Covered benefits after a Waiting Periods
In addition to the benefits stated in the General Conditions, the Insurance Company covers the following cases, after the waiting periods detailed here below:
• After 90 days:
Any procedure or treatment related to the cardiovascular system unless it falls under a preexisting condition in which case exclusion number 4 will apply, or except as stipulated otherwise in the particular conditions &/or Policy Schedule.
• After 365 days:
1- Preexisting cases known or un-known except as stipulated otherwise in the particular conditions &/or Policy Schedule.
2- All Types of Hernia and thyrioglossal cyst.
3- Ear, Nose & Throat system including sinus, deviated septum and nose related surgery, unless due to a covered accident occurring during the Policy contractual period, where it would be covered immediately subject to the prior written approval of the Administrator or the insurance company. In Hospital treatments other than surgeries are, however, covered as from inception.
4- Birth control procedures and their consequences, treatment of impotence, varicocele and their consequences Infertility Sterility but excluding In-Vitro, ICSI (Intra Cytoplasmic Sperm Injection) and surrogate maternity procedures, and all screening tests, medication and treatments, during hospital confinement, related thereto and their consequences, including coelioscopy and hysteroscopy, shall be covered during hospital confinement and Up to US$ 3,000- per person/per year for class A and up to US$2,000- per person/per year for classes B and K combined limit for IN & OUT patient.
5- Uterine fibroids, Hysterectomy, Endometriosis and Ovarian cyst.
6- Gall bladder diseases, Stomach ulcers and Kidney stones.
7- Hemorrhoids, anal fissures and dermoid cyst.
9- Surgical Treatments for respiratory system diseases and Asthma, except respiratory chronic allergy.
a. Maternity, including complication of pregnancy, will be covered after 300 days from the inception of the 1st year policy, or the new employee adherence, for both normal deliveries and cesarean sections including Epidural unless stipulated otherwise in the particular conditions.
b. New Born
The Insurance Company will bear the boarding costs of a nursery and the use of an incubator for each newborn baby as of birth irrespective of the period of stay of the mother, in addition to the fees of one consultation of the attending pediatrician, for a maximum limit of USD15,000- (Fifteen Thousand US Dollars) for Lux and A Classes and USD10,000- (Ten Thousand US Dollars) for B and K classes.
Newborn Babies medically eligible, and whose maternity has been covered by the Insurance Company, will be added to the Policy, from day zero, free of charge, and for the remaining contractual period of the parents Policy, and will benefit from the same Policy terms and conditions.
All congenital cases are covered only in the instances where the Insured was medically eligible at birth, and covered with the company without interruption, for lifetime, from day Zero of birth date from a covered maternity up to the following limits:
US$.15,000- for Class A
US$.10,000- for Classes B & K
However for Non ADIR baby, congenital cases are not covered except for hernia & thyrioglossal cyst that should follow one year waiting period
c. When maternity is covered under this Policy, the Insurance Company will bear the epidural cost in addition to the boarding costs of a nursery and/or the use of an incubator for the newborn baby, as of birth and irrespective of the period of stay of the mother provided an uninterrupted hospital confinement, in addition to the fees of one consultation of the attending pediatrician. The above will apply for a covered hospital confinement under both normal deliveries and cesarean sections.
Such extensions do not constitute any vested right for the newborn baby in any other cover or benefit of whatsoever kind.
d. In all cases, the Insurance Company will bear the fees and expenses for male circumcision, if performed during the same hospital confinement and/or following one month of the delivery of the newborn baby.
EXCLUSIONS TO IN-HOSPITAL HEALTHCARE BENEFIT PLAN
The Insurance Company does not cover the following conditions, the complications and the consequences arising therefrom:
1. All Ambulatory healthcare services not specifically covered under an Applicable Healthcare Plan, defined as: healthcare services (e.g. diagnostic tests, check-up tests, treatments) that are medically justified but do not mandate hospital confinement, such as those delivered at a physician’s office, clinic, medical center or out-patient hospital facility.
2. Any special limitation and/or exclusion per Insured provided for in the Policy schedule or endorsements.
3. Any hospitalization not medically mandatory for the Insured’s health (e.g. sight correction surgery, and organ donation).
4. Any preexisting condition. This exclusion will be waived after 365 days except as stipulated otherwise in the particular conditions &/or Policy Schedule.
The automatic waiver of preexisting conditions does not have any effect on the other exclusions listed in the Policy, that remain in full force and effect.
In all instances, the Policyholder and the Insured remain subject to the duty of full disclosure and full declaration of their health condition and that of their legal dependents, as well as any fact relating thereto. Thus, any false declaration or non-disclosure made by the Policyholder and/or by the Insured, discovered at any time, will render this Policy null and void from inception without the need for a written notice, even if the Policyholder and/or the Insured has benefited from the waiver of the preexisting condition exclusion.
5. Sleep disorder studies procedures and surgeries related thereto except for Polysomnography that remains covered up to $500 per person/year.
6. Peritoneal dialysis, hemodialysis and the arterio venostomy related thereto. As a special exception to the above general exclusion, only the sessions of dialysis for acute renal failure delivered during the initial admission, and till discharge will be covered up to a maximum of 3 sessions.
7. Mental or psychiatric disorders and nervous breakdowns, psychological testing or evaluation are excluded except when due to a covered accident or illness as stated in benefits of the Policy.
8. Claims arising from the Insured taking an active part in any of the following events: war, civil war, warlike activities, act of foreign enemy, civil commotion, invasion, hostilities, mutiny, strike, riots, terrorist activities, rebellion, revolution, insurrection, conspiracy, military or usurped powers, martial law, state of siege or any of the events or causes which determine the proclamation or maintenance of martial law or state of siege. Crimes and misdemeanors; any claim arising from an illegal act of the insured during his stay in prison
9. All congenital cases as well as the complications arising therefrom. Congenital cases are defined as follows: diseases, anomalies, birth defects and deficiencies present at birth, either in an evident manner or in a potential manner triggered at a later stage.
As special exceptions to the above general exclusion, the following congenital cases are covered only in the instances where the Insured was medically eligible at birth, and covered under the Next Care System without interruption from day zero up to US$ 15,000 for class A and up to US$10,000 For classes B and K.
However for Non ADIR baby, congenital cases are not covered except for hernia & thyrioglossal cyst that should follow one year waiting period.
In addition to the above, the Company shall also cover the In hospital medical treatment of transient neonatal jaundice, for newborn babies under Next Care system, medically eligible, as from birth and irrespective of the period of stay of the mother.
Such extension does not constitute any vested right for the newborn baby, in any other cover or benefit of whatsoever kind.
10. Rest cures, sanatorium, custodial care and periods of quarantine, special diets and weight control procedures and surgeries, costs related to convalescence even when initial hospitalization was covered under the Policy.
11. Suicide, self-inflicted injury or any such attempt of self damaging whether the insured is sane or insane.
12. All consequences arising from using or addiction to alcohol, drugs and such substances and/or abuse of medicines under no medical supervision, also excluding all their medical complications.
13. Treatment of injuries and sickness consequent to the participation of the Insured, either as an amateur or professional, in hazardous sports (e.g. motor or motorcycling race, deep sea diving, scuba-diving, snorkeling, parachuting, hang gliding, delta-plane, bungee jumping, all kind of martial arts…etc.) however, normal skiing is included unless covered by the insurance of the skiing resort. Also claims related to motorcycling are covered up to US$2,000 provided no racing is involved.
14. Claims arising from insured’s exposure to ionization, polluting chemicals or nuclear contamination.
15. Dental and gum medical or surgical treatment of any condition including abscess prosthesis and disorders of the temporomandibular joints, unless necessitated by a covered accidental injury, occurring during the Policy contractual period. In this latter case, treatment should be provided within a maximum of 6 (six) months of accident and will be subject to the prior written approval of the Administrator while the Policy is in force or renewed with no interruption. Any treatment that might be provided to the Insured after the period of six months from the accident is excluded from the coverage.
16. Any cosmetic and / or plastic surgery unless mandated by a covered accidental injury, occurring during the Policy’s contractual period. In this latter case, only the In-Hospital treatment, provided within 9 (nine) months of accident, will be covered subject to the prior written approval of the Administrator while the Policy is in force or renewed with no interruption. Any treatment that might be provided to the insured after the period of nine months from the accident is excluded from the coverage.
17. The surgery and cost of all kinds of organ transfer and/or transplantation, including bone marrow transplantation except for the surgery related to the cornea transplant, where the operation is covered but not the cost of the cornea unless the case is related to Keratoconus.
18. Abortion that is not medically mandated but the Amniosysthesis procedure remains covered.
19. Tubal legation, all procedures related to the change of sex, all sexual fortifying products medicines (e.g. Viagra) and procedures, and the treatment of all consequences related thereto.
20. Sexually Transmitted Diseases (S.T.D.), Human Immune Deficiency Virus (H.I.V.), AIDS, Liver infections, Hepatitis Type B & C, Syphilis and all screening tests, medications and treatments related thereto.
21. Ambulance and air ambulance expenses.
22. All procedures relating to the treatment (medical or surgical) of the falling of hair and all consequences related thereto.
23. All kind of surgeries performed for the Parkinson disease including all related surgical methods
24. All kinds of genetic tests and procedures (whether medical or surgical) including genetic engineering and cloning.
25. Dynamic phototherapy procedures (e.g. verteporfine…) or which are not FDA approved (e.g. Avastine Injection…)
26. All treatments related to speech therapy except the first 30 sessions following an accident or critical illness (e.g. cancer etc…) which are covered under “Limits Out of Hospital Rider” )
27. Work related hospitalization indemnified under Workmen’s Compensation Insurance unless specifically covered under the particular conditions &/or Policy Schedule of the policy, and subject to an additional premium.
28. Treatment or surgical operations for nearsightedness, farsightedness, astigmatism or cross-eyes.
29. Treatment related to Senility and age-related disorders.
30. Claims arising from Nuclear, Chemical or Biological Terrorism as well as of mass destruction.
31. New medical procedures and technologies unless approved by the Insurance Company.
32. Treatments of all kinds of Chronic Allergy are excluded except for Asthma that remains covered after one year.
EXCLUSIONS TO AMBULATORY HEALTHCARE BENEFIT PLAN
1. All exclusions applicable to the In-Hospital plan are applicable to the Ambulatory Plan, including routine checkups.
2. Doctors ‘fees.
3. Thalassemia (except moderate Thalassemia), H.I.V, syphilis tests, except when required for pre-marital tests on reimbursement procedures basis.