The Lagos State Government in its determination to achieve Universal Health Coverage (UHC), promote Ilera Eko at the grassroots and increase the number of enrolment, has partnered with media organisations in the State.
In a bid to create more awareness and sensitization on the Lagos State Health Scheme (LSHS), the Lagos State Health Management Agency (LASHMA) has launched ‘Ilera Eko’ campaign to achieve a universal health coverage for all Lagosians.
1.1. The POLICYHOLDER‘s health insurance SCHEME is an annual insurance contract, “the SCHEME”, with Lagos State Health Management Agency, hereinafter referred to as the “AGENCY”, and the POLICYHOLDER named on the Insurance Certificate.
1.2. The SCHEME, the Individual Benefit Guide, the Table of Benefits, the Insurance Certificate and the information provided to the AGENCY by, or on behalf of, the POLICYHOLDER in the signed Application Form, submitted Online Application Form, Confirmation of Health Status Form or others (hereafter referred to collectively as the “relevant application form”) or other supporting medical information constitutes the entire contract between the parties hereto.
1.3. This SCHEME will not take effect before all documents and information required by the AGENCY have been received and accepted by the AGENCY and the Initial premium has been fully paid.
Purpose of the SCHEME
2.1. Coverage is subject to the SCHEME terms and conditions set out in the Individual Benefit Guide, the benefit limits set out in the Table of Benefits and any terms, including special conditions, outlined in the Insurance Certificate and subject to payment of the agreed premium. The AGENCY shall pay the costs of medically necessary medical treatment occurring during the period of cover resulting from an accident or medical illness for the INSURED PERSON(S) covered under this SCHEME.
The following definitions apply to benefits included in the Lagos State Health Scheme Range of Plans and to some other commonly used terms.
The benefits the INSURED PERSON(S) are covered for are listed in the Table of Benefits. If any unique benefits apply to the POLICYHOLDER’s chosen plan(s), the definition will appear in the “Notes” section at the end of the Table of Benefits. Wherever the following words/phrases appear in the POLICYHOLDER’s SCHEME documents, they will always be defined as follows.
3.1. Accident is an injury which is the result of an unexpected event, independent of the will of the INSURED PERSON and which arises from a cause outside the individual’s control. The cause and symptoms must be medically and objectively definable, allow for a diagnosis and require therapy.
3.2. Acute refers to sudden onset.
3.3. 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 recognized cure.
• Is not generally deemed to respond well to treatment.
• Requires palliative treatment.
• Requires prolonged supervision or monitoring.
• Leads to permanent disability.
The “Notes” section of the Table of Benefits will confirm whether chronic conditions are covered.
3.4. The AGENCY Lagos State Health Management Agency, legal entity underwriting the risk under the contractual terms of the insurance.
3.5. Complementary treatment refers to therapeutic and diagnostic treatment that exists outside the institutions where conventional Western medicine is taught. Such medicine includes chiropractic treatment, osteopathy, Chinese herbal medicine, homeopathy and acupuncture as practiced by approved therapists.
3.6. Complications of childbirth refer only to the following conditions that arise during childbirth and that require a recognized obstetric procedure: post-partum hemorrhage and retained placental membrane. Complications of childbirth are only payable where the INSURED PERSON’s cover also includes a routine maternity benefit. Where cover includes a routine maternity benefit, complications of childbirth shall also refer to medically necessary cesarean sections.
3.7. Complications of pregnancy relate to the health of the mother which may include the pre-natal stages of pregnancy are covered: ectopic pregnancy, gestational diabetes, pre- eclampsia, miscarriage, threatened miscarriage and stillbirth.
3.8. Co-payment is the percentage of the costs which the INSURED PERSON must pay as indicated in the Table of Benefits.
3.9. Deductible is that part of the cost which remains payable by the INSURED PERSON and which has to be deducted from the reimbursable sum. The deductibles are payable per INSURED PERSON per Insurance Year, as stated in the Table of Benefits.
3.10. Dental treatment includes a maximum of one (1) scaling and polishing and three (3) simple extractions that can be accomplished from above the gum using traditional elevators and forceps. Surgical extractions are not covered.
3.11. Dependent is the POLICYHOLDER’s spouse and/or unmarried children financially dependent on the POLICYHOLDER up to the day before their 18th birthday and also named in the Insurance Certificate as one of the POLICYHOLDER’s dependents.
3.12. Diagnostic tests are investigations such as x-rays or blood tests, undertaken in order to determine the cause of the presented symptoms.
3.13. Emergency constitutes the onset of a sudden and unforeseen medical condition that requires urgent medical assistance. Only treatment commencing within 24 hours of the emergency event will be covered.
3.14. Emergency out-patient treatment is treatment received in a casualty ward/emergency room following an accident or sudden illness, where the INSURED PERSON does not, out of medical necessity, occupy a hospital bed.
3.15. Emergency treatment outside area of cover is treatment for emergencies which occur during business or holiday trips outside the Lagos State but limited to Nigeria.
3.16. Family history exists where a parent, grandparent, sibling, child, aunt or uncle has been previously diagnosed with the medical condition in question.
3.17. Health Care Provider is any establishment which has been accredited by HEFAMAA to operate as a healthcare facility to provide health care services in Lagos State.
3.18. Hospital accommodation refers to standard general accommodation as indicated in the Table of Benefits. Deluxe, executive rooms and suites are not covered.
3.19. Infertility treatment refers to treatment for both sexes including all invasive investigative procedures necessary to establish the cause for infertility such as hysterosalpingogram, laparoscopy or hysteroscopy.
3.20. In-patient treatment refers to treatment received in a hospital where an overnight stay is medically necessary.
3.21. Insurance Certificate is a document outlining the details of the INSURED PERSON’s cover and is issued by the AGENCY. It confirms that an insurance relationship exists between the INSURED PERSON and the AGENCY.
3.22. Insurance Year applies from the effective date of the insurance, as indicated on the Insurance Certificate and ends exactly one year later.
3.23. INSURED PERSON(S) is the POLICYHOLDER and his/her dependents as stated on the Insurance Certificate.
3.24. Local ambulance is ambulance transport required for an emergency or out of medical necessity, to the nearest available and appropriate hospital or licensed medical facility.
3.25. Long term care refers to care over an extended period of time after the acute treatment has been completed, usually for a chronic condition or disability requiring periodic, intermittent or continuous care. Long term care can be provided at home, in the community, in a hospital or in a nursing home.
3.26. Medical necessity refers to those medical services or supplies that are determined to be medically necessary and appropriate. They must be:
• Essential to identify or treat a patient’s condition, illness or injury.
• Consistent with the patient’s symptoms, diagnosis or treatment of the underlying condition.
• In accordance with generally accepted medical practice and professional standards of medical care in the medical community at the time.
• Required for reasons other than the comfort or convenience of the patient or his/her physician.
• Proven and demonstrated to have medical value.
• Considered to be the most appropriate type and level of service or supply.
• Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of a patient’s medical condition.
• Provided only for an appropriate duration of time.
• As used in this definition, the term “appropriate” shall mean taking patient safety and cost effectiveness into consideration. When specifically applied to in-patient treatment, medically necessary also means that diagnosis cannot be made, or treatment cannot be safely and effectively provided on an out- patient basis.
3.27. Medical practitioner is a physician who is licensed to practice medicine under the law of the country and accredited by the regulatory bodies in the country.
3.28. Newborn care includes customary examinations required to assess the integrity and basic function of the child’s organs and skeletal structures. These essential examinations are carried out immediately following birth.
3.29. Obesity is diagnosed when a person has a Body Mass Index (BMI) of over 30.
3.30. Occupational therapy refers to treatment that addresses the individual’s development of fine motor skills, sensory integration, coordination, balance and other skills such as dressing, eating, grooming, etc. in order to aid daily living and improve interactions with the physical and social world.
3.31. Oncology refers to specialist fees, diagnostic tests, radiotherapy, chemotherapy and hospital charges incurred in relation to the planning and carrying out treatment for cancer, from the point of diagnosis.
3.32. Organ transplant is the surgical procedure in performing the following organ and/or tissue transplants: heart, heart/valve, heart/lung, liver, pancreas, pancreas/kidney, kidney, bone marrow, parathyroid, muscular/skeletal and cornea transplants. Expenses incurred in the acquisition of organs are not reimbursable
3.33. Orthodontics is the use of devices to correct malocclusion and restore the teeth to proper alignment and function.
3.34. Out-patient surgery is a surgical procedure performed in a surgery, hospital, day-care facility or out- patient department that does not require the patient to stay overnight out of medical necessity.
3.35. Out-patient treatment refers to treatment provided in the practice or surgery of a medical practitioner, therapist or specialist that does not require the patient to be admitted to hospital.
3.36. Palliative care refers to on-going treatment aimed at alleviating the physical/psychological suffering associated with progressive, incurable illness and maintaining quality of life. It includes in-patient, day- care or out-patient treatment following the diagnosis that the condition is terminal and treatment can no longer be expected to cure the condition. Palliative care is not covered in the scheme.
3.37. Periodontics refers to dental treatment related to gum disease.
3.38. Policyholder refers to the principal INSURED PERSON named on the insurance certificate.
3.39. Post-natal care refers to the routine post-partum medical care received by the mother, up to six weeks after delivery.
3.40. Pre-existing conditions are medical conditions or any related conditions for which one or more symptoms have been displayed at some point during the INSURED PERSON’s lifetime, irrespective of whether any medical treatment or advice was sought.
3.41. Pregnancy refers to the period of time, from the date of the first diagnosis until delivery.
3.42. Pre-natal care includes common screening and follow-up tests as required during a pregnancy.
3.43. Prescribed drugs refer to products prescribed by a physician for the treatment of a confirmed diagnosis or medical condition, or to compensate vital bodily substances including, but not limited to, insulin, hypodermic needles or syringes. The prescribed drugs must be clinically proven to be effective for the condition and recognized by the pharmaceutical regulator in Nigeria with National Food and Drug Administration and Control
3.44. Prescribed medical aids refers to any instrument, apparatus or device which is medically prescribed as an aid to the function or capacity of the INSURED PERSON, such as hearing aids, speaking aids (electronic larynx), crutches or wheelchairs, orthopedic supports/braces, artificial limbs, stoma supplies, graduated compression stockings as well as orthopedic arch-supports. Costs for medical aids that form part of palliative care or long term care is not covered
3.45. Prescribed physiotherapy refers to treatment by a registered physiotherapist following referral by a medical practitioner.
3.46. Psychiatry and psychotherapy is the treatment of a mental disorders carried out by a psychiatrist or clinical psychologist.
3.47. Routine maternity refers to any medically necessary costs incurred during pregnancy and childbirth, including hospital charges, specialist fees, and the mother’s pre- and post-natal care, nursing care as well as newborn care.
3.48. Specialist is a qualified and licensed medical physician possessing the necessary additional qualifications and expertise to practice as a recognized specialist of diagnostic techniques, treatment and prevention in a particular field of medicine.
3.49. Specialist Care refers to non-surgical treatment performed or administered by a specialist.
3.50. Speech therapy refers to treatment carried out by a qualified speech therapist to treat diagnosed physical impairments, including, 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).
3.51. Surgical appliances and prostheses refer to artificial body parts or devices, which are an integral part of a surgical procedure or part of any medically necessary treatment following surgery.
3.52. Treatment refers to a medical procedure needed to cure or relieve illness or injury.
3.53. Vaccinations refer to all basic immunizations and booster injections required under regulation of the country as recommended by the National Program on Immunization (NPI) for children under five (5) years.
3.54. Waiting period is a period of time between the payment of premium and the commencement of care.
Cover under this SCHEME is available only to the INSURED PERSON(S) as referred to in the Insurance Certificate issued by the AGENCY.
4.2. Application procedure
All policies are subject to the completion of the appropriate Application procedures including but not limited to an Application Form, other forms that The AGENCY deems to be necessary.
Additions and deletions of INSURED PERSON(S) and premiums relating thereto:
Adding dependentsThe POLICYHOLDER may apply to include any of his/her eligible family members under his/her SCHEME as one of his/her dependents, providing they meet the definition of ‘dependent’ and the POLICYHOLDER completes the relevant application form.Newborn infants will be accepted for cover from birth without medical underwriting, provided that the AGENCY is notified within 28days of the date of birth. To notify the HIA of the POLICYHOLDER’s intention to have his/her newborn child included on his/her SCHEME, a request should be made in writing and sent by email to the HIA.Notification of the birth after four weeks will result in newborn children being underwritten and cover will only commence from the date of acceptance. For Family Policy it is possible to add the newborn to the policy at any time. The contract for newborn will expire when the family policy expires. If the family size is completed, the additional family member maybe added as an additional dependent and policy will expire when family plan expires irrespective of time when the addition is requested.
4.4. Paying premiums
The POLICYHOLDER is required to pay the full premium due to the AGENCY in advance for the duration of his/her SCHEME
The full premium should be paid in advance by the POLICYHOLDER. The AGENCY is not responsible for payments made through third parties. The premium should be paid in the currency the POLICYHOLDER elected to pay when applying for cover.
Changes in payment terms can be made at SCHEME renewal, via written instructions, which must be received by the AGENCY a minimum of 30 days prior to the renewal date.
If the POLICYHOLDER does not pay the premium by the due date, The INSURANCE AGENCY reserves the right to suspend cover and deny claims. The SCHEME shall be deemed null and void if the full premium is not received by the INSURANCE AGENCY from the POLICYHOLDER. If the POLICYHOLDER does not pay the premium during the 10 day notice period the INSURANCE AGENCY will send a notification to the POLICYHOLDER to notify the POLICYHOLDER of the cancellation of the SCHEME.
Changes to premiums and other charges
Each year, on the renewal date, the AGENCY may change how it calculates the POLICYHOLDER’s premiums, how it determine the premiums, what the POLICYHOLDER has to pay and the method of payment. If the AGENCY does make changes, they will only apply from the POLICYHOLDER’s renewal date.
Some types of medical treatment may require pre-authorization in accordance with the procedures stipulated in the Table of Benefits.
o If the treatment received is subsequently proven to be medically unnecessary, the AGENCY reserves the right to decline the INSURED PERSON’s claim.
o For the benefits listed in the Table of Benefits, the AGENCY reserves the right to decline the INSURED PERSON’s treatment plan if the respective treatment is subsequently proven to be not medically necessary.
4.6. Modification of plan
The POLICYHOLDER may elect to change the plan of insurance selected on the original application only as at the renewal date of the SCHEME and subject to the acceptance of the AGENCY. If change involves an increase in cover, an additional premium amount will be payable and waiting periods may apply
4.7. Participation in insurance
If it is found that there is an in force insurance policy or policies belonging to the INSURED PERSON or anyone else had issued it in favor of the INSURED, covering the same insured risks covered under this SCHEME at the time of claim, the AGENCY will abide to compensate the full up to the limit of the SCHEME.
4.8. Insurance cancellation
The POLICYHOLDER cannot cancel this insurance once premium has been received.
All the INSURED PERSON’s rights arising from this Policy will forfeiture in the following cases:
A. Incorrect disclosure by the INSURED or his/her representative in the application form or in the declarations given, with the purpose of urging the AGENCY to accept the insurance or any non-disclosure to the AGENCY of any material facts which he/she had to inform the AGENCY with before the SCHEME commencement date.
B. Violation by the INSURED or his/her representatives of the laws or regulations, which organizes the performance of his/her, own activity, if involving intentional felony or misdemeanor or prosecution.
The INSURED or the beneficiaries’ rights to claim will forfeiture if the insured or his/her representative submits misleading or fraudulent data or support the claim form with fraudulent data or if the indemnity has been fabricated.
Cancellation and fraud
A. The POLICYHOLDER shall reimburse the AGENCY in the event that the relevant insurance cards issued by the AGENCY or its appointed Third Party Administrator are misused by the INSURED PERSON(S).
B. The POLICYHOLDER shall reimburse the HOSPITAL in respect of any additional expenses above the limits as specified by the benefit package.
C. Death. Upon the death of the POLICYHOLDER the dependant will still be covered till the end of the policy.
D. Death. Upon the death of the POLICYHOLDER or dependent the HIA should be notified in writing within 28 days.
E. If a dependent dies, they will be taken off the SCHEME and another dependant cannot be added.
This SCHEME is issued for the period from the Contract Effective Date to the Expiry Date as stated in the Insurance SCHEME, and may be renewed by the POLICYHOLDER at the SCHEME renewal date for another period of one year, subject to the terms in force at the time of each renewal date and to payment of premium, unless there is written notice given by the POLICYHOLDER or THE AGENCY at least thirty (30) days prior to the renewal date to cancel the SCHEME. THE AGENCY reserves the right to review the SCHEME terms and conditions and to alter the Premium rates at renewal of the SCHEME.
4.11 SCHEME expiry
Upon expiry of the SCHEME, the right of the INSURED PERSON to reimbursement ends. Any expenses covered under the insurance SCHEME and incurred during the period of cover shall be reimbursed up to one month after the expiry of the insurance SCHEME. However, any ongoing or further treatment that is required after the expiry date of the SCHEME will no longer be covered.
4.12 Medical records
The INSURED PERSON(S) agrees to assist the AGENCY in obtaining all necessary information to process a claim. The AGENCY has the right to access all medical records and to have direct discussions with the medical provider or the treating physician. The AGENCY may, at its own expense, request a medical examination by the AGENCY’s medical representative when the AGENCY deems this to be necessary. All information will be treated in strict confidence. The AGENCY reserves the right to withhold benefits if the INSURED PERSON has not honored these obligations
4.13 Observance of terms
The due observance and fulfillment of the terms and conditions of this SCHEME in so far as they relate to anything to be done or complied with the POLICYHOLDER or an INSURED PERSON shall be a condition precedent to any liability of the AGENCY.
Any claimant under this SCHEME shall at the request and expense of the AGENCY take and permit to be taken all necessary steps for enforcing rights against any other party in the name of the Insured before or after any payment is made by the AGENCY.
4.15 Time bar
The insurance coverage under this SCHEME will be subject to Law No. 4 of Laws of Lagos State of 25 May 2015.
The AGENCY’s liability to the INSURED PERSON(S) is limited to the amounts indicated in the Table of Benefits and any subsequent SCHEME endorsements. In no event will the amount of reimbursement, whether under this SCHEME, public medical schemes and any other insurance, exceed the amount of the invoice.
4.17 Making contact with dependents
In order to administer the SCHEME in accordance with the insurance contract, there may be circumstances when the AGENCY will need to request further information. If the AGENCY needs to make contact in relation to a dependent on a SCHEME (e.g. where further information is required to process a claim), the POLICYHOLDER, acting for and on behalf of the dependent, may be contacted by the AGENCY and be asked to provide the relevant information. Similarly, all information in relation to any person covered by the SCHEME, for the purposes of administering claims, may be sent directly to the POLICYHOLDER.
4.18 Force majeure
The AGENCY shall not be liable for any failure or delay in the performance of its obligations under the terms of this SCHEME, caused by, or resulting from, force majeure which shall include, but is not limited to: events which are unpredictable, unforeseeable or unavoidable, such as extremely severe weather, floods, landslides, earthquakes, storms, lightning, fire, subsidence, epidemics, acts of terrorism, outbreaks of military hostilities (whether or not war is declared), riots, explosions, strikes or other labour unrest, civil disturbances, sabotage, expropriation by governmental authorities and any other act or event that is outside of the AGENCY’s reasonable control.
4.19 Changes, declarations
The AGENCY may alter both the Individual Benefit Guide and/or the Table of Benefits from time to time but no alteration shall take effect until the next annual renewal of this Agreement. The AGENCY shall notify such changes to the POLICYHOLDER in writing and – where appropriate – shall issue replacement documents to the POLICYHOLDER. This SCHEME can only be varied in writing. No variation will be admitted unless it is in writing and signed on behalf of the AGENCY and the POLICYHOLDER.
4.20 Designated courts
All disputes arising from the interpretation or execution of this SCHEME shall be settled by the relevant Nigerian courts in whose jurisdiction lies the office of the AGENCY which issued the SCHEME.
4.21 Data protection
The AGENCY and all other parties authorized by the AGENCY shall obtain and process personal information for the purposes of providing and improving services related hereto including but not limited to preparing quotations, underwriting policies, collecting premium, verification of identity, paying claims, customer support, customer communication, research and for any other purpose which is directly related to administering policies in accordance with the insurance contract.
The AGENCY and all other parties authorized by the AGENCY have the right to communicate with the INSURED PERSON(S) by various means including but not limited to SMS, telephone and email.
The AGENCY shall not share your personal information without your consent to third parties or unauthorized persons, except as provided in this policy, to act on your behalf or request, as required by law or when necessary for operation fulfilment of the services hereunder or related hereto. For certain services the AGENCY may be required to use third party services. The AGENCY shall remain responsible for the protection of your personal information and shall take every step to ensure your privacy.
The AGENCY retains the right to pursue legitimate interests by processing and sharing anonymized data and results with various partners and stakeholders . This includes carrying out, or having third parties carry out, statistical analyses to support the AGENCY and carrying out the services and for the benefit of improving access to healthcare and to evaluate and improve the quality of healthcare services offered by healthcare providers and/or any other service necessary to provide you with the services.
The confidentiality of patient and INSURED PERSON information is of paramount concern to the AGENCY. The INSURED PERSON(S) has a right to access the personal data that is held about them. The INSURED PERSON(S) also has the right to request that the AGENCY amend or delete any information which the INSURED PERSON(S) believes is inaccurate or out of date.
The AGENCY will not retain the INSURED PERSON’s data for longer than is necessary for the purposes for which it was obtained.
Extent of Cover Overview
The POLICYHOLDER’s Table of Benefits specifies the plan(s) selected and the associated benefits available to him/her and his/her covered dependents. Further details about the INSURED PERSON(S) benefits are provided in the “Definitions” section of this document. Not all of the benefits listed in the “Definitions” section are necessarily covered under the POLICYHOLDER’s SCHEME. Cover is subject to the AGENCY’s SCHEME definitions, exclusions, benefit limits and any special conditions indicated on the Insurance Certificate.
The AGENCY would like to specifically highlight the following important points:Benefits 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 the AGENCY will pay for all benefits in total, per INSURED PERSON, per Insurance Year, under that particular plan.Some benefits also have a specific benefit limit which 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 the AGENCY will pay a percentage of the costs for the specific benefit. Where a specific benefit limit applies the POLICYHOLDER bears the cost of the additional care.
All limits are per INSURED PERSON, per Insurance Year, unless otherwise stated in the Table of Benefits
If the INSURED PERSON is covered for maternity benefits, these will be stated in the Table of Benefits along with any benefit limit and/or waiting period which applies. Benefit limits for “Routine maternity” and “Complications of childbirth” are payable on either a “per pregnancy” or “per Insurance Year” basis (this will also be confirmed in the Table of Benefits). If the benefit is payable on a “per pregnancy” basis and a pregnancy spans two Insurance Years, please note that if a change is applied to the benefit limit at SCHEME renewal, the following will apply:
• All eligible expenses incurred in the first year will be subject to the benefit limit that applies in year one and not transferable to year two.
• All eligible expenses incurred in the second year will be subject to the benefit limit that applies in year two.
Changing state of residence
Coverage is only limited to care within Lagos State. It is important that the POLICYHOLDER advises the AGENCY when they or their covered dependents change state of residence, as it may impact their cover.
Medical necessity and customary charges
This SCHEME provides cover for medical treatment, related costs, services and/or supplies that the AGENCY determines to be medically necessary and appropriate to treat a patient’s condition, illness or injury as stated in the Table of Benefits. The AGENCY will only pay for medical costs as stated on the tariff agreement and for the treatment provided, in accordance with standard treatment guidelines. If a claim is deemed by the AGENCY to be inappropriate, the AGENCY reserves the right to reduce the amount payable by them.
The “Notes” section of the Table of Benefits will confirm if pre-existing conditions are covered.
Geographical Area of Cover
The geographical area where MEDICAL TREATMENT may be obtained is within accredited healthcare providers in Lagos State in the Federal Republic of Nigeria.If the necessary medical treatment for which the INSURED PERSON is covered is not available locally, the INSURED PERSON can avail of treatment in any other location at their own cost.If the necessary medical treatment for which the INSURED PERSON is covered is available locally, but he/she chooses to travel to another area, the AGENCY will not reimburse any of the eligible medical costs incurred within the terms of the SCHEME.
ExclusionsAlthough the AGENCY covers most medically necessary treatment, expenses incurred for the following treatments, medical conditions and procedures are not covered under the SCHEME unless confirmed otherwise in the Table of Benefits or any written SCHEME endorsement.
7.1. Any form of treatment or drug therapy which in the AGENCY’s reasonable opinion is experimental or unproven, based on generally accepted medical practice.
7.2. Any treatment carried out by a plastic surgeon, whether or not for medical / psychological purposes and any cosmetic or aesthetic treatment to enhance the INSURED PERSON’s appearance, even when medically prescribed.
7.3. Care and/or treatment of drug addiction or alcoholism (including detoxification programmes and treatments related to the cessation of smoking), instances of death, or the treatment of any condition that in the AGENCY’s reasonable opinion is related to, or a direct consequence of, alcoholism or addiction (e.g. organ failure or dementia).
7.4. Care and/or treatment of intentionally caused diseases or self-inflicted injuries including a suicide attempt and all associated costs.
7.5. Complementary treatment, with the exception of those treatments indicated in theTable of Benefits.
7.6. Consultations performed, as well as any drugs or treatment prescribed, by the INSURED PERSON’s spouse, parents or children.
7.7. Developmental delay, the AGENCY does not cover conditions in which a child is slightly, temporarily or permanently lagging in development.
7.8. All expenses for the acquisition of an organ including, but not limited to, donor search, typing, harvesting, transport and administration costs.
7.9. Genetic testing, except where specific genetic tests are included within the INSURED PERSON’S plan.
7.10. Home Visits, unless otherwise stated in the Table of Benefits.
7.11. Infertility treatment including medically assisted reproduction or any adverse consequences thereof.
7.12. Investigations into, and treatment of, loss of hair and any hair replacement.
7.13. Investigations into, and treatment of, obesity.
7.14. Unless stated otherwise in the Table of Benefits, cover is not provided for investigations into, treatment and complications arising from sterilization, sexual dysfunction.
7.15. Medical evacuation/repatriation.
7.16. Medical practitioner fees for the completion of a Claim Form, medical report or other administration charges.
7.17. Pre-and post-natal classes.
7.18. Products classified as Vitamins or minerals (except during pregnancy or to treat diagnosed, clinically significant vitamin deficiency syndromes) including, but not limited to, special infant formula and cosmetic products, even if medically recommended or prescribed or acknowledged as having therapeutic effects. Costs incurred as a result of nutritional or dietary consultations are not covered, unless a specific benefit is included within the INSURED PERSON’s Table of Benefits.
7.19. Products that can be purchased without a doctor’s prescription except where a specific benefit covering these costs appears in the Table of Benefits.
7.20. Sex change operations and related treatments.
7.21. Speech therapy related to developmental delay, dyslexia, dyspraxia or expressive language disorder.
7.22. Stays in a cure center, bath center, spa, heath resort and recovery center, even if the stay is medically prescribed.
7.23. Termination of pregnancy, except in the event of danger to the life of the pregnant woman.
7.24. Treatment directly related to surrogacy whether the INSURED PERSON is acting as surrogate, or is the intended parent.
7.25. Treatment for any medical conditions arising directly or indirectly from chemical contamination, radioactivity or any nuclear material whatsoever, including the combustion of nuclear fuel.
7.26. The AGENCY does not cover treatment for conditions such as conduct disorder, attention deficit hyperactivity disorder, autism spectrum disorder, oppositional defiant disorder, antisocial behavior, obsessive-compulsive disorder, phobic disorders, attachment disorder, adjustment disorders, eating disorders, personality disorders or treatments that encourage positive social-emotional relationship, such as family therapy.
7.27. Travel costs to and from medical facilities (including parking costs) for eligible treatment, except any travel costs covered under local ambulance, medical evacuation and medical repatriation benefits.
7.28. Treatment of sleep disorders including insomnia.
7.29. Treatment or diagnostic procedures for injuries arising from an engagement in professional sports.
7.30. Treatment outside the geographical area of cover unless for emergencies or authorized by the AGENCY.
7.31. Treatment required as a result of medical error.
7.32. Tumour marker testing unless the state in the Table of Benefits.
7.33. The following treatments, medical conditions or procedures or any adverse consequences or complications thereof, are not covered, unless otherwise indicated in the Table of Benefits:
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 the INSURED PERSON’S core plan.
2. Dietician fees.
3. Emergency dental treatment.
4. Health and wellbeing checks including cancer screening.
5. Home delivery.
6. Infertility treatment.
7. In-patient psychiatry and psychotherapy treatment.
8. Laser eye treatment.
9. Medical repatriation.
10. Organ transplant.
11. Out-patient treatment.
12. Out-patient psychiatry and psychotherapy treatment.
13. Prescribed glasses and contact lenses including eye examination.
14. Prescribed medical aids.
15. Preventive treatment.
16. Rehabilitation treatment.