Can you explain to me how the most common benefits work?
To be certain of your level of cover, you should always consult your Table of Benefits in conjunction with your Benefit Guide, where you can find full details of the cover applicable to you, including definitions and/or exclusions applicable to your plan.
However, for your convenience, we list below some of the most common benefits available under our standard International Healthcare Plans.
Please check your Table of Benefits to confirm if any of the below benefits are included in your cover and refer to your Benefit Guide to verify if the terms, definitions and exclusions related to your covered benefits are the same as described below, as cover differs depending on the plans available to you.
Please refer to the specific question/ answer below for more detail on the relevant benefit.
What does “In-patient treatment” mean?
In-patient treatment refers to treatment received in a hospital where an overnight stay is medically necessary.
What does “Day-care treatment” mean?
Day-care treatment is planned treatment received in a hospital or day-care facility during the day, including a hospital room and nursing, that does not medically require the patient to stay overnight and where a discharge note is issued.
Please note that any endoscopic procedures such as gastroscopy or colonoscopy are covered under the “Day-care treatment” benefit, except if they are done for routine health check purposes – in that case, they will be covered under the relevant benefit included in your Out-patient Plan, if this is included in your policy.
What does “Out-patient treatment” mean?
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.
Any regular doctor visits and laboratory tests that do not require overnight stay in the hospital are considered out-patient treatment.
Which maternity-related expenses are covered under my plan?
Under the multiple plans we offer, we include a number of different maternity-related benefits. These could be “Routine maternity”, “Complications of pregnancy”, “Complications of childbirth”, “Home delivery” etc. Depending on the plans available to you, you may be covered for some or all of these benefits. It is therefore important that you refer to your Table of Benefits to confirm which maternity-related benefits are available to you and whether any benefit limits and/or waiting periods apply.
Below we provide you with a generic explanation of the most common maternity-related benefits which you may be covered for, depending on your plan. Please note that the terms (e.g. definitions and exclusions) related to the below benefits may be slightly different depending on the plan you have, so please check your Benefit Guide to confirm your cover.
a) Routine maternity
Routine maternity refers to any medically necessary costs incurred during pregnancy and childbirth, including hospital charges, specialist fees, the mother's pre- and post-natal care, midwife fees (during labour only) as well as newborn care.
Costs related to complications of pregnancy or complications of childbirth are not payable under routine maternity. In addition, any non-medically necessary caesarean sections will be covered up to the cost of a routine delivery in the same hospital, subject to any benefit limit in place. If the home delivery benefit is included in your plan, a lump sum up to the amount specified in the Table of Benefits will be paid in the event of a home delivery.
b) Pre-natal care
Pre-natal care includes common screening and follow-up tests as required during a pregnancy. For women aged 35 and over, this includes Triple/Bart’s, Quadruple or Spina Bifida tests, amniocentesis and DNA-analysis, if directly linked to an eligible amniocentesis.
Post-natal care refers to the routine post-partum medical care received by the mother, up to six weeks after delivery.
d) Newborn care
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. Further preventive diagnostic procedures, such as routine swabs, blood typing and hearing tests, are not covered. Any medically necessary follow-up investigations and treatment are covered under the newborn's own policy.
Please note that for multiple birth babies born as a result of medically assisted reproduction, in-patient treatment may be limited to a specified amount per child for the first three months following birth (please consult your Benefit Guide for full details). Out-patient treatment is paid within the terms of the Out-patient Plan.
e) Complications of pregnancy
Complications of pregnancy relate to the health of the mother. Only the following complications that arise during the pre-natal stages of pregnancy are covered: ectopic pregnancy, gestational diabetes, pre-eclampsia, miscarriage, threatened miscarriage, stillbirth and hydatid form mole.
f) Complications of childbirth
Complications of childbirth refer only to the following conditions that arise during childbirth and that require a recognised obstetric procedure: post-partum haemorrhage and retained placental membrane. Where the insured’s plan also includes a routine maternity benefit, complications of childbirth shall also refer to medically necessary caesarean sections.
g) Maternity-related benefit limits
Benefit limits for “Routine maternity” and “Complications of childbirth” are payable on either a “per pregnancy” or “per Insurance Year” basis (this will be confirmed in your Table of Benefits). If your 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 policy 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.
- All eligible expenses incurred in the second year will be subject to the updated benefit limit that applies in year two, less the total benefit amount reimbursed in year one.
- In the event that the benefit limit decreases in year two and this updated amount has been reached or exceeded by eligible costs incurred in year one, no additional benefit amount will be payable.
h) Maternity-related exclusions
- Termination of pregnancy, except in the event of danger to the life of the pregnant woman.
- Treatment directly related to surrogacy, whether you are acting as a surrogate, or are the intended parent.
- Genetic testing, except:
a) where specific genetic tests are included within your plan;
b) where DNA tests are directly linked to an eligible amniocentesis i.e. in the case of women aged 35 or over; c) testing for genetic receptor of tumours is covered.
- Pre- and post-natal classes.
- Triple/Bart’s, Quadruple or Spina Bifida tests, except for women aged 35 or over.
Which dermatology- related expenses are covered under my plan?
Dermatologist consultations and treatments are covered if medically necessary under the “Specialist fees” benefit (if this is listed in your Table of Benefit and therefore included under your plan). If the skin condition is seen by a general medical practitioner rather than a specialist, then you will be covered under the “Medical Practitioner fees” benefit (if included under your plan).
Please note that normally, depending on the plan available to you, exclusions may be related to dermatology treatments. Please check you Benefit Guide to confirm what exclusions relate to your policy.
For your convenience, we indicate below the exclusions related to dermatology that are normally included in our standard International Healthcare Plans:
Any treatment carried out by a plastic surgeon, whether or not for medical/psychological purposes and any cosmetic or aesthetic treatment to enhance your appearance, even when medically prescribed. The only exception is reconstructive surgery necessary to restore function or appearance after a disfiguring accident, or as a result of surgery for cancer, if the accident or surgery occurs during your membership of the scheme.
Loss of hair and hair replacement
Investigations into, and treatment of, loss of hair and any hair replacement unless the loss of hair is due to cancer treatment.
What cover is available in relation to psychiatry and psychotherapy expenses?
This cover is available to you if the “Psychiatry and psychotherapy” benefit is listed in your Table of Benefits, either under the Core Plan or under the Out-patient Plan (or in both), depending on the plans available to you. Where covered, your Table of Benefits will also state any benefit limits and/or waiting periods which apply to the cover for psychiatry and psychotherapy.
Our standard definition of the “Psychiatry and psychotherapy” benefit and related exclusions are as follows, although they may vary slightly depending on the plans available to you – please refer to your Benefit Guide for the definition and any exclusions applicable to your plan.
|Psychiatry and psychotherapy is the treatment of mental disorders carried out by a psychiatrist or clinical psychologist. The condition must be clinically significant and not related to bereavement, relationship or academic problems, acculturation difficulties or work pressure. If included under your plan all day-care or in-patient admissions must include prescription medication related to the condition. Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or your dependants are initially diagnosed by a psychiatrist and referred to a clinical psychologist for further treatment.
In addition, outpatient psychotherapy treatment (where covered) is initially restricted to 10 sessions per condition, after which treatment must be reviewed by the referring psychiatrist. Should further sessions be required, a progress report must be submitted to us, which indicates the medical necessity for any further treatment.
Family therapy and counselling
Costs in respect of a family therapist or counsellor for out-patient psychotherapy treatment (regardless if your plan includes a benefit for psychiatry and psychotherapy).
Behavioural and personality disorders
Treatment for conditions such as conduct disorder, attention deficit hyperactivity disorder, autism spectrum disorder, oppositional defiant disorder, antisocial behaviour, obsessive compulsive disorder, phobic disorders, attachment disorders, adjustment disorders, eating disorders, personality disorders or treatments that encourage positive social-emotional relationships, such as family therapy, are not covered unless indicated otherwise in the Table of Benefits.
If you want to confirm cover for your planned treatment
If you would like us to confirm cover for a psychiatry or psychotherapy benefit before commencing treatment, please forward us (using the email address below) a detailed medical report from the referring psychiatrist that includes the DSM-IV or ICD-10 code and that indicates the causes or reason of your condition. Our medical team will promptly review the report and will be able to advise you about your cover.
Please note that any psychiatry or psychotherapy treatment due to take place on an in-patient or day-care basis requires submission of a completed Treatment Guarantee Form and approval in advance of treatment. Find out more about the Treatment Guarantee Process here.
Which treatments are covered under the dental and orthodontic benefits?
If dental benefits form part of your cover, under most of our plans you can simply pay for your treatment and then claim back any eligible expenses via our MyHealth app
(if this is available under your plan) or by submitting a completed Claim Form
along with all supporting documentation by e-mail, fax or post.
Any dental benefits available to you are shown on your Table of Benefits along with any deductibles, co-payments, benefit limits, waiting periods or age restrictions which apply. Your Table of Benefits should be read in conjunction with your Benefit Guide for full details of your dental benefits, including definitions and/or exclusions.
For your convenience, below we list the definitions and the exclusions related to dental benefits that apply to our standard international healthcare plans – these may vary slightly depending on the plans you have, so please consult your Benefit Guide and Table of Benefits to confirm the definitions and exclusions available to you:
01. Dental treatment
Dental treatment includes an annual check up, simple fillings related to cavities or decay, root canal treatment and dental prescription drugs.
02. Dental prescription
Dental prescription drugs are those prescribed by a dentist for the treatment of a dental inflammation or infection. The prescription drugs must be proven to be effective for the condition and recognised by the pharmaceutical regulator in a given country. This does not include mouthwashes, fluoride products, antiseptic gels and toothpastes.
03. Dental surgery
Dental surgery includes the surgical extraction of teeth, as well as other tooth related surgical procedures such as apicoectomy and dental prescription drugs. All investigative procedures necessary to establish the need for dental surgery such as laboratory tests, X-rays, CT scans and MRI(s) are included under this benefit. Dental surgery does not cover any surgical treatment that is related to dental implants.
Periodontics refers to dental treatment related to gum disease.
Orthodontics is the use of devices to correct malocclusion and restore the teeth to proper alignment and function. Orthodontic treatment is covered only in cases of medical necessity, and for this reason, at the point of claiming, we will ask you to submit supporting information to determine that your treatment is medically necessary and therefore eligible for cover. The supporting information required (depending on your case) may include, but is not limited to, the following documents:
- Medical report issued by the specialist, stating the diagnosis (type of malocclusion) and a description of the patient’s symptoms caused by the orthodontic problem
- Treatment plan indicating the estimated treatment duration, estimated cost and type/material of the appliance used
- The payment arrangement agreed with the medical provider
- Proof that payment has been made in respect of the orthodontic treatment
- Photographs of both jaws clearly showing dentition prior to treatment
- Clinical photographs of the jaws in central occlusion from frontal and lateral views
- Orthopantomogram (panoramic x-ray)
- Profile x-ray (cephalometric x-ray)
Please note that we will only cover orthodontic treatment where the standard metallic braces and/or standard removable appliances are used. Cosmetic appliances such as lingual braces and invisible aligners are covered up to the cost of metallic braces, subject to the “Orthodontic treatment and dental prostheses” benefit limit.
In summary, the “Orthodontics” benefit covers:
Other related treatment such as x-rays or photographs of jaws
Orthodontic treatments take place on an Out-Patient basis. They are usually carried out over the course of several years: however, you do not need to wait until the end of your treatment to be reimbursed. You might submit invoices throughout the duration of your treatment (e.g. quarterly), but only once the part of the treatment relating to the invoice you submit has all taken place. For example, you could submit an invoice at the end of every quarter for the treatment that has taken place in that quarter.
06. Dental prostheses
Dental prostheses include crowns, inlays, onlays, adhesive reconstructions/restorations, bridges, dentures and implants as well as all necessary and ancillary treatment required.
07. Emergency Out-Patient Dental treatment
Emergency Out-Patient Dental treatment refers to treatment received in a dental surgery/hospital emergency room for the immediate relief of dental pain caused by an accident or an injury to a sound natural tooth, including pulpotomy or pulpectomy and the subsequent temporary fillings, limited to three fillings per Insurance Year. The treatment must be received within 24 hours of the emergency event. This does not include any form of dental prostheses, permanent restorations or the continuation of root canal treatment. If a Dental Plan was selected, you will be covered under the terms of this plan for dental treatment in excess of the (Core Plan) emergency out-patient dental treatment benefit limit.
Dental veneers and related procedures are not covered, unless medically necessary.
What does the benefit for “Complementary treatment” cover?
Below you will find the definition related to “Complementary treatment” that apply to our standard international healthcare plans – these may vary slightly depending on the plans you have, so please consult your Benefit Guide and Table of Benefits to confirm the definitions and exclusions available to you:
|Complementary treatment refers to therapeutic and diagnostic treatment that exists outside the institutions where conventional Western medicine is taught. Please refer to your Table of Benefits to confirm whether any of the following complementary treatment methods are covered: chiropractic treatment, osteopathy, Chinese herbal medicine, homeopathy, acupuncture and podiatry as practiced by approved therapists.
Where covered, this benefit does not require pre-authorization, therefore in order to claim for your expenses you can simply follow the procedure detailed in the section “Claiming your out-patient, dental and other expenses” under Claims queries.
Which optical benefits are available to me?
Below you will find the definition related to “Prescribed glasses and contact lenses including eye examination” that apply to our standard international healthcare plans – these may vary slightly depending on the plans you have, so please consult your Benefit Guide and Table of Benefits to confirm the definitions and exclusions available to you:
Prescribed glasses and contact lenses including eye examination provides cover for a routine eye examination carried out by an optometrist or ophthalmologist (one per Insurance Year) and for lenses and glasses to correct vision.
Pre-approval is not required to access this benefit but you will need to submit your prescription (stating your dioptre) together with your invoice when claiming your expenses.
What does the benefit “Diagnostic tests” cover? Do I need pre-authorisation before I undergo diagnostic tests?
Below you will find the definition related to “Diagnostic tests” that apply to our standard international healthcare plans – these may vary slightly depending on the plans you have, so please consult your Benefit Guide and Table of Benefits to confirm the definitions and exclusions available to you:
- Diagnostic tests are investigations such as x-rays or blood tests, undertaken in order to determine the cause of the presented symptoms.
Usually these tests do not require pre-authorization, however please be aware that some more invasive tests will need to be pre-authorised via submission of a Treatment Guarantee/Pre-authorization Form. Please refer to your Table of Benefits to confirm this.
You can find more information on pre-approval in the “Emergency and pre-authorization process” tab.
What does the benefit for “Health and wellbeing checks” cover?
Below you will find the definition related to “Health and wellbeing checks” that apply to our standard international healthcare plans – these may vary slightly depending on the plans you have, so please consult your Benefit Guide and Table of Benefits to confirm the definitions and exclusions available to you:
Health and wellbeing checks
Health and wellbeing checks including screening for the early detection of illness or disease are health checks, tests and examinations, performed at an appropriate age interval, that are undertaken without any clinical symptoms being present. Checks are limited to:
- Physical examination
- Blood tests (full blood count, biochemistry, lipid profile, thyroid function test, liver function test, kidney function test)
- Cardiovascular examination (physical examination, electrocardiogram, blood pressure)
- Neurological examination (physical examination)
- Cancer screening:
a. Annual pap smear
b. Mammogram (every two years for women aged 45+, or earlier where a family history exists)
c. Prostate screening (yearly for men aged 50+, or earlier where a family history exists)
d. Colonoscopy (every five years for members aged 50+, or 40+ where a family history exists)
e. Annual faecal occult blood test
- Bone densitometry (every five years for women aged 50+)
- Well child test (for children up to the age of six years, up to a maximum of 15 visits per lifetime)
- BRCA1 and BRCA2 genetic test (where a direct family history exists and where included in your Table of Benefits)
What does the benefit “Medical practitioner fees” cover?
Below you will find the definitions related to “Medical practitioner fees” that apply to our standard international healthcare plans – these may vary slightly depending on the plans you have, so please consult your Benefit Guide and Table of Benefits to confirm the definitions and exclusions available to you:
Medical practitioner is a physician who is licensed to practice medicine under the law of the country in which treatment is given and where he/she is practising within the limits of his/her licence.
Medical practitioner fees
Medical practitioner fees refer to non-surgical treatment performed or administered by a medical practitioner.
What does the benefit “Specialist fees” refer to?
Below you will find the definitions related to “Specialist fees” that apply to our standard international healthcare plans – these may vary slightly depending on the plans you have, so please consult your Benefit Guide and Table of Benefits to confirm the definitions and exclusions available to you:
Specialist is a qualified and licensed medical physician possessing the necessary additional qualifications and expertise to practice as a recognised specialist of diagnostic techniques, treatment and prevention in a particular field of medicine. This benefit does not include cover for psychiatrist or psychologist fees. Where covered, a separate benefit for psychiatry and psychotherapy will appear in the Table of Benefits.
Specialist fees refer to non-surgical treatment performed or administered by a specialist.
Any fee applied for an eligible consultation or treatment provided by a qualified specialist, i.e. ENT, endocrinologist, gynaecologist, cardiologist, etc. will be covered under the “Specialist fees” benefit.
If the “Specialist fees” benefit is listed in your Table of Benefits, cover will be provided in line with the terms and conditions of your policy without the need for pre-authorization, i.e. on a pay and claim basis.
However, if the specialist fees you need to pay are related to an in-patient treatment (or to any treatment which require pre-authorization as stated in your Table of Benefits) and you will need to include them on the Treatment Guarantee/Pre-authorization Form that you will send us, to enable us to organise the settlement of your bill directly with the hospital (where possible).
Please be aware that in some countries you might need to visit your general doctor in order to get a referral for a specialist consultation.
Is out-patient physiotherapy covered under my plan?
Below you will find the definitions related to physiotherapy that apply to our standard international healthcare plans – these may vary slightly depending on the plans you have, so please consult your Benefit Guide and Table of Benefits to confirm the definitions and exclusions available to you:
Non-prescribed physiotherapy refers to treatment by a registered physiotherapist where referral by a medical practitioner has not been obtained prior to undergoing treatment.
Where this benefit applies, cover is limited to the number of sessions indicated in your Table of Benefits. Additional sessions required over and above this limit must be prescribed in order for cover to continue; these sessions will be subject to the prescribed physiotherapy benefit limit.
Physiotherapy (either prescribed, or a combination of non-prescribed and prescribed treatment) is initially restricted to 12 sessions per condition, after which the treatment must be reviewed by the referring medical practitioner. Should further sessions be required, a progress report must be submitted to us, which indicates the medical necessity for any further treatment. Physiotherapy does not include therapies such as Rolfing, Massage, Pilates, Fango and Milta therapy.
Prescribed physiotherapy refers to treatment by a registered physiotherapist following referral by a medical practitioner.
Physiotherapy is initially restricted to 12 sessions per condition, after which the treatment must be reviewed by the referring medical practitioner. Should further sessions be required, a new progress report must be submitted to us after every set of 12 sessions, which indicates the medical necessity for any further treatment. Physiotherapy does not include therapies such as Rolfing, Massage, Pilates, Fango and Milta therapy.
If the “Prescribed physiotherapy” benefit is included in your cover, it does not require pre-authorization; therefore you should pay for the sessions received and submit the bills for reimbursement to us, together with the referral or prescription from your treating doctor. Please note that if you are claiming for multiple sessions, you will need to provide the breakdown of costs and dates of each individual session.