What is a network/network provider list?
A list (or lists) of Providers, as shown in the Table of Benefits, available to the Insured Person to visit for Treatments, services and supplies from the commencement of the Policy, that may later be updated and superseded from time to time by a new list (or lists) at the discretion of the Insurer.
What is direct billing?
A service provided by a Network Provider whereby costs incurred by the Insured Person will be charged directly to the Insurer, so the Insured Person will not be required to pay for Treatments, services and supplies upon presentation of their Membership Card or a Provider accepting them as a GlobalCare Plan member.
What is a policy holder?
A registered and licenced company which (or in the case of individual or family policies, the named person who) enters a contract (the Policy) with the Insurer to provide Cover for its employees or workers (or in the case of individual or family policies for themselves and/or their family members), and optionally also for their Dependants where the context permits.
What is considered an accident?
A sudden, unexpected, unusual, specific and definable event occurring at an identifiable time and place acting on the body and causing injury.
What is the annual policy limit?
The maximum that the Policy will Cover in the Policy Term for each Insured Person, for the sum of all the valid Claims paid by the Insurer.
What is the benefit limit?
A monetary amount/limit, for each Insured Person, expressly provided in the Table of Benefits for a specific Benefit, for the sum of valid Claims against that specific Benefit in the Policy Term. Any such valid Claims also reduce the remaining Annual Policy Limit, which remains the ultimate limit. Where no specific Benefit Limit is provided, the limit for that specific Benefit is up to the Annual Policy Limit less all other valid Claims already approved by the Insurer in the Period of Cover.
How is medically necessary defined?
Any medical Treatment, service or supply which, in the opinion of a qualified Medical Practitioner, is appropriate and consistent with the diagnosis and which, in accordance with generally accepted medical standards, could not have been omitted without adversely affecting the Insured Person’s condition and/or the quality of basic medical care provided.
What is a co-insurance?
The percentage of the costs for a specific Benefit the Insured Person must pay. For example, if there is 20% Co-insurance on a dental Benefit with a limit of AED 6,250, the Insured Person will be required to pay AED 1,250 (20%), and the Insurer AED 5,000 (80%) if a total incurred cost amounts to AED 6,250. The Insured Person will be required to pay 100% of any incurred costs over and above the AED 6,250 limit.
What is a deductible/excess?
The amount that, if specified in the wording of a Benefit in the Table of Benefits, must be paid by the Insured Person to the Provider at the point at which a Treatment or service or a supply is delivered or accessed.
What is a medical practitioner?
A Doctor or specialist who is licensed to practice medicine under the law of the country in which Treatment, services or supplies are provided, and where he/she is practicing within the limits of his/her licence.
How is a usual customary and reasonable (UCR) charge defined?
Refers to the standard or typical charge for a particular Treatment, service or supply when rendered in a particular country or geographic area. Claims for any eligible Treatment, service or supply that are of a higher value than the respective UCR Charge may not be paid in full and may only be paid up to the specific UCR Charge amount.
What is an acute condition?
A severe condition with sudden onset.
What is a chronic condition?
Health conditions or diseases that are persistent or otherwise long-lasting in their effects.
What constitutes a Medical Emergency?
A sudden, unforeseen and severe Medical Condition or injury that requires urgent medical assistance. Emergency medical Treatment will only be covered up to the point where the Medical Practitioner in charge of the Insured Person’s Treatment advises that their condition has stabilised.
What are congenital disorders?
Diseases, birth defects or anomalies, existing at or before birth regardless of cause, which may or may not be obvious at birth.
What is a hereditary condition?
A disease or disorder that is inherited genetically.
What is a pre-existing condition?
A Medical Condition that started, existed or for which symptoms first appeared prior to the Policy Start Date, regardless of whether a Medical Practitioner was consulted, or Treatment undertaken.
What is the meaning of Medical History Disregarded (MHD)?
The Insurer and Reinsurer waive the requirement, that prior to executing a Policy, every person to be included in that Policy completes a Health Declaration Form to more accurately determine their state of their health, however A Declaration of Major Medical Conditions Form must still be completed by an authorised person on behalf of the Policy Holder, for underwriting purposes. In some circumstances the Insurer reserves the right to request a Health Declaration Form be completed by certain applicants for medical insurance Cover.
How is a terminal illness defined?
A diagnosed illness (or condition) resulting in the Insured Person being given 6 months or less to live by a Medical Practitioner.
What is understood under palliative & hospice care?
Physical and psychological Treatment (including prescribed medication for pain management) and care delivered by Medical Practitioners, Qualified Nurses, carers, psychologists and counsellors), which may also include home visits and, if recommended by a Medical Practitioner, accommodation in a Hospice or Hospital.
What is covered under the antenatal benefit?
Visits: All care provided by Obstetrician for low risk or Specialist Obstetrician for high-risk referrals. Initial investigations to include: 1)
- Full Blood Count (FBC) and Platelets
- Blood group, Rhesus status and Antibodies
- Venereal Disease Research Laboratory Test (VDRL), Midstream Specimen of Urine (MSU) and Urinalysis, Rubella Serology, Human Immunodeficiency Virus (HIV), Hep C offered to high risk patients, Glucose Tolerance Test (GTT) if high risk, Fasting Blood Sugar (FBS), Random S or A1c.
What is covered under the preventive check-ups benefit?
A specific Benefit expressly mentioned in the Table of Benefits. For Insured Persons 18 years of age or older only the following are Covered:
- Consultation with a GP (Height, Weight, BMI, Blood Pressure, Temperature and Complete physical examination (inspection, palpation, auscultation) of the following systems: Skin, Ear-Nose-Throat, Cardiovascular, Respiratory, Digestive, Genitourinary, Central Nervous System, Psychological well-being)
- Laboratory Tests (Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), Fasting Blood Sugar, Glycosylated Haemoglobin (HbA1C), Fasting Lipid Profile, Blood Urea Nitrogen (BUN), Creatinine, Electrolytes (Na+, K+, Cl-), Liver function (AST, ALT, GGT), Urinalysis and TSH)
- Investigations (Chest X-Ray and ECG)
What is covered under the newborn cover benefit?
Cover for a newborn baby for 30 days from birth under the mother’s Policy for:
- Standard neo-natal physical examinations
- Standard hearing test
- Critical congenital heart disease screening (for Abu Dhabi residents insured with HAAD compliant plans only)
- Neo-natal laboratory screening (standard heel-prick/blood-spot tests)
- Vaccinations – Bacillus Calmette-Guerin (BCG), Hepatitis B & Vitamin K
- Life threatening illnesses and defects, and anything else mandated by local laws and regulations
What is covered under medical repatriation/evacuation?
In case of an eligible Medical Condition or Emergency for which it is agreed there is no suitable or adequate medical Treatment available locally, the following reasonable and appropriate costs are Covered:
- Transportation (including medical care and assistance if required), to the nearest suitable Hospital or where possible to a Hospital in the Insured Person’s choice of either their Home Country or Country of Residence for Treatment, and if repatriated for Day Patient Treatment, hotel accommodation including breakfast and taxis (to and from the airport, and to and from the Hospital for Treatment as necessary). A repatriation/evacuation must be arranged where possible through the respective Helpline.
- An economy airfare, taxis (to and from the airport and daily to and from the Hospital for visits) and hotel accommodation including breakfast for a Dependant accompanying an Insured Person receiving Inpatient Treatment if outside their Country of Residence.
- If required an economy airfare to the Country of Residence after Treatment for the Insured Person and any accompanying Dependant, up to 30 days after the Treatment has been completed.
What is covered under the repatriation of mortal remains benefit?
In the event of the death of an Insured Person, Cover for the cost of embalming, a coffin suitable to transport the body and transportation from a morgue, or in the case where the Insured Person has been cremated, from the place of cremation, to an airport in their Home Country. Claims will only be reimbursable if submitted with a death certificate.