Policy Summary & Key Facts

Transcription

1 Policy Summary & Key Facts For Guernsey policies Disclaimer This document summarises key benefits and the most significant or unusual exclusions of Cigna s plans. However, a summary cannot fully describe all of the terms, conditions and exclusions and you must read the full Policy Rules including the General Exclusions, and the Customer Guide which contains the List of Benefits, and claiming information. It is also very important that you read the list of special exclusions attached to your Certificate of insurance, since these are likely to be of particular significance to you. The insurance will be provided by Insurer Cigna Global Insurance Company Limited St Martin s House, Le Bordage, St Peter Port, Guernsey GY1 4AU The insurance is administered by Cigna European Services (UK) Limited. Regulator The insurer is authorised and regulated by the Guernsey Financial Services Commission for the conduct of insurance business in Guernsey, including matters relating to this policy. Main business activity Cigna s main business activities are affecting and carrying out contracts of medical and life insurance. Address for summons and Authorised representative Mr Alastair Watt Address as above. Directors Alastair Watt, Sébastien Haslé, Reter Greskoff, John Langlois.

2 Type of insurance and cover Duration of cover and procedure for renewal Termination and cancellation The policy is for individual private medical insurance, for international expatriates only. It covers certain costs of medically necessary treatment and certain services related to that treatment, as shown in the List of Benefits. A summary of benefits is set out at the end of this document. The policy duration is one year, effective from the policy start date, which will be shown on your Certificate of insurance. If you renew your policy, you may need to review and update your cover to ensure that it remains adequate. Cover will end if: you do not pay your full premium on time; or we give you 14 days notice that the policy is to end; or it becomes unlawful for us to provide any of the cover available under this policy; or any beneficiary is identified on any trade sanctions listings; or you have given dishonest or incomplete answers or have failed to take any care to answer honestly and fully. Please read through the policy carefully. If it has not been issued in accordance with your intention, return the policy to us for alteration or cancellation within 14 days from the date of issue. Your obligations You must take reasonable care to answer all questions in your application honestly and fully. This is important to enable us to calculate the appropriate premium and tailor your insurance cover to your personal situation. Careless misrepresentation could result in us reducing the amount of any claims proportionately; whereas deliberate or reckless misrepresentation could result in us rejecting claims, and/or cancelling cover. You are obliged to pay your premium on time. You are obliged to abide by the rest of the terms and conditions in your Policy Rules. Premiums can be paid in the following ways: Premium Annually by electronic funds transfer Monthly, quarterly or annually by credit or debit card Your premiums, and details of how you have chosen to pay, are stated on your certificate of insurance.

3 Taxes or other fees Taxes, fees or costs which may result from your insurance policy are neither payable via the undertaking nor imposed by it. There may be a deductible payment applicable to this plan. Please refer to your Certificate of insurance for full details of any deductible that applies. The deductible is payable for each person covered under the policy. Benefits are subject to limits and the patient is responsible for paying any expenses above the limits. The amount of the deductible is stated on your Certificate of insurance, and the benefit limits are stated in the List of Benefits within the Customer Guide. Deductible (various) A deductible is a portion of a claim or claims that is not covered by your plan. Claim deductibles and benefit limits So, for example if you choose a deductible of 500 for International Medical Insurance, you ll need to pay the first 500 of a covered claim or covered claims in any period of cover. If a deductible is chosen, you would only have to pay this once during any period of cover irrespective of the number of claims. The higher the deductible you apply, the lower your premium will be. The deductible is payable by each person covered by the policy. Cost share (after deductible) A cost share is the portion, specified as a percentage, of each claim that is not covered by your plan. The out of pocket maximum is the maximum amount you will need to pay in cost share in a period of cover. For example, if you select a cost share of 20% and an out of pocket maximum of $2,000, you will need to pay the first 20% of each covered claim, up to a maximum of $2,000 per period of cover. Please refer to your Customer Guide for more information about how deductibles, cost shares and out of pocket maximums work and the limits you can select. How does the contract come into force? If we accept your application, we will notify you of special exclusions (if any) which would apply to you and any covered beneficiaries, and then ask whether you wish to purchase the insurance. You may accept our quote within 14 days. The contract will come into force when you agree to purchase the insurance, unless we agree a different date with you. The start date will be shown on your Certificate of insurance.

4 You must obtain prior approval from us, before receiving treatment or incurring costs. If you do not, you will be responsible for paying 20% of your eligible treatment costs. Making a claim outside the USA IMPORTANT Claims for treatment should be sent to: Cigna 1 Knowe Road Greenock Scotland PA15 4RJ If you require assistance call: 24 Hour Helpline No: +44 (0) Toll Free No: You must obtain prior approval from us, before receiving treatment or incurring costs. If you do not, you will be responsible for paying 50% of your eligible treatment costs. Making a claim in the USA IMPORTANT In addition, you must use the Cigna PPO in-network providers to receive full reimbursement of eligible treatment costs. If you use an out-of-network provider, you will be responsible for paying 20% of your eligible treatment costs. The only exception to this is if treatment is not available in your location, or in an emergency. Claims for treatment carried out in the USA should be sent to: Cigna International PO Box Wilmington, Delaware United States of America If you require assistance call: 24 Hour Helpline No: +44 (0) Toll Free No: You must notify us of a claim in writing on a Cigna claim form, with original invoices, within 90 days of the start of treatment or as soon as reasonably possible after that. Notification of claims You must provide written proof to substantiate the claim within 6 months of the start of treatment for which the claim is made. The proof provided must describe the occurrence, nature and extent of the treatment and the loss that was incurred as a result. If notification of the claim, and written proof substantiating the claim, are not submitted to Cigna within 12 months, the claim will not be paid.

5 In the event that you wish to make a complaint, you may: write to Head of Customer Service, Cigna, 1 Knowe Road, Greenock, PA15 4RJ or telephone +44 (0) If you are not satisfied, you may complain to the following bodies without prejudice to your right to bring proceedings in court. Details of other local Ombudsmen are available from us on request. Complaints Country Complaints body UK Financial Ombudsman Service Landlines: Mobile phones: complaint.info@financialombudsman.org.uk The Financial Ombudsman Service South Quay Plaza 183 Marsh Wall London, E14 9SR. Insurer insolvency Depending on the country in which you are habitually resident, and the relevant scheme rules, a local guarantee scheme may apply, details of which are available from us on request. Language of the contract and precontractual negotiations Documents and information will be provided in English only. Governing law The law to which the insurer proposes to shall govern this policy is the law of England and Wales.

6 Key Benefits and Significant Exclusions International Medical Insurance Your overall limit Silver Gold Platinum Annual benefit maximum per beneficiary per period of cover. This includes claims paid across all sections of International Medical Insurance. $1,000, , ,000 $2,000,000 1,600,000 1,300,000 $3,000,000 2,500,000 2,000,000 Your standard medical benefits Silver Gold Platinum Hospital charges for: nursing and accommodation for inpatient and daypatient treatment. recovery room for semi-private room Hospital charges for: operating theatre. prescribed medicines, drugs and dressings for inpatient or daypatient treatment. treatment room fees for outpatient surgery. Intensive care intensive therapy. coronary care. high dependency unit. Parental accommodation This applies to eligible dependent children under the age of 18. Cigna will pay for reasonable costs for a parent staying in the same hospital with the child where the child is required to stay in the hospital overnight. Up to the maximum amount shown per period of cover. $1, $1, Surgeons and anaesthetists fees Where surgery is provided on an inpatient, daypatient or outpatient basis. Specialists consultation fees for regular visits by a specialist during stays in hospital including intensive care by a specialist for as long as is required by medical necessity.

7 Your standard medical benefits Silver Gold Platinum Transplant services Where treatment is provided on an inpatient basis. Kidney dialysis Where treatment is provided on an inpatient, daypatient or outpatient basis. Pathology, radiology and diagnostic tests (excluding Advanced Medical Imaging) Where investigations are provided on an inpatient or daypatient basis. Advanced Medical Imaging (MRI, CT and PET scans) We will pay for these scans whether received on an inpatient, daypatient or an outpatient basis. $10,000 7,400 6,650 Physiotherapy and complementary therapies Where treatment is provided on an inpatient or daypatient basis. $2,500 1,850 1,650 Home nursing Up to 30 days and the maximum amount shown per period of cover. $2,500 1,850 1,650 Rehabilitation Up to 30 days and the maximum amount shown per period of cover. $2,500 1,850 1,650 Hospice stay to receive palliative care Up to the maximum amount shown per lifetime. $2,500 1,850 1,650 Internal prosthetic devices/surgical and medical appliances We will pay for: a prosthetic implant, device or appliance which is inserted during surgery. External prosthetic devices/surgical and medical appliances We will pay for: a prosthetic device or appliance which is a necessary part of the treatment immediately following surgery for as long as is required by medical necessity. a prosthetic device or appliance which is medically necessary and is part of the recuperation process on a short-term basis. For adults, we will pay for one external prosthetic device. For children up to the age of 16, we will pay for the initial prosthetic device and up to two replacement devices. For each prosthetic device $3,100 2,400 2,000 For each prosthetic device $3,100 2,400 2,000 For each prosthetic device $3,100 2,400 2,000 Up to the maximum amount shown per period of cover.

8 Your standard medical benefits Silver Gold Platinum Local ambulance and air ambulance services Medically necessary travel by local road ambulance or local air ambulance, such as a helicopter, when related to covered hospitalisation. Inpatient cash benefit We will make a cash payment to the beneficiary when they: receive treatment in hospital which is covered under this plan; stay in a hospital overnight; and have not been charged for their room, board and treatment costs. Per night up to 30 nights per period of cover. $ $ $ Emergency dental treatment Dental treatment in hospital after a serious accident. Your psychiatric care Silver Gold Platinum Psychiatric treatment We will pay for: treatment of mental health conditions and disorders. addiction treatment. Whether the beneficiary is staying in a hospital overnight or receiving treatment as a daypatient or outpatient. A combined maximum total of 90 days cover is available in the period of cover, including up to 30 days of inpatient treatment. For daypatient and outpatient treatment, each visit will count as one day. An overall 5 year total limit of 180 days cover will apply, of which a maximum of 60 days can be used for inpatient treatment. $10,000 7,400 6,650

9 Your cancer care Silver Gold Platinum Cancer Treatment We will pay for active and evidence-based treatment received for, or related to cancer, including chemotherapy, radiotherapy, oncology, diagnostic tests and drugs whether the beneficiary is staying in a hospital overnight or receiving treatment as a daypatient or outpatient. Your parent and baby care Silver Gold Platinum Routine maternity benefit and childbirth cover Available once the mother has been covered by the policy for 10 months or more. Inpatient and outpatient treatment, including hospital charges, obstetricians and midwives fees. Not covered $7,000 5,500 4,500 $14,000 11,000 9,000 Complications from maternity Available once the mother has been covered by the policy for 10 months or more. Inpatient and outpatient treatment for complications resulting from pregnancy. Caesarean sections are only covered when these are required by medical necessity. Not covered $14,000 11,000 9,000 $28,000 22,000 18,000 Homebirths Available once the mother has been covered by the policy for 10 months or more. Up to the maximum amount shown per period of cover. Not covered $ $1, Newborn care If at least one parent has been covered by the policy for a continuous period of 10 months or more prior to the newborn s birth. We will not require information about the newborn s health or a medical examination if an application is received by us to add the newborn to the policy within 30 days of the newborn s date of birth. If an application is received after 30 days of the newborn s date of birth, the newborn will be subject to medical underwriting and we will require the completion of a medical health questionnaire whereby we may apply special restrictions or exclusions. If neither parent has been covered by the policy for a continuous period of 10 months or more prior to the newborn s birth and an application is received by us to add the newborn to the policy as a beneficiary. The newborn will be subject to medical underwriting and we will require the completion of a medical health questionnaire. Cover for the newborn will be subject to medical underwriting whereby we may apply special restrictions or exclusions. Up to the maximum amount shown for treatment within the first 90 days following birth. $25,000 18,500 16,500 $75,000 55,500 48,000 $156, , ,000 Congenital conditions Where treatment is provided on an inpatient or daypatient basis and the congenital condition manifested itself before the beneficiary s 18th birthday. Up to the maximum amount shown per period of cover $20,000 14,800 13,300 $39,000 30,500 25,000

10 Your deductible and cost share options Silver Gold Platinum Deductible (various) A deductible is the amount which you must pay before any claims are covered by your plan. $0 / $375 / $750 / $1,500 / $3,000 / $7,500 / $10,000 0 / 275 / 550 / 1,100 / 2,200 / 5,500 / 7,400 0 / 250 / 500 / 1,000 / 2,000 / 5,000 / 6,650 Cost share after deductible and out of pocket maximum Cost share is the percentage of each claim not covered by your plan. The out of pocket maximum is the maximum amount of cost share you would have to pay in a period of cover. The cost share amount is calculated after the deductible is taken into account. Only amounts you pay related to cost share contribute to the out of pocket maximum. First, choose your cost share percentage: 0% / 10% / 20% / 30% Next, choose your out of pocket maximum: $2,000 or 1,480 or 1,330 or International Outpatient Your overall limit Silver Gold Platinum Annual benefit maximum per beneficiary per period of cover. This includes claims paid across all sections of International Medical Outpatient. $10,000 7,400 6,650 $25,000 18,500 16,625 $78,000 61,000 50,000 Your standard medical benefits Silver Gold Platinum Consultations with medical practitioners and specialists $125 / 90 / 80 limit per visit. Up to 15 visits per year. $250 / 185 / 165 limit per visit. Up to 30 visits per year. Pathology, radiology and diagnostic tests (excluding Advanced Medical Imaging) Where investigations are provided on an outpatient basis $2,500 1,850 1,650 Physiotherapy Where treatment is provided on an outpatient basis. $2,500 1,850 1,650 Osteopathy and chiropractic treatment Up to the maximum visits shown per period of cover. Acupuncture, Homeopathy and Chinese medicine Up to a combined maximum of 15 visits per period of cover. up to 15 visits up to 15 visits up to 30 visits Restorative Speech therapy Provided on a short-term basis following a condition such as a stroke. $2,500 1,850 1,650 Drugs and dressings When prescribed by a medical practitioner on an outpatient basis. $ $2,000 1,480 1,330

11 Your standard medical benefits Silver Gold Platinum Rental of durable medical equipment Up to a maximum of 45 days in the period of cover. Adult vaccinations Dental accidents We will pay for dental treatment required for the damage to the beneficiary s sound natural tooth/teeth as the result of an accident. Treatment must commence immediately after the accident and be completed within 30 days of the date of the accident. Well child tests Payable for children at appropriate age intervals up to the age of 6. Child immunisations Payable for children aged 17 or younger. Annual routine tests One eye test and hearing test for children aged 15 or younger. $ $1, Your deductible and cost share options Silver Gold Platinum Deductible (various) A deductible is the amount which you must pay before any claims are covered by your plan. Cost share after deductible and out of pocket maximum Cost share is the percentage of each claim not covered by your plan. The out of pocket maximum is the maximum amount of cost share you would have to pay in a period of cover. The cost share amount is calculated after the deductible is taken into account. Only amounts you pay related to cost share contribute to the out of pocket maximum. $0 / $150 / $500 / $1,000 / $1,500 0 / 110 / 370 / 700 / 1,100 0 / 100 / 335 / 600 / 1,000 First, choose your cost share percentage: 0% / 10% / 20% / 30% Your out of pocket maximum is: $3,000 2,200 2,000

12 International Medical Evacuation Your overall limit Silver Gold Platinum Annual benefit Maximum per beneficiary Your standard medical benefits Silver Gold Platinum Medical Evacuation Transfer to the nearest centre of medical excellence if the treatment the beneficiary needs is not available locally. Medical repatriation Repatriation of mortal remains Travel cost for an accompanying person Compassionate visit Up to a maximum of 5 trips per lifetime Compassionate visit - travel costs Up to the maximum amount shown per period of cover $1,200 1, $1,200 1, $1,200 1, Compassionate visit - living allowance costs Up to the maximum amount shown per day for each visit with a maximum of 10 days per visit. $ $ $

13 International Health and Wellbeing benefits Your standard medical benefits Silver Gold Platinum Routine adult physical exams We will pay for routine physical examinations for persons aged 18 or older. Up to the maximum amount shown per period of cover $ $ $ Pap smear We will pay for an annual Papanicolaou screening. Up to the maximum amount shown per period of cover $ $ Prostate cancer screening We will pay for an annual prostate cancer screening for men aged 50 or older. Up to the maximum amount shown per period of cover $ $ Mammograms for breast cancer screening or diagnostic purposes We will pay for: Aged 35-39: one baseline mammogram for asymptomatic women. Aged 40-49: one mammogram for asymptomatic women every two years, or more if medically necessary. Aged 50 or older: one mammogram each year. Up to the maximum amount shown per period of cover $ $ Bowel cancer screening We will pay for an annual bowel cancer screening for beneficiaries aged 55 or older. Up to the maximum amount shown per period of cover $ $ Bone densitometry We will pay for an annual scan to determine the density of the beneficiary s bones. Up to the maximum amount shown per period of cover $ $ Dietetic consultations We will pay for up to 4 meetings with a dietitian per period of cover Not covered Not covered Life management (customer assistance programme) Available 24 hours a day, 7 days a week, 365 days a year. Up to 5 face-to-face sessions with a professional counsellor. Provides information, resources, and counselling on any work, life, personal, or family issue that matters to you. Convenient online counselling via E-counselling. Unlimited telephonic support. SMS texting text the support you need and receive a call back. Crisis support. Access life management services from your secure customer area. Online health education, health assessments and web-based coaching programmes

14 International Vision and Dental benefits Vision Care Silver Gold Platinum One eye examination per period of cover by an optometrist or ophthalmologist. Maximum per beneficiary per period of cover. $ $ Expenses for: Spectacle lenses. Contact lenses. Spectacle frames. Prescription sunglasses. $ $ $ Dental Treatment Your overall limit Silver Gold Platinum Annual benefit Maximum per beneficiary per period of cover. $1, $2,500 1,850 1,650 $5,500 4,300 3,500 Your standard dental benefits Silver Gold Platinum Preventative Available after the beneficiary has been covered on this option for 3 months. Routine Available after the beneficiary has been covered on this option for 3 months. 80% refund per period of cover 90% refund per period of cover Major restorative After the beneficiary has been covered on this option for 12 consecutive months. If the beneficiary needs to claim within the first 12 months, 50% reimbursement will apply. 70% refund per period of cover 80% refund per period of cover Orthodontic treatment Available for beneficiaries aged 18 or younger, after they have been covered on this option for 2 consecutive years. 40% refund per period of cover 50% refund per period of cover 50% refund per period of cover

15 General Exclusions The following significant exclusions or limitations apply to the International Medical Insurance Plan and each of the coverage options. Where we have stated that we will pay for treatment in some circumstances, this is subject to the beneficiary having cover under the appropriate coverage option or options. Exclusions which apply to all coverage and options. We will not offer cover or pay claims when it is illegal for us to do so under applicable laws. Examples include but are not limited to, exchange controls, local licensing regulations, sanctions or trade embargo. The treatment must be recommended by a medical practitioner. We will not pay for treatment for a pre-existing condition of which the policyholder was (or should reasonably have been) aware of at the date cover commenced, and in respect of which we have not expressly agreed to provide cover. We will not pay for treatment for any conditions to which a special exclusion applies as stated in your certificate of insurance. We will not pay for treatment in establishments which are not a hospital. We will not pay for treatment for a related condition resulting from addictive conditions, disorders and any kind of substance or alcohol use or misuse. We will not pay any expenses for ship-to-shore evacuations. We will not pay for treatment for or in connection with speech therapy that is not restorative in nature. We will not pay for artificial life maintenance where such treatment will not or is not expected to result in the beneficiary s recovery or restore them to their previous state of health. We will not pay for treatment that arises from or is in any way connected with attempted suicide. We will not pay for treatment for or as a result of obesity. We will not pay for treatment needed because of or relating to infertility or any type of fertility treatment, including complications arising out of such treatment, with the exception of infertility to the point of diagnosis. We will not pay for treatment by way of intentional termination of pregnancy, unless the pregnancy were to endanger the life or mental stability of the mother.

16 We will not pay for treatment directly related to surrogacy. We will not pay maternity benefits: to a beneficiary who acts as a surrogate; or to anyone else acting as a surrogate for a beneficiary. We will not pay for Newborn Care benefits for children born as a result of fertility treatment such as IVF, or for children born to a surrogate, or who have been adopted. These children can only join once they are 90 days old, and will be subject to medical underwriting. We will not pay for supportive treatment for chronic kidney failure or kidney failure which cannot be cured. Treatment for kidney dialysis will be covered if such treatment is available in the beneficiary s country of habitual residence. We will not pay for preventative treatment. We will not pay for treatment outside the selected area of coverage. We will not pay for any charges for more than one visit to a medical practitioner for preventative care services at each of the appropriate age intervals up to a total of 13 visits for each child who is a beneficiary. Exclusions which apply specifically to the Vision and Dental option We will not pay for treatment which is purely cosmetic, such as the replacement of a sound natural tooth with an implant or veneer. We will not pay for treatment that is not necessary for continued oral health. We will not pay for treatment for the replacement of any dental appliance which is lost or stolen. We will not pay for procedures, services and supplies which are deemed by Cigna to be medical procedures, services and supplies including mouthwashes, and services and supplies provided in a hospital (except where dental treatment is neither wholly or partly the reason for the stay in hospital) We will not pay for sunglasses unless medically prescribed. We will not pay for lenses which are not a medical necessity and are not prescribed by an Optometrist or Opthalmologist or frames for such lenses. We will not pay for medical or surgical treatment of the eye. We will not pay for treatment which is, to any extent, made necessary by a beneficiary engaging in any illegal activity.

17 Exclusions which apply specifically to the International Medical Evacuation option The treatment must not be available locally. The treatment must be covered under the plan. The beneficiary must have cover for the country in which they are going to be treated. We will not pay for any other costs related to the evacuation or repatriation such as taxis or hotel accommodation. We will not pay for someone to travel with the beneficiary when the purpose of the evacuation is for the beneficiary to receive outpatient treatment. We will not pay for burial or cremation, the costs of burial caskets, etc, or the transport costs for someone to collect or accompany the beneficiary s mortal remains. We will not pay for compassionate visit living allowance when either an evacuation or repatriation has taken place. We will not pay for extra nights in hospital when a beneficiary is no longer receiving treatment and is awaiting a return flight. We will not pay for any expenses for international emergency services which were not approved in advance by the medical assistance service. We will not pay for international services expenses for emergency evacuation, medical repatriation and transportation costs for third parties where the treatment needed is not covered under the plan. Key Facts GUERNSEY (07/13a)