible and totally reliable. This guide aims to provide you with important information about our member services, your cover and the claims process. Should you have any questions or require any further information please contact our 24/7 Helpline. This document is intended as an information guide only and does not form part of the insurance contract. For details of your insurance contract please refer to the Group Medical Insurance Contract. Member Services Please find details of all our member services below. Helpline Service Our in-house team of professional, multilingual staff are available 24 hours a day, 7 days a week to handle your policy enquiries. Our Helpline staff has instant access to your policy details 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 Toll-free from Australia, Austria, Belgium, China, Canada, France, Germany, Italy, Japan, Spain, Switzerland, United Kingdom and USA: Telephone (from anywhere in the world): [email protected] Fax: If you are an American national or a resident of the United States, or if you require emergency medical treatment whilst in the United States please call (+1) This number will direct you to Olympus Managed Healthcare, who will help you to locate a medical provider in the USA or answer any other queries you may have regarding treatment in the USA. Calls to our Helpline may be recorded and may be monitored for training, quality and regulatory purposes. Please note that in some instances the toll-free numbers are not accessible from a mobile phone, in which case please call FRM-Unido-MG-NPPP-EN-1212

2 Your Medical and Dental Cover What You Are Covered For Overview of your Medical and Dental Cover This section provides an outline of the cover provided for you. 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. If you are eligible to claim benefits from another insurance company, the applicable reimbursement percentages or ceilings are applied to the difference between the actual costs incurred and the reimbursement obtained from the other insurance company. Medical claims for reimbursement must be submitted to us within two years of the treatment date. Overall Medical Cover Benefit Limit Your medical cover is subject to an overall maximum reimbursement limit of USD 10,000 per beneficiary per period of cover as specified in the group contract. Medical Treatment Medical treatment prescribed by doctors qualified to treat patients will be reimbursed at a rate of 100% (in-patient and out-patient), subject to the limitations below. Radiological Treatment The costs of radiological treatment shall be reimbursed at a rate of 100% if the patient has been referred to the specialist by the doctor in attendance. Psychiatric Care The cost of psychiatric treatment including psychoanalysis will be reimbursed only if the patient is treated by a psychiatrist. The cost of psychiatric treatment is reimbursed at a rate of 50% and is subject to a maximum of USD 500, for no more than 50 visits per beneficiary in any six consecutive months. Dental Treatment The cost of dental care, periodontic treatment, false teeth, crowns, bridges, other similar appliances and dento-facial orthopaedics are reimbursed at a rate of 100% up to a maximum of USD 500 per beneficiary, per period of cover. Hospitalisation Hospital services are reimbursed at a rate of 100%. This includes the following: Accommodation (maximum rate: the rate of Two / Three Person Room) General nursing services Use of operating rooms and equipment Use of recovery rooms and equipment Laboratory examinations X-ray examinations Drugs and medicine for use in the hospital Transport Charges for a professional ambulance service used to transport the beneficiary between the place where he/she is injured by an accident or stricken by disease and the first hospital where treatment is given will be reimbursed at a rate of 100%. In the case of emergency or major disability, special transport of the beneficiary (including costs of an accompanying person or attendant) shall be reimbursed up to a maximum of USD 7,500. Following the death of a beneficiary in circumstances that would otherwise give rise to a claim under this plan, the cost of preparation and repatriation of the remains of the deceased to his/her home country, shall be reimbursed up to a maximum of USD 7,500. Co-payments A co-payment is a percentage of the reimbursable costs incurred, which is payable by you. Deductible A deductible is the part of the cost which remains payable by you and which has to be deducted from the reimbursable sum. Your medical plan is subject to a USD 10 deductible per individual period of cover. Where You Are Covered You are covered for eligible medical and dental costs incurred worldwide. 2

3 Cost Containment Beneficiaries are reminded that the choice of medical providers and products made by them and their eligible dependants have a direct impact on the performance of UNIDO s group medical insurance plan. The active co-operation of beneficiaries in being cost-conscious when incurring medical expenses therefore remains the most effective measure to contain the beneficiaries own uncovered share and the premium increases. Free Choice of Providers and Treatment You have a free choice of doctors, treatment, hospitalisation and medication in line with the terms of the contract. How to Claim If you are eligible to claim benefits from another insurance company, please submit your claim to them for initial reimbursement before sending your claim and proof of settlement to us. We will then reimburse the difference between the costs actually incurred and the reimbursement obtained from the other insurer, subject to any benefit limits specified in your Table of Benefits. Please note the following important points: 1. Please keep copies of all correspondence provided to us (in particular, copies of Claim Forms and medical prescriptions). We do not usually return original documents. However, if you ask us at the time of sending the original documents to us, we will of course return them to you. 2. Fully completed Claim Forms are processed and payment instructions issued to your bank within 48 hours of receipt by us. Where further information is required to complete the claim, you/your medical practitioner will automatically be notified by or mail within 48 hours of receipt of the Claim Form. 3. A separate Claim Form is required for each person claiming reimbursement. 4. Claim payments will be reimbursed in USD in accordance with the terms of the contract. 5. Please ensure that the payment details that you supply on the Claim Form are correct, to avoid delays to claims settlement. If you do not provide a bank account on the Claim Form we will transfer any reimbursement to the last bank account we received for you. 6. Please note that only costs for incurred treatment will be reimbursed within the limits of your policy and in line with the ceilings and co-payments specified in the group contract. 7. All claims should be submitted to us with original supporting documentation, invoices and receipts no later than 2 years after the treatment date. 8. Please be aware that we may access all medical records and have direct discussions with the medical provider or the treating physician. All information will be treated in strict confidence. 9. Any conversion of expenses sustained in a currency other than USD will be made on the basis of the commercial rate of exchange prevailing on the date of the invoice. In-patient Claims If you have to go to a hospital we will, with sufficient notice, arrange for direct settlement with the medical provider subject to any co-payments and benefit limits, i.e. we will settle the bill for you by dealing directly with the hospital. Direct settlement is excluded only in an exceptional case should the hospital not accept a direct settlement from us. Out-patient and Dental Claims For out-patient or dental treatment, please pay the medical provider for these costs at the time of treatment and then seek reimbursement from us, subject to the benefit limits of your plan. When you visit a medical practitioner, dentist, physician or specialist on an out-patient basis please follow the steps below: 1. Please get an invoice from the doctor/medical provider which states the diagnosis or medical condition treated, the nature of the treatment and the fees charged. 2. Please complete a Claim Form, available for download from The Claim Form is available as a PDF which can be filled in electronically. This means that you can save the document and re-use it without having to fill in the common information each time. 3

4 3. When submitting your Claim Form to us, please attach all original supporting documentation, invoices and receipts, proofs of payment and prescriptions for medication with pharmacy receipts. 4. If you have received reimbursement of part of the bill from another insurer, please submit details of the amounts paid with your Claim Form. An will automatically be sent to you (where addresses have been provided to us) to advise you of when the claim has been processed. If we do not hold an address for you, we will write to you at your correspondence address to advise you when your claim has been processed. Treatment in the USA To provide you with a local and efficient service, we have selected Olympus Managed Healthcare to administer your healthcare policy on our behalf within the USA. Olympus will deal directly with medical providers to co-ordinate the direct settlement of your eligible medical treatment. To locate a medical provider in the USA, you can call Olympus who will be happy to assist you with any questions you may have regarding the choice of a provider. The Allianz Worldwide Care Services dedicated Helpline at Olympus is available 24/7 on: (+1) (toll-free from the USA). You can also apply for a discount pharmacy card from Olympus, which can be used any time your prescription is not covered by your healthcare policy. To register and obtain your discount pharmacy card, simply go to: and click on Print Discount Card. Your Life and Permanent Disability Plan Overview This section provides a summary of your permanent disability and death benefits. Please be aware that this cover is subject to policy definitions, exclusions and limitations. Life Cover (in the event of death from any cause) The capital sum payable on the death of a beneficiary is USD 25,000 subject to the following limitation: In the event of death of a beneficiary aged 63 or over by natural causes, only 50% of the benefit will be paid. The cost of preparation and repatriation of the remains to the home country of the beneficiary will be reimbursed up to a maximum of USD 7,500. Following the death of a beneficiary, the capital sum insured will be paid to UNIDO on receipt of the following documentation: The beneficiary s birth certificate or an equivalent extract from the birth records. The death certificate. A satisfactory medical certificate stating cause of death and whether death is as a result of an accident or illness. Permanent Disability (as a result of any cause including accident) Total Permanent Disability The capital sum payable in the case of a total permanent disability is USD 40,000. Partial Permanent Disability If the permanent disability is partial, a proportion of the capital sum shall be paid, subject to the degree of disability and in accordance with the following scale: 4

5 Partial Permanent Disability Proportion of Capital Sum Incurable mental alienation 100% Total organic paralysis 100% Total blindness 100% Amputation or permanent loss of the use of: Both arms or both hands 100% Both legs or both feet 100% One arm or hand and one leg or foot 100% Total loss of the sight of one eye with ablation 30% Total loss of one eye with/without ablation 25% Loss of whole thickness of the skull over: An area at least 6 cm 2 40% An area of from 3 to 6 cm 2 20% An area of less then 3 cm 2 10% Incurable total deafness in both ears 40% Incurable total deafness in one ear 15% Ablation of the lower jaw: Total 70% Partial (upright branch plus the whole half of the maxillary bone) 40% Loss of top and bottom teeth and their sockets 10% - 30% (Preventing the fitting of dental prosthesis) In the case of possible prosthesis with established functional improvement 1% -10% Right Left Loss of an arm or hand 75% 60% Total paralysis of an upper limb 65% 55% Total paralysis of the circumflex nerve 20% 15% Total paralysis of the median nerve 45% 35% Total paralysis of the cubital nerve at the elbow 30% 25% Total paralysis of the nerve at the hand 20% 15% Total paralysis of the radial nerve above the triceps 40% 30% Complete anchylosis of the scapulohumeralarticulation: With immobilisation of the shoulder blade 65% 55% With mobility of the shoulder blade 35% 25% Non-consolidated fracture of the arm 30% 25% Total loss of movement of the elbow: In an unfavourable position 40% 35% In a favourable position 25% 20% 5

6 Right Left Non-consolidated fracture of the forearm: Both bones 25% 20% Single bone 10% 8% Total loss of movement of the wrist: In an unfavourable position (flexion, forced extension of) 40% 30% In a favourable position (straight or prone) 20% 15% Amputation of the thumb: Total 20% 18% Partial (ungula phalanx) 10% 8% Anchylosis of thumb: Total 15% 12% Partial (ungula phalanx) 10% 8% Amputation of an index finger: Total 16% 14% Two phalanxes 12% 10% One phalanx 6% 5% Amputation of a second finger 12% 10% Amputation of a third finger 10% 8% Amputation of a fourth finger 8% 6% Total paralysis of lower limb 60% Complete paralysis of the internal popliteal sciatic nerve 30% Complete paralysis of the external popliteal sciatic nerve 30% Complete paralysis of both popliteal sciatic nerves 40% Shortening of the lower limb: At least 5 cm 30% From 3 to 5 cm 20% From 1 to 3 cm 10% Complete anchylosis of the hip: In a bad position (flexion, adduction or abduction) 60% In a straight position 40% Amputation of the thigh: Upper half 60% Lower half 50% Non consolidated fracture of the thigh or both bones of the leg 50% (constitution of pseudo-arthrosis) 6

7 Complete anchylosis of the knee: In flexion (from 130 degrees) 50% Straight or almost straight 25% Chronic hydrarthrosis according to the degree of muscular atrophy 3% to 20% Non consolidated fracture of the knee cap with separation of the fragments 40% and difficulty in extension of the leg from the thigh Amputation of a leg 50% Tibio-tarsian anchylosis 15% Amputation of a foot: Total (tibio-tarsian disarticulation) 50% Sub-astragalian 40% Media-tarsian 35% Tarso-metatarsian 30% Amputation of all toes 20% Amputation of big toe 10% Amputation of a toe other than a big toe 5% Anchylosis of the big toe 3.5% Please note the following: For a person who is left-handed, provided that the beneficiary has declared so in the application for insurance, the rates relative to the upper right limb will be applied to the left and vice-versa. The loss of the use of a limb will be considered like the loss of a limb. The total amount reimbursed for several invalidities resulting from the same accident shall never exceed the total insured capital amount. The invalidities which have not been mentioned before shall be indemnified according to their importance compared to those which have been mentioned, the beneficiary s profession not being taken into consideration. Indemnities will be paid upon receipt of a statement of the permanent disability by a physician acceptable to both UNIDO and Allianz. 7

8 Definitions Wherever the following words and phrases appear in your policy documentation, they will always have the meanings as defined below. 1.1 Accident is the sudden action of an external force causing impairment of physical integrity. 1.2 Beneficiary is a person who is entitled to the benefits provided under the plan as reported to Allianz by UNIDO. 1.3 Co-payment is the percentage of the costs which the beneficiary must pay. 1.4 Deductible is the part of the cost which remains payable by you and which has to be deducted from the reimbursable sum. 1.5 Hospitalisation is any stay including at least one night in an establishment. 1.6 Individual period of coverage: the shorter period between 12 months and the duration of the service agreement of the beneficiary. 1.7 Maternity is taken in its wider sense and includes pregnancy. 1.8 Medical Treatment refers to all examinations or measures taken to restore health. 1.9 Out-patient Treatment refers to treatment provided in the practice or surgery of a medical practitioner or specialist that does not require the patient to be admitted to hospital Permanent Disability refers to injury or illness resulting in disfigurement of loss of member or function which is incurable or lasting for at least 12 months and being thereafter beyond hope of improvement Sickness is a deterioration in health, confirmed by a legally qualified physician We/Our/Us is Allianz You/Your refers to the eligible beneficiary or member. What your Medical, Life and Permanent Disability 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: 1. Hearing aids, spectacles and fees for examination of the eye for glasses. 2. Periodic, preventive health examinations. 3. Spa cures, rejuvenation cures and cosmetic treatment (cosmetic surgery is covered when it is necessary as the result of an accident for which coverage is provided). 4. The consequences of insurrections or riots, if by taking part, the beneficiary has broken the applicable laws; and the consequences of brawls, except in cases of self-defence. 5. The consequences of injuries resulting from motor-vehicle racing and dangerous competitions on which betting is allowed. Injuries resulting from normal sports competitions are covered. 6. Expenses for, or in connection with, travel or transportation, whether by ambulance or otherwise, except that charges for professional ambulance service used to transport the beneficiary between the place where he/she is injured by an accident or stricken by disease and the first hospital where treatment is given shall not be excluded. Please refer to the Transport section on page 2 for further details. 7. The consequences of illness or accidents resulting from wilful and intentional action on the part of the beneficiary such as attempted suicide or intentional mutilation. 8. Medical expenses of persons who are mobilised or voluntarily enter military, naval or air service, in respect of whom coverage shall be suspended. 9. Direct or indirect results of nuclear explosions and related heat release or irradiation. 10. Aircraft accidents unless the beneficiary is on board an aircraft with a valid certificate of air-worthiness, and piloted by a person in possession of a valid license for the type of aircraft in question. 8 The Underwriter of your insurance is Allianz VIE, Société anonyme with capital of , governed by the Code des assurances, with registered office at 87, rue de Richelieu Paris, France - N RCS Paris and which is regulated in France by the Autorité de Contrôle Prudentiel to carry out classes 20, 22, in life insurance and classes 1 and 2 in non-life insurance. The Administrator of your insurance is Allianz Worldwide Care Services Limited - Belgium Branch having its branch trading address at rue de Laeken 35, 1000 Brussels, Belgium. VAT: BE RPM Bruxelles: IBAN: BE BIC: BBRUBEBB.