Medivac Care - Schedule of Benefits and Limits

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Clementine Collins
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1 1. Benefit Medivac Care - Schedule of Benefits and Limits This table is a summary only and benefits are payable subject to the terms and conditions set out below. BENEFIT 1.1 Approved Local Specialised Treatment by a Preferred Provider in Fiji 1.2 Specialised Treatment by a Preferred Provider in India - Where Treatment is not available in Fiji 1.3 Medical Emergency Evacuation to New Zealand or Australia - Where Treatment is not available in Fiji and cannot be treated in India due to time constraints LIMITS AND TERMS 100% of charged costs subject to Policy Limits and a combined Limit per Condition of $150,000 Provided that Treatment is Medically Necessary and Prior Approval has been granted, the Insured is entitled to: Approved Local Specialised Treatment in Fiji at a BSP Health Preferred Provider or if Treatment is not available in Fiji: medical and surgical Treatment in India at a BSP Health Preferred Provider or medical and surgical Treatment in New Zealand or Australia at a BSP Health Preferred Provider in the event of a Medical Emergency up to a combined Limit per Condition of $150,000. BSP Health will make a determination as to whether Treatment is available in Fiji after taking into account the following factors: (i) (ii) (iii) (iv) (v) availability of Visiting Consultants availability of specialised equipment seriousness of the Condition urgency of the need for Treatment advice from a local Specialist. 1.1 APPROVED LOCAL SPECIALISED TREATMENT BY A PREFERRED PROVIDER IN FIJI Benefit Subject to the terms and conditions stated in the Policy, BSP Health will cover the cost of Treatment for the following healthcare services provided by its Preferred Provider in Fiji if BSP Health is satisfied that Treatment for the Condition is Medically Necessary: Hospital Expenses Insured patient s travel, accommodation and meals accompanying person s travel, accommodation and meals ambulance services subject to the overall Limit per Condition set out in Part 1 and Limits applying to each benefit as set out in this Part 1.1. Prior Approval must be obtained for this benefit and once granted, BSP Health will make the necessary arrangements for the Insured including settlement of all medical and Hospital costs with its Preferred Provider in Fiji Hospital Expenses Medivac Care Page 1 SPECIMEN

2 Subject to the terms and conditions stated in the Policy, costs incurred in respect of the following will be covered by BSP Health if BSP Health is satisfied that the service is Medically Necessary and Prior Approval is granted: (g) (h) Hospitalisation Surgical Expenses intensive care Prosthesis pre and post operative Outpatient pharmaceuticals special nursing provided it is Medically Necessary Post Discharge Care Diagnostics and Specialist consultation prior to Admission Insured patient s travel, accommodation and meals Subject to the terms and conditions stated in the Policy, if Prior Approval has been granted the Insured has two options: 1. To make his/her own travel, accommodation and meal arrangements through a hotel or motel. In which case, BSP Health will reimburse the Insured s reasonable travel, accommodation and meal costs up to a: Limit of $100 per Day for accommodation Limit of $50 per Day for meals and transportation, or 2. To stay with relatives in which case BSP Health will provide the Insured a cash allowance of $50 per Day. Once the Insured chooses an option above, that choice is irrevocable. This allowance only applies to the period after Discharge until the first review if the Insured has to arrange an overnight stay in a town or city that is outside of his/her usual place of residence. Transportation costs are covered on a reimbursement basis for return travel between the airport, approved hotel or motel, the Local Public Hospital, the Approved Private Medical Facility and the Insured s normal place of residence Accompanying person s travel, accommodation and meals Subject to the terms and conditions stated in the Policy, if Prior Approval has been granted the accompanying person has two options: 1. To make his/her own travel, accommodation and meal arrangements through a hotel or motel. In this case, BSP Health will reimburse the accompanying person s reasonable travel, accommodation and meal costs up to a: Limit of $100 per Day for accommodation Limit of $50 per Day for meals and transportation subject to a Limit of $2,250 for the first 15 Days. Further Prior Approval is required if a stay of more than 15 days is necessary in which case an additional Limit of $1,500 applies, or 2. To stay with relatives, in which case BSP Health will provide the accompanying person a cash allowance of $50 per Day up to a Limit of $750 for the first 15 Days. Further Prior Medivac Care Page 2 SPECIMEN

3 Approval is required if a stay of more than 15 days is necessary in which case, an additional Limit of $500 applies. BSP Health will assess whether an accompanying person is necessary during the Insured s Treatment. In certain circumstances it may request evidence that a Specialist deems it Medically Necessary that an accompanying person be present during the Insured s Treatment. Once an accompanying person chooses an option above, that choice is irrevocable. The accommodation allowance applies from the day before Admission until the day of Discharge if the accompanying person has to arrange an overnight stay in a town or city that is outside of his/her usual place of residence. The meals and transportation allowance applies from the day before Admission until the Insured s first review. Transportation costs are covered on a reimbursement basis for return travel between the airport, approved hotel or motel, the Local Public Hospital, the Approved Private Medical Facility and the accompanying person s normal place of residence Ambulance Services BSP Health will reimburse the charged cost for a stretcher, medical attendant (if Medically Necessary) and ambulance services if the Insured needs to be transported to the Hospital or Approved Private Medical Facility. 1.2 SPECIALISED TREATMENT PROVIDED BY A PREFERRED PROVIDER IN INDIA WHERE TREATMENT IS NOT AVAILABLE IN FIJI Benefit Subject to the terms and conditions stated in the Policy, BSP Health will cover the cost of Treatment for the following healthcare services provided by its Preferred Provider in India if BSP Health is satisfied that Treatment for the Condition is Medically Necessary: Hospital Expenses Insured patient s travel, accommodation and meals accompanying person s travel, accommodation and meals medical attendant s travel, accommodation and meals repatriation of body transportation subject to the overall Limit per Condition set out in Part 1 and subject to Limits applying to each benefit as set out in this Part 1.2. Prior Approval must be obtained for this benefit and once granted, BSP Health will make the necessary travel, accommodation and meal arrangements for the Insured, accompanying person or medical attendant (if required) including settlement of all medical and Hospital costs with its Preferred Provider in India Hospital Expenses Subject to the terms and conditions stated in the Policy, costs incurred in respect of the following will be covered by BSP Health if BSP Health is satisfied that the service is Medically Necessary and Prior Approval is granted: Hospitalisation Surgical Expenses intensive care Prosthesis pre and post operative Outpatient pharmaceuticals Medivac Care Page 3 SPECIMEN

4 special nursing provided it is Medically Necessary with a Limit per Evacuation of $1,200 (g) Post Discharge Care with a Limit per Evacuation of $3,200 (h) Diagnostics and Specialist consultation prior to Admission Insured patient s travel, accommodation and meals following costs if Prior Approval has been granted:. The return journey may be upgraded to business class based on the medical advice of the attending Specialist confirming that the upgrade is Medically Necessary accommodation, however any upgrade will be at the Insured s own cost meals in a hotel or motel, with a Limit per Day of $50. This allowance does not apply if meals are Accompanying person s travel, accommodation and meals following if Prior Approval has been granted: accommodation, however any upgrade will be at the Accompanying person s own cost meals up to a Limit per Day of $50. This allowance does not apply if meals are However if the accompanying person arranges his/her own accommodation and meals, the following allowance will apply instead of and above: a cash allowance with a Limit per Day of $50 up to a Limit per Evacuation of $750 for the first 15 days. Further Prior Approval is required if a stay of more than 15 days is necessary in which case an additional Limit per Day of $50 applies up to a total Limit per Evacuation of $1,000. BSP Health will assess whether an accompanying person is necessary during the Insured s Treatment. In certain circumstances it may request evidence that a Specialist deems it Medically Necessary that an accompanying person be present during the Insured s Treatment Medical attendant s travel, accommodation and meals following if Prior Approval has been granted accommodation, however any upgrade will be at the medical attendant s own cost meals up to a Limit per Day of $50. This allowance does not apply if meals are medical attendant s fees subject to a Limit per Day of $200 for a registered nurse, $400 for a General Practitioner and $500 for a Specialist to a Limit per Evacuation of 8 Days However if the medical attendant arranges his/her own accommodation and meals, the following allowance will apply instead of and above: a cash allowance with a Limit per Day of $50 up to a Limit per Evacuation of $400 Medivac Care Page 4 SPECIMEN

5 In order to assess the application for Prior Approval, BSP Health must be provided with evidence that a Specialist deems it Medically Necessary that a medical attendant be present during the Insured s Evacuation Repatriation of body BSP Health will make the necessary arrangements and cover the cost of a coffin, embalming and transportation to return the Insured s body to Fiji in the event of death subject to a Limit per Insured of $10, Transportation BSP Health will cover the Insured s reasonable transportation between the airport, the approved hotel or motel and the Hospital where Treatment is provided Follow up care for Overseas Treatment BSP Health retains the right to determine the place of Treatment for the Insured s follow up care. Treatment may be provided at a local Approved Private Medical Facility or Local Public Hospital if BSP Health is able to source medication from overseas and in consultation with the attending Specialist. 1.3 MEDICAL EMERGENCY EVACUATION TO NEW ZEALAND OR AUSTRALIA WHERE TREATMENT IS NOT AVAILABLE IN FIJI BSP Health will determine whether the condition is a Medical Emergency after considering the following factors: seriousness of the Condition urgency of the need for Treatment advice from a local Specialist Benefit Subject to the terms and conditions stated in the Policy, BSP Health will cover the cost of Treatment for the following healthcare services provided by its Preferred Provider in New Zealand or Australia if BSP Health is satisfied that Treatment for the Condition is Medically Necessary in the event of a Medical Emergency which cannot be treated in India due to time constraints: Hospital Expenses Insured patient s travel, accommodation and meals accompanying person s travel, accommodation and meals medical attendant s travel, accommodation and meals repatriation of body transportation subject to the overall Limit per Condition set out in Part 1 and subject to Limits applying to each benefit as set out in this Part 1.3. Prior Approval must be obtained for this benefit and once granted, BSP Health will make the necessary travel, accommodation and meal arrangements for the Insured, accompanying person or medical attendant (if required) including settlement of all medical and Hospital costs with its Preferred Provider in New Zealand or Australia. Medivac Care Page 5 SPECIMEN

6 1.3.2 Hospital Expenses Subject to the terms and conditions stated in the Policy, costs incurred in respect of the following will be covered by BSP Health if BSP Health is satisfied that the service is Medically Necessary and Prior Approval is granted: Hospitalisation Surgical Expenses intensive care Prosthesis pre and post operative Outpatient pharmaceuticals special nursing provided it is Medically Necessary with a Limit per Evacuation of $1,200 (g) Post Discharge Care with a Limit per Evacuation of $3,200 (h) Diagnostics and Specialist consultation prior to Admission Insured patient s travel, accommodation and meals following provided Prior Approval has been granted:. The return journey may be upgraded to business class based on the medical advice of the attending Specialist confirming that the upgrade is Medically Necessary accommodation, however any upgrade will be at the Insured s own cost meals in a hotel or motel, with a Limit per Day of $120. This allowance will not apply if meals are Accompanying person s travel, accommodation and meals following if Prior Approval has been granted: accommodation, however any upgrade will be at the Accompanying person s own cost meals up to a Limit per Day of $120. This allowance does not apply if meals are However if the accompanying person arranges his/her own accommodation and meals, the following allowance will apply instead of and above: a cash allowance with a Limit per Day of $120 up to a Limit per Evacuation of $1,800 for the first 15 days. Further Prior Approval is required if a stay of more than 15 days is necessary in which case, an additional Limit per Day of $120 up to a Limit per Evacuation of $1,200 applies. BSP Health will assess whether an accompanying person is necessary during the Insured s Treatment. In certain circumstances it may request evidence that a Specialist deems it Medically Necessary that an accompanying person be present during the Insured s Treatment Medical attendant s travel, accommodation and meals following if Prior Approval has been granted: Medivac Care Page 6 SPECIMEN

7 accommodation, however any upgrade will be at the medical attendant s own cost meals up to a Limit per Day of $120. This allowance does not apply if meals are medical attendant s fees subject to a Limit per Day of $200 for a registered nurse, $400 for a General Practitioner and $500 for a Specialist to a Limit per Evacuation of 2 Days However if the medical attendant arranges his/her own accommodation and meals, the following allowance will apply instead of and above: a cash allowance with a Limit per Day of $120 up to a Limit per Evacuation of $240 In order to assess the application for Prior Approval, BSP Health must be provided with evidence that a Specialist deems it Medically Necessary that a medical attendant be present during the Insured s Evacuation Repatriation of body BSP Health will make the necessary arrangements and cover the cost of a coffin, embalming and transportation to return the Insured s body to Fiji in the event of death subject to a Limit per Insured of $10, Transportation BSP Health will cover the Insured s reasonable transportation to and from the approved hotel or motel to the Hospital where Treatment is provided, or airport. Medivac Care Page 7 SPECIMEN

Insurance Information For Participants of. LB0013 Travel Insurance Plan Comfort

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