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TRANSCRIPT
INDIVIDUALBenefit Guide
Healthcare PlansValid from 1st November 2018
HOW TO USEYOUR COVER
WelcomeYou and your family can depend on Allianz Care as your international health insurer togive you access to the best care possible
This guide consists of two parts ldquoHow to use your coverrdquo is a summary of all importantinformation you are likely to use on a regular basis ldquoTerms and conditions of your coverrdquoexplains your cover in more detail
To make the most of your international healthcare plan please read this guide inconjunction with your Insurance Certificate and Table of Benefits
HOW TO USE YOUR COVER
Member services 5
Cover overview 14
Seeking treatment 18
TERMS AND CONDITIONS OF YOUR COVER
Your cover explained 30
Claims and Treatment Guarantee process 32
Paying premiums 36
Administration of your policy 38
Additional terms 42
Data protection and release of medical records 44
Complaints and dispute resolution procedure 46
Definitions 48
Exclusions 58
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny IrishBranch registered in the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland AllianzCare and Allianz Partners are registered business names of AWP Health amp Life SA
In the following pages we describe the full range of member services we offer Discover what is availableto you from our MyHealth app to the Expat Assistance Programme
Talk to us we love to helpOur multilingual Helpline is available 24 hours a day 7 days a week to handle any questions about yourpolicy or if you need assistance in case of an emergency
Helpline
Phone +353 1 630 1301For our latest list of toll-free numbers please visit
wwwallianzworldwidecarecomtoll-free-numbers
Email clientservicesallianzworldwidecarecom
Fax +353 1 630 1306
MEMBER SERVICESWe believe in making a difference by providing you with the superior level of service thatyou deserve anytime anywhere
Did you knowhelliphellipthat most of our members findthat their queries are handledquicker when they call us
54
For more information please visit
wwwallianzworldwidecarecommyhealth
MyHealth appOur pioneering MyHealth app has been designed to give you easy and convenient access toyour cover no matter where you are With MyHealth app you can access the followingfeatures from your mobile device
Other Services - access your policy documents and your Membership Card on the go look up the local equivalent names ofbranded drugs and translate common ailments into one of 17 languages
All personal data within the MyHealth App are encrypted for data protection Most features areaccessible even when offline
GETTING STARTED
MY CLAIMSSubmit your claims in 3 simple steps and view your claims history
MY CONTACTSAccess our 247 multilingual Helpline and local emergency numbers
FIND A HOSPITALLocate medical providers nearby and get GPS directions
SYMPTOM CHECKERFor a quick and easy evaluation of your symptoms
Download ndash you can download the app from the App Store or Google Play by simplysearching for ldquoAllianz MyHealthrdquo and following the on-screen instructions
Initial setup ndash once downloaded open the app and provide your policy numberThen if prompted register to receive a username and temporary passwordOtherwise please insert the login details available from your Membership PackWhen requested change the temporary password provided to something you caneasily remember If you re-install the app or setup the app on another device pleaseuse this setup information again Please note that you can also use these details tologin to our Online Services
Set PIN ndash finally set your own unique PIN number In the future this PIN number willbe all you need to access the Allianz MyHealth app and all its features
76
Online ServicesYou can access our secure Online Services from the comfort of your home Our Online Services allowsyou to
View and amend your personal details onlinebullDownload your policy documents including your Membership CardbullView your Table of Benefits and check how much remains payable under each benefitbullConfirm the status of any claims submitted to us and view claims related correspondencebullPay your premiums by credit card and update your credit card detailsbull
To access our secure Online Services please log on to myallianzworldwidecarecom and
Login using the unique username and temporary password included in your Membership Pack1
When requested change the temporary password provided to something you can easily remember2Please keep this information safe yoursquoll need it again Please note that you can also use thesedetails to login to our MyHealth App
Click on ldquologinrdquo and browse away3
Web-based member servicesOn our website you can search for medical providers download forms and access our BMI calculatorYou are not restricted to using the medical providers listed on our website
wwwallianzworldwidecarecommembers
Medi24This medical advice service provided by an experienced medical team offers information and advice ona wide range of topics including blood pressure and weight management infectious diseases first aiddental care vaccinations oncology disability speech fertility paediatrics mental health and generalhealth Medi24 is available 247 in English German French and Italian
+44 (0) 208 416 03929
For policy or cover related queries (eg benefit limits or the status of a claim) please contact ourHelpline
If you have not received a Membership Pack go to myallianzworldwidecarecom select ldquoRegisterrdquoand enter the information requested Your username and temporary password will be sent to theemail address we have on record for you
98
Let us help
+1 905 886 3605
wwwworkhealthlifecomAWCExpat(available in English French and Spanish)
Download the ldquoMy Allianz EAPrdquo app from App Store or Google Play
The calls are answered by an English-speaking agent However additional language support is also available If our agentsare not available in the language you require we will organise interpreter services
This is not a free phone number Local phone numbers are available in many countries To see the full list of our lsquoWorldwideAccess Numbersrsquo visit wwwworkhealthlifecomAWC
The Expat Assistance Programme Services are made available by Morneau Shepell Limited subject to your acceptance ofAWPrsquos our terms and conditions You understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health ampLife Services Limited are not responsible or liable for any claim loss or damage directly or indirectly resulting from your use ofthe Expat Assistance Programme Services
Expat Assistance Programme (EAP)The Expat Assistance Programme where provided will be shown in the Table of Benefits This service is aconfidential and professional 247 multilingual support service that can help you and your dependantsaddress a wide range of life issues and challenges such as
WorkLife balancebullFamilyParentingbullRelationshipsbullStress depression anxietybullWorkplace challengesbullCross-cultural transitionbullCultural shockbullCoping with isolation and lonelinessbullAddiction concernsbull
This multilingual service is available locally anytime anywhereEAP offers you and your dependants access to the following range of 247 multilingual support services
Confidential professional counselling is available face to face phone video email or online chat
CONFIDENTIAL PROFESSIONAL COUNSELLING
CRITICAL INCIDENT SUPPORT
LEGAL AND FINANCIAL SUPPORT SERVICES
WELLNESS WEBSITE ACCESS
1110
Travel Security ServicesAs the world continues to witness an increase in security threats we provide services that enable you tomanage your personal risk conveniently and effectively The Travel Security Services offer access to a richpool of professional advice and support that is available whenever you need it via phone email orwebsite This service where provided will be shown in the Table of Benefits
Travel Security Services offer 247 access to personal security information and advice for all your travelsafety queries This includes
To access the service please contact us
+44 207 741 2185This is not a free phone number
allianzcustomerenquiriesworldawarecom
httpsmyworldawarecomawcRegister by entering your policy number (indicated in your Insurance Certificate)
Download lsquoTravelKitrsquo app from App store or Google Play
All Security Support Services are provided in English Interpreter services are available where required
The Travel Security Services are made available by WorldAware LTD subject to your acceptance of our terms and conditionsYou understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health amp Life Services Limited are notresponsible or liable for any claim loss or damage directly or indirectly resulting from your use of the Travel Security Services
EMERGENCY SECURITY ASSISTANCE HOTLINETalk to a security specialist for any safety concerns associated with a traveldestination or if immediate assistance is needed while travelling
COUNTRY INTELLIGENCE AND SECURITY ADVICESecurity information for a number of countries worldwide as well as comprehensivesecurity advice
DAILY SECURITY NEWS UPDATES AND TRAVEL SAFETY ALERTSWeekly newsletter and email alert notifications of high-risk events includingterrorism civil unrest and severe weather risks in or near your current location
1312
Is your family growing We have you coveredAre you getting married or going to have a baby Congratulations
You can add your spouse or partner to your policy by simply completing our Application Form availableat
wwwallianzworldwidecarecomapplication
To add a new born child to your policy simply send an email to our underwriting team including a copyof the birth certificate When adding a new born child to your policy make sure to send your requestwithin four weeks of the date of birth to ensure that the child is accepted for cover without medicalunderwriting and for cover to start from birth For further information in how to add a dependantincluding important information in how to add multiple babies adopted and foster children please referto the ldquoAdding dependantsrdquo section of this guide
What am I covered forYou are covered for all benefits indicated in your Table of Benefits Pre-existing conditions (including anypre-existing chronic conditions) are generally covered unless we indicate otherwise in your policydocuments If in doubt please refer to the ldquoNotesrdquo section of your Table of Benefits to confirm if pre-existing conditions are covered
Where can I receive treatmentYou can avail of treatment in any country within your area of cover (which is indicated in your InsuranceCertificate)
If the treatment you require is available locally but you choose to travel to another country within yourarea of cover we will reimburse all eligible medical costs incurred within the terms of your policy apartfrom your travel expenses However if the eligible treatment is not available locally and ldquoMedicalevacuationrdquo is included in your cover travel costs to the nearest centre of excellence are also covered Inorder to seek reimbursement for medical and travel expenses incurred you will need to complete andsubmit the Treatment Guarantee Form before travelling
What are benefit limitsYour cover may be subject to a maximum plan benefit This is the maximum we will pay in total for allbenefits included in the plan Although many benefits included in your Table of Benefits are covered infull some are capped to a specific amount (eg euro30000) This specific amount is a benefit limit
For further information on benefit limits please refer to the ldquoBenefit limitsrdquo section of this guide
COVER OVERVIEWWe understand the importance of your own and your familyrsquos health Below is a summaryto help you understand the scope of your health cover
1514
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
HOW TO USEYOUR COVER
WelcomeYou and your family can depend on Allianz Care as your international health insurer togive you access to the best care possible
This guide consists of two parts ldquoHow to use your coverrdquo is a summary of all importantinformation you are likely to use on a regular basis ldquoTerms and conditions of your coverrdquoexplains your cover in more detail
To make the most of your international healthcare plan please read this guide inconjunction with your Insurance Certificate and Table of Benefits
HOW TO USE YOUR COVER
Member services 5
Cover overview 14
Seeking treatment 18
TERMS AND CONDITIONS OF YOUR COVER
Your cover explained 30
Claims and Treatment Guarantee process 32
Paying premiums 36
Administration of your policy 38
Additional terms 42
Data protection and release of medical records 44
Complaints and dispute resolution procedure 46
Definitions 48
Exclusions 58
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny IrishBranch registered in the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland AllianzCare and Allianz Partners are registered business names of AWP Health amp Life SA
In the following pages we describe the full range of member services we offer Discover what is availableto you from our MyHealth app to the Expat Assistance Programme
Talk to us we love to helpOur multilingual Helpline is available 24 hours a day 7 days a week to handle any questions about yourpolicy or if you need assistance in case of an emergency
Helpline
Phone +353 1 630 1301For our latest list of toll-free numbers please visit
wwwallianzworldwidecarecomtoll-free-numbers
Email clientservicesallianzworldwidecarecom
Fax +353 1 630 1306
MEMBER SERVICESWe believe in making a difference by providing you with the superior level of service thatyou deserve anytime anywhere
Did you knowhelliphellipthat most of our members findthat their queries are handledquicker when they call us
54
For more information please visit
wwwallianzworldwidecarecommyhealth
MyHealth appOur pioneering MyHealth app has been designed to give you easy and convenient access toyour cover no matter where you are With MyHealth app you can access the followingfeatures from your mobile device
Other Services - access your policy documents and your Membership Card on the go look up the local equivalent names ofbranded drugs and translate common ailments into one of 17 languages
All personal data within the MyHealth App are encrypted for data protection Most features areaccessible even when offline
GETTING STARTED
MY CLAIMSSubmit your claims in 3 simple steps and view your claims history
MY CONTACTSAccess our 247 multilingual Helpline and local emergency numbers
FIND A HOSPITALLocate medical providers nearby and get GPS directions
SYMPTOM CHECKERFor a quick and easy evaluation of your symptoms
Download ndash you can download the app from the App Store or Google Play by simplysearching for ldquoAllianz MyHealthrdquo and following the on-screen instructions
Initial setup ndash once downloaded open the app and provide your policy numberThen if prompted register to receive a username and temporary passwordOtherwise please insert the login details available from your Membership PackWhen requested change the temporary password provided to something you caneasily remember If you re-install the app or setup the app on another device pleaseuse this setup information again Please note that you can also use these details tologin to our Online Services
Set PIN ndash finally set your own unique PIN number In the future this PIN number willbe all you need to access the Allianz MyHealth app and all its features
76
Online ServicesYou can access our secure Online Services from the comfort of your home Our Online Services allowsyou to
View and amend your personal details onlinebullDownload your policy documents including your Membership CardbullView your Table of Benefits and check how much remains payable under each benefitbullConfirm the status of any claims submitted to us and view claims related correspondencebullPay your premiums by credit card and update your credit card detailsbull
To access our secure Online Services please log on to myallianzworldwidecarecom and
Login using the unique username and temporary password included in your Membership Pack1
When requested change the temporary password provided to something you can easily remember2Please keep this information safe yoursquoll need it again Please note that you can also use thesedetails to login to our MyHealth App
Click on ldquologinrdquo and browse away3
Web-based member servicesOn our website you can search for medical providers download forms and access our BMI calculatorYou are not restricted to using the medical providers listed on our website
wwwallianzworldwidecarecommembers
Medi24This medical advice service provided by an experienced medical team offers information and advice ona wide range of topics including blood pressure and weight management infectious diseases first aiddental care vaccinations oncology disability speech fertility paediatrics mental health and generalhealth Medi24 is available 247 in English German French and Italian
+44 (0) 208 416 03929
For policy or cover related queries (eg benefit limits or the status of a claim) please contact ourHelpline
If you have not received a Membership Pack go to myallianzworldwidecarecom select ldquoRegisterrdquoand enter the information requested Your username and temporary password will be sent to theemail address we have on record for you
98
Let us help
+1 905 886 3605
wwwworkhealthlifecomAWCExpat(available in English French and Spanish)
Download the ldquoMy Allianz EAPrdquo app from App Store or Google Play
The calls are answered by an English-speaking agent However additional language support is also available If our agentsare not available in the language you require we will organise interpreter services
This is not a free phone number Local phone numbers are available in many countries To see the full list of our lsquoWorldwideAccess Numbersrsquo visit wwwworkhealthlifecomAWC
The Expat Assistance Programme Services are made available by Morneau Shepell Limited subject to your acceptance ofAWPrsquos our terms and conditions You understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health ampLife Services Limited are not responsible or liable for any claim loss or damage directly or indirectly resulting from your use ofthe Expat Assistance Programme Services
Expat Assistance Programme (EAP)The Expat Assistance Programme where provided will be shown in the Table of Benefits This service is aconfidential and professional 247 multilingual support service that can help you and your dependantsaddress a wide range of life issues and challenges such as
WorkLife balancebullFamilyParentingbullRelationshipsbullStress depression anxietybullWorkplace challengesbullCross-cultural transitionbullCultural shockbullCoping with isolation and lonelinessbullAddiction concernsbull
This multilingual service is available locally anytime anywhereEAP offers you and your dependants access to the following range of 247 multilingual support services
Confidential professional counselling is available face to face phone video email or online chat
CONFIDENTIAL PROFESSIONAL COUNSELLING
CRITICAL INCIDENT SUPPORT
LEGAL AND FINANCIAL SUPPORT SERVICES
WELLNESS WEBSITE ACCESS
1110
Travel Security ServicesAs the world continues to witness an increase in security threats we provide services that enable you tomanage your personal risk conveniently and effectively The Travel Security Services offer access to a richpool of professional advice and support that is available whenever you need it via phone email orwebsite This service where provided will be shown in the Table of Benefits
Travel Security Services offer 247 access to personal security information and advice for all your travelsafety queries This includes
To access the service please contact us
+44 207 741 2185This is not a free phone number
allianzcustomerenquiriesworldawarecom
httpsmyworldawarecomawcRegister by entering your policy number (indicated in your Insurance Certificate)
Download lsquoTravelKitrsquo app from App store or Google Play
All Security Support Services are provided in English Interpreter services are available where required
The Travel Security Services are made available by WorldAware LTD subject to your acceptance of our terms and conditionsYou understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health amp Life Services Limited are notresponsible or liable for any claim loss or damage directly or indirectly resulting from your use of the Travel Security Services
EMERGENCY SECURITY ASSISTANCE HOTLINETalk to a security specialist for any safety concerns associated with a traveldestination or if immediate assistance is needed while travelling
COUNTRY INTELLIGENCE AND SECURITY ADVICESecurity information for a number of countries worldwide as well as comprehensivesecurity advice
DAILY SECURITY NEWS UPDATES AND TRAVEL SAFETY ALERTSWeekly newsletter and email alert notifications of high-risk events includingterrorism civil unrest and severe weather risks in or near your current location
1312
Is your family growing We have you coveredAre you getting married or going to have a baby Congratulations
You can add your spouse or partner to your policy by simply completing our Application Form availableat
wwwallianzworldwidecarecomapplication
To add a new born child to your policy simply send an email to our underwriting team including a copyof the birth certificate When adding a new born child to your policy make sure to send your requestwithin four weeks of the date of birth to ensure that the child is accepted for cover without medicalunderwriting and for cover to start from birth For further information in how to add a dependantincluding important information in how to add multiple babies adopted and foster children please referto the ldquoAdding dependantsrdquo section of this guide
What am I covered forYou are covered for all benefits indicated in your Table of Benefits Pre-existing conditions (including anypre-existing chronic conditions) are generally covered unless we indicate otherwise in your policydocuments If in doubt please refer to the ldquoNotesrdquo section of your Table of Benefits to confirm if pre-existing conditions are covered
Where can I receive treatmentYou can avail of treatment in any country within your area of cover (which is indicated in your InsuranceCertificate)
If the treatment you require is available locally but you choose to travel to another country within yourarea of cover we will reimburse all eligible medical costs incurred within the terms of your policy apartfrom your travel expenses However if the eligible treatment is not available locally and ldquoMedicalevacuationrdquo is included in your cover travel costs to the nearest centre of excellence are also covered Inorder to seek reimbursement for medical and travel expenses incurred you will need to complete andsubmit the Treatment Guarantee Form before travelling
What are benefit limitsYour cover may be subject to a maximum plan benefit This is the maximum we will pay in total for allbenefits included in the plan Although many benefits included in your Table of Benefits are covered infull some are capped to a specific amount (eg euro30000) This specific amount is a benefit limit
For further information on benefit limits please refer to the ldquoBenefit limitsrdquo section of this guide
COVER OVERVIEWWe understand the importance of your own and your familyrsquos health Below is a summaryto help you understand the scope of your health cover
1514
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
In the following pages we describe the full range of member services we offer Discover what is availableto you from our MyHealth app to the Expat Assistance Programme
Talk to us we love to helpOur multilingual Helpline is available 24 hours a day 7 days a week to handle any questions about yourpolicy or if you need assistance in case of an emergency
Helpline
Phone +353 1 630 1301For our latest list of toll-free numbers please visit
wwwallianzworldwidecarecomtoll-free-numbers
Email clientservicesallianzworldwidecarecom
Fax +353 1 630 1306
MEMBER SERVICESWe believe in making a difference by providing you with the superior level of service thatyou deserve anytime anywhere
Did you knowhelliphellipthat most of our members findthat their queries are handledquicker when they call us
54
For more information please visit
wwwallianzworldwidecarecommyhealth
MyHealth appOur pioneering MyHealth app has been designed to give you easy and convenient access toyour cover no matter where you are With MyHealth app you can access the followingfeatures from your mobile device
Other Services - access your policy documents and your Membership Card on the go look up the local equivalent names ofbranded drugs and translate common ailments into one of 17 languages
All personal data within the MyHealth App are encrypted for data protection Most features areaccessible even when offline
GETTING STARTED
MY CLAIMSSubmit your claims in 3 simple steps and view your claims history
MY CONTACTSAccess our 247 multilingual Helpline and local emergency numbers
FIND A HOSPITALLocate medical providers nearby and get GPS directions
SYMPTOM CHECKERFor a quick and easy evaluation of your symptoms
Download ndash you can download the app from the App Store or Google Play by simplysearching for ldquoAllianz MyHealthrdquo and following the on-screen instructions
Initial setup ndash once downloaded open the app and provide your policy numberThen if prompted register to receive a username and temporary passwordOtherwise please insert the login details available from your Membership PackWhen requested change the temporary password provided to something you caneasily remember If you re-install the app or setup the app on another device pleaseuse this setup information again Please note that you can also use these details tologin to our Online Services
Set PIN ndash finally set your own unique PIN number In the future this PIN number willbe all you need to access the Allianz MyHealth app and all its features
76
Online ServicesYou can access our secure Online Services from the comfort of your home Our Online Services allowsyou to
View and amend your personal details onlinebullDownload your policy documents including your Membership CardbullView your Table of Benefits and check how much remains payable under each benefitbullConfirm the status of any claims submitted to us and view claims related correspondencebullPay your premiums by credit card and update your credit card detailsbull
To access our secure Online Services please log on to myallianzworldwidecarecom and
Login using the unique username and temporary password included in your Membership Pack1
When requested change the temporary password provided to something you can easily remember2Please keep this information safe yoursquoll need it again Please note that you can also use thesedetails to login to our MyHealth App
Click on ldquologinrdquo and browse away3
Web-based member servicesOn our website you can search for medical providers download forms and access our BMI calculatorYou are not restricted to using the medical providers listed on our website
wwwallianzworldwidecarecommembers
Medi24This medical advice service provided by an experienced medical team offers information and advice ona wide range of topics including blood pressure and weight management infectious diseases first aiddental care vaccinations oncology disability speech fertility paediatrics mental health and generalhealth Medi24 is available 247 in English German French and Italian
+44 (0) 208 416 03929
For policy or cover related queries (eg benefit limits or the status of a claim) please contact ourHelpline
If you have not received a Membership Pack go to myallianzworldwidecarecom select ldquoRegisterrdquoand enter the information requested Your username and temporary password will be sent to theemail address we have on record for you
98
Let us help
+1 905 886 3605
wwwworkhealthlifecomAWCExpat(available in English French and Spanish)
Download the ldquoMy Allianz EAPrdquo app from App Store or Google Play
The calls are answered by an English-speaking agent However additional language support is also available If our agentsare not available in the language you require we will organise interpreter services
This is not a free phone number Local phone numbers are available in many countries To see the full list of our lsquoWorldwideAccess Numbersrsquo visit wwwworkhealthlifecomAWC
The Expat Assistance Programme Services are made available by Morneau Shepell Limited subject to your acceptance ofAWPrsquos our terms and conditions You understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health ampLife Services Limited are not responsible or liable for any claim loss or damage directly or indirectly resulting from your use ofthe Expat Assistance Programme Services
Expat Assistance Programme (EAP)The Expat Assistance Programme where provided will be shown in the Table of Benefits This service is aconfidential and professional 247 multilingual support service that can help you and your dependantsaddress a wide range of life issues and challenges such as
WorkLife balancebullFamilyParentingbullRelationshipsbullStress depression anxietybullWorkplace challengesbullCross-cultural transitionbullCultural shockbullCoping with isolation and lonelinessbullAddiction concernsbull
This multilingual service is available locally anytime anywhereEAP offers you and your dependants access to the following range of 247 multilingual support services
Confidential professional counselling is available face to face phone video email or online chat
CONFIDENTIAL PROFESSIONAL COUNSELLING
CRITICAL INCIDENT SUPPORT
LEGAL AND FINANCIAL SUPPORT SERVICES
WELLNESS WEBSITE ACCESS
1110
Travel Security ServicesAs the world continues to witness an increase in security threats we provide services that enable you tomanage your personal risk conveniently and effectively The Travel Security Services offer access to a richpool of professional advice and support that is available whenever you need it via phone email orwebsite This service where provided will be shown in the Table of Benefits
Travel Security Services offer 247 access to personal security information and advice for all your travelsafety queries This includes
To access the service please contact us
+44 207 741 2185This is not a free phone number
allianzcustomerenquiriesworldawarecom
httpsmyworldawarecomawcRegister by entering your policy number (indicated in your Insurance Certificate)
Download lsquoTravelKitrsquo app from App store or Google Play
All Security Support Services are provided in English Interpreter services are available where required
The Travel Security Services are made available by WorldAware LTD subject to your acceptance of our terms and conditionsYou understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health amp Life Services Limited are notresponsible or liable for any claim loss or damage directly or indirectly resulting from your use of the Travel Security Services
EMERGENCY SECURITY ASSISTANCE HOTLINETalk to a security specialist for any safety concerns associated with a traveldestination or if immediate assistance is needed while travelling
COUNTRY INTELLIGENCE AND SECURITY ADVICESecurity information for a number of countries worldwide as well as comprehensivesecurity advice
DAILY SECURITY NEWS UPDATES AND TRAVEL SAFETY ALERTSWeekly newsletter and email alert notifications of high-risk events includingterrorism civil unrest and severe weather risks in or near your current location
1312
Is your family growing We have you coveredAre you getting married or going to have a baby Congratulations
You can add your spouse or partner to your policy by simply completing our Application Form availableat
wwwallianzworldwidecarecomapplication
To add a new born child to your policy simply send an email to our underwriting team including a copyof the birth certificate When adding a new born child to your policy make sure to send your requestwithin four weeks of the date of birth to ensure that the child is accepted for cover without medicalunderwriting and for cover to start from birth For further information in how to add a dependantincluding important information in how to add multiple babies adopted and foster children please referto the ldquoAdding dependantsrdquo section of this guide
What am I covered forYou are covered for all benefits indicated in your Table of Benefits Pre-existing conditions (including anypre-existing chronic conditions) are generally covered unless we indicate otherwise in your policydocuments If in doubt please refer to the ldquoNotesrdquo section of your Table of Benefits to confirm if pre-existing conditions are covered
Where can I receive treatmentYou can avail of treatment in any country within your area of cover (which is indicated in your InsuranceCertificate)
If the treatment you require is available locally but you choose to travel to another country within yourarea of cover we will reimburse all eligible medical costs incurred within the terms of your policy apartfrom your travel expenses However if the eligible treatment is not available locally and ldquoMedicalevacuationrdquo is included in your cover travel costs to the nearest centre of excellence are also covered Inorder to seek reimbursement for medical and travel expenses incurred you will need to complete andsubmit the Treatment Guarantee Form before travelling
What are benefit limitsYour cover may be subject to a maximum plan benefit This is the maximum we will pay in total for allbenefits included in the plan Although many benefits included in your Table of Benefits are covered infull some are capped to a specific amount (eg euro30000) This specific amount is a benefit limit
For further information on benefit limits please refer to the ldquoBenefit limitsrdquo section of this guide
COVER OVERVIEWWe understand the importance of your own and your familyrsquos health Below is a summaryto help you understand the scope of your health cover
1514
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
For more information please visit
wwwallianzworldwidecarecommyhealth
MyHealth appOur pioneering MyHealth app has been designed to give you easy and convenient access toyour cover no matter where you are With MyHealth app you can access the followingfeatures from your mobile device
Other Services - access your policy documents and your Membership Card on the go look up the local equivalent names ofbranded drugs and translate common ailments into one of 17 languages
All personal data within the MyHealth App are encrypted for data protection Most features areaccessible even when offline
GETTING STARTED
MY CLAIMSSubmit your claims in 3 simple steps and view your claims history
MY CONTACTSAccess our 247 multilingual Helpline and local emergency numbers
FIND A HOSPITALLocate medical providers nearby and get GPS directions
SYMPTOM CHECKERFor a quick and easy evaluation of your symptoms
Download ndash you can download the app from the App Store or Google Play by simplysearching for ldquoAllianz MyHealthrdquo and following the on-screen instructions
Initial setup ndash once downloaded open the app and provide your policy numberThen if prompted register to receive a username and temporary passwordOtherwise please insert the login details available from your Membership PackWhen requested change the temporary password provided to something you caneasily remember If you re-install the app or setup the app on another device pleaseuse this setup information again Please note that you can also use these details tologin to our Online Services
Set PIN ndash finally set your own unique PIN number In the future this PIN number willbe all you need to access the Allianz MyHealth app and all its features
76
Online ServicesYou can access our secure Online Services from the comfort of your home Our Online Services allowsyou to
View and amend your personal details onlinebullDownload your policy documents including your Membership CardbullView your Table of Benefits and check how much remains payable under each benefitbullConfirm the status of any claims submitted to us and view claims related correspondencebullPay your premiums by credit card and update your credit card detailsbull
To access our secure Online Services please log on to myallianzworldwidecarecom and
Login using the unique username and temporary password included in your Membership Pack1
When requested change the temporary password provided to something you can easily remember2Please keep this information safe yoursquoll need it again Please note that you can also use thesedetails to login to our MyHealth App
Click on ldquologinrdquo and browse away3
Web-based member servicesOn our website you can search for medical providers download forms and access our BMI calculatorYou are not restricted to using the medical providers listed on our website
wwwallianzworldwidecarecommembers
Medi24This medical advice service provided by an experienced medical team offers information and advice ona wide range of topics including blood pressure and weight management infectious diseases first aiddental care vaccinations oncology disability speech fertility paediatrics mental health and generalhealth Medi24 is available 247 in English German French and Italian
+44 (0) 208 416 03929
For policy or cover related queries (eg benefit limits or the status of a claim) please contact ourHelpline
If you have not received a Membership Pack go to myallianzworldwidecarecom select ldquoRegisterrdquoand enter the information requested Your username and temporary password will be sent to theemail address we have on record for you
98
Let us help
+1 905 886 3605
wwwworkhealthlifecomAWCExpat(available in English French and Spanish)
Download the ldquoMy Allianz EAPrdquo app from App Store or Google Play
The calls are answered by an English-speaking agent However additional language support is also available If our agentsare not available in the language you require we will organise interpreter services
This is not a free phone number Local phone numbers are available in many countries To see the full list of our lsquoWorldwideAccess Numbersrsquo visit wwwworkhealthlifecomAWC
The Expat Assistance Programme Services are made available by Morneau Shepell Limited subject to your acceptance ofAWPrsquos our terms and conditions You understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health ampLife Services Limited are not responsible or liable for any claim loss or damage directly or indirectly resulting from your use ofthe Expat Assistance Programme Services
Expat Assistance Programme (EAP)The Expat Assistance Programme where provided will be shown in the Table of Benefits This service is aconfidential and professional 247 multilingual support service that can help you and your dependantsaddress a wide range of life issues and challenges such as
WorkLife balancebullFamilyParentingbullRelationshipsbullStress depression anxietybullWorkplace challengesbullCross-cultural transitionbullCultural shockbullCoping with isolation and lonelinessbullAddiction concernsbull
This multilingual service is available locally anytime anywhereEAP offers you and your dependants access to the following range of 247 multilingual support services
Confidential professional counselling is available face to face phone video email or online chat
CONFIDENTIAL PROFESSIONAL COUNSELLING
CRITICAL INCIDENT SUPPORT
LEGAL AND FINANCIAL SUPPORT SERVICES
WELLNESS WEBSITE ACCESS
1110
Travel Security ServicesAs the world continues to witness an increase in security threats we provide services that enable you tomanage your personal risk conveniently and effectively The Travel Security Services offer access to a richpool of professional advice and support that is available whenever you need it via phone email orwebsite This service where provided will be shown in the Table of Benefits
Travel Security Services offer 247 access to personal security information and advice for all your travelsafety queries This includes
To access the service please contact us
+44 207 741 2185This is not a free phone number
allianzcustomerenquiriesworldawarecom
httpsmyworldawarecomawcRegister by entering your policy number (indicated in your Insurance Certificate)
Download lsquoTravelKitrsquo app from App store or Google Play
All Security Support Services are provided in English Interpreter services are available where required
The Travel Security Services are made available by WorldAware LTD subject to your acceptance of our terms and conditionsYou understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health amp Life Services Limited are notresponsible or liable for any claim loss or damage directly or indirectly resulting from your use of the Travel Security Services
EMERGENCY SECURITY ASSISTANCE HOTLINETalk to a security specialist for any safety concerns associated with a traveldestination or if immediate assistance is needed while travelling
COUNTRY INTELLIGENCE AND SECURITY ADVICESecurity information for a number of countries worldwide as well as comprehensivesecurity advice
DAILY SECURITY NEWS UPDATES AND TRAVEL SAFETY ALERTSWeekly newsletter and email alert notifications of high-risk events includingterrorism civil unrest and severe weather risks in or near your current location
1312
Is your family growing We have you coveredAre you getting married or going to have a baby Congratulations
You can add your spouse or partner to your policy by simply completing our Application Form availableat
wwwallianzworldwidecarecomapplication
To add a new born child to your policy simply send an email to our underwriting team including a copyof the birth certificate When adding a new born child to your policy make sure to send your requestwithin four weeks of the date of birth to ensure that the child is accepted for cover without medicalunderwriting and for cover to start from birth For further information in how to add a dependantincluding important information in how to add multiple babies adopted and foster children please referto the ldquoAdding dependantsrdquo section of this guide
What am I covered forYou are covered for all benefits indicated in your Table of Benefits Pre-existing conditions (including anypre-existing chronic conditions) are generally covered unless we indicate otherwise in your policydocuments If in doubt please refer to the ldquoNotesrdquo section of your Table of Benefits to confirm if pre-existing conditions are covered
Where can I receive treatmentYou can avail of treatment in any country within your area of cover (which is indicated in your InsuranceCertificate)
If the treatment you require is available locally but you choose to travel to another country within yourarea of cover we will reimburse all eligible medical costs incurred within the terms of your policy apartfrom your travel expenses However if the eligible treatment is not available locally and ldquoMedicalevacuationrdquo is included in your cover travel costs to the nearest centre of excellence are also covered Inorder to seek reimbursement for medical and travel expenses incurred you will need to complete andsubmit the Treatment Guarantee Form before travelling
What are benefit limitsYour cover may be subject to a maximum plan benefit This is the maximum we will pay in total for allbenefits included in the plan Although many benefits included in your Table of Benefits are covered infull some are capped to a specific amount (eg euro30000) This specific amount is a benefit limit
For further information on benefit limits please refer to the ldquoBenefit limitsrdquo section of this guide
COVER OVERVIEWWe understand the importance of your own and your familyrsquos health Below is a summaryto help you understand the scope of your health cover
1514
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Online ServicesYou can access our secure Online Services from the comfort of your home Our Online Services allowsyou to
View and amend your personal details onlinebullDownload your policy documents including your Membership CardbullView your Table of Benefits and check how much remains payable under each benefitbullConfirm the status of any claims submitted to us and view claims related correspondencebullPay your premiums by credit card and update your credit card detailsbull
To access our secure Online Services please log on to myallianzworldwidecarecom and
Login using the unique username and temporary password included in your Membership Pack1
When requested change the temporary password provided to something you can easily remember2Please keep this information safe yoursquoll need it again Please note that you can also use thesedetails to login to our MyHealth App
Click on ldquologinrdquo and browse away3
Web-based member servicesOn our website you can search for medical providers download forms and access our BMI calculatorYou are not restricted to using the medical providers listed on our website
wwwallianzworldwidecarecommembers
Medi24This medical advice service provided by an experienced medical team offers information and advice ona wide range of topics including blood pressure and weight management infectious diseases first aiddental care vaccinations oncology disability speech fertility paediatrics mental health and generalhealth Medi24 is available 247 in English German French and Italian
+44 (0) 208 416 03929
For policy or cover related queries (eg benefit limits or the status of a claim) please contact ourHelpline
If you have not received a Membership Pack go to myallianzworldwidecarecom select ldquoRegisterrdquoand enter the information requested Your username and temporary password will be sent to theemail address we have on record for you
98
Let us help
+1 905 886 3605
wwwworkhealthlifecomAWCExpat(available in English French and Spanish)
Download the ldquoMy Allianz EAPrdquo app from App Store or Google Play
The calls are answered by an English-speaking agent However additional language support is also available If our agentsare not available in the language you require we will organise interpreter services
This is not a free phone number Local phone numbers are available in many countries To see the full list of our lsquoWorldwideAccess Numbersrsquo visit wwwworkhealthlifecomAWC
The Expat Assistance Programme Services are made available by Morneau Shepell Limited subject to your acceptance ofAWPrsquos our terms and conditions You understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health ampLife Services Limited are not responsible or liable for any claim loss or damage directly or indirectly resulting from your use ofthe Expat Assistance Programme Services
Expat Assistance Programme (EAP)The Expat Assistance Programme where provided will be shown in the Table of Benefits This service is aconfidential and professional 247 multilingual support service that can help you and your dependantsaddress a wide range of life issues and challenges such as
WorkLife balancebullFamilyParentingbullRelationshipsbullStress depression anxietybullWorkplace challengesbullCross-cultural transitionbullCultural shockbullCoping with isolation and lonelinessbullAddiction concernsbull
This multilingual service is available locally anytime anywhereEAP offers you and your dependants access to the following range of 247 multilingual support services
Confidential professional counselling is available face to face phone video email or online chat
CONFIDENTIAL PROFESSIONAL COUNSELLING
CRITICAL INCIDENT SUPPORT
LEGAL AND FINANCIAL SUPPORT SERVICES
WELLNESS WEBSITE ACCESS
1110
Travel Security ServicesAs the world continues to witness an increase in security threats we provide services that enable you tomanage your personal risk conveniently and effectively The Travel Security Services offer access to a richpool of professional advice and support that is available whenever you need it via phone email orwebsite This service where provided will be shown in the Table of Benefits
Travel Security Services offer 247 access to personal security information and advice for all your travelsafety queries This includes
To access the service please contact us
+44 207 741 2185This is not a free phone number
allianzcustomerenquiriesworldawarecom
httpsmyworldawarecomawcRegister by entering your policy number (indicated in your Insurance Certificate)
Download lsquoTravelKitrsquo app from App store or Google Play
All Security Support Services are provided in English Interpreter services are available where required
The Travel Security Services are made available by WorldAware LTD subject to your acceptance of our terms and conditionsYou understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health amp Life Services Limited are notresponsible or liable for any claim loss or damage directly or indirectly resulting from your use of the Travel Security Services
EMERGENCY SECURITY ASSISTANCE HOTLINETalk to a security specialist for any safety concerns associated with a traveldestination or if immediate assistance is needed while travelling
COUNTRY INTELLIGENCE AND SECURITY ADVICESecurity information for a number of countries worldwide as well as comprehensivesecurity advice
DAILY SECURITY NEWS UPDATES AND TRAVEL SAFETY ALERTSWeekly newsletter and email alert notifications of high-risk events includingterrorism civil unrest and severe weather risks in or near your current location
1312
Is your family growing We have you coveredAre you getting married or going to have a baby Congratulations
You can add your spouse or partner to your policy by simply completing our Application Form availableat
wwwallianzworldwidecarecomapplication
To add a new born child to your policy simply send an email to our underwriting team including a copyof the birth certificate When adding a new born child to your policy make sure to send your requestwithin four weeks of the date of birth to ensure that the child is accepted for cover without medicalunderwriting and for cover to start from birth For further information in how to add a dependantincluding important information in how to add multiple babies adopted and foster children please referto the ldquoAdding dependantsrdquo section of this guide
What am I covered forYou are covered for all benefits indicated in your Table of Benefits Pre-existing conditions (including anypre-existing chronic conditions) are generally covered unless we indicate otherwise in your policydocuments If in doubt please refer to the ldquoNotesrdquo section of your Table of Benefits to confirm if pre-existing conditions are covered
Where can I receive treatmentYou can avail of treatment in any country within your area of cover (which is indicated in your InsuranceCertificate)
If the treatment you require is available locally but you choose to travel to another country within yourarea of cover we will reimburse all eligible medical costs incurred within the terms of your policy apartfrom your travel expenses However if the eligible treatment is not available locally and ldquoMedicalevacuationrdquo is included in your cover travel costs to the nearest centre of excellence are also covered Inorder to seek reimbursement for medical and travel expenses incurred you will need to complete andsubmit the Treatment Guarantee Form before travelling
What are benefit limitsYour cover may be subject to a maximum plan benefit This is the maximum we will pay in total for allbenefits included in the plan Although many benefits included in your Table of Benefits are covered infull some are capped to a specific amount (eg euro30000) This specific amount is a benefit limit
For further information on benefit limits please refer to the ldquoBenefit limitsrdquo section of this guide
COVER OVERVIEWWe understand the importance of your own and your familyrsquos health Below is a summaryto help you understand the scope of your health cover
1514
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
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- TERMS AND CONDITIONS OF YOUR COVER
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- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Let us help
+1 905 886 3605
wwwworkhealthlifecomAWCExpat(available in English French and Spanish)
Download the ldquoMy Allianz EAPrdquo app from App Store or Google Play
The calls are answered by an English-speaking agent However additional language support is also available If our agentsare not available in the language you require we will organise interpreter services
This is not a free phone number Local phone numbers are available in many countries To see the full list of our lsquoWorldwideAccess Numbersrsquo visit wwwworkhealthlifecomAWC
The Expat Assistance Programme Services are made available by Morneau Shepell Limited subject to your acceptance ofAWPrsquos our terms and conditions You understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health ampLife Services Limited are not responsible or liable for any claim loss or damage directly or indirectly resulting from your use ofthe Expat Assistance Programme Services
Expat Assistance Programme (EAP)The Expat Assistance Programme where provided will be shown in the Table of Benefits This service is aconfidential and professional 247 multilingual support service that can help you and your dependantsaddress a wide range of life issues and challenges such as
WorkLife balancebullFamilyParentingbullRelationshipsbullStress depression anxietybullWorkplace challengesbullCross-cultural transitionbullCultural shockbullCoping with isolation and lonelinessbullAddiction concernsbull
This multilingual service is available locally anytime anywhereEAP offers you and your dependants access to the following range of 247 multilingual support services
Confidential professional counselling is available face to face phone video email or online chat
CONFIDENTIAL PROFESSIONAL COUNSELLING
CRITICAL INCIDENT SUPPORT
LEGAL AND FINANCIAL SUPPORT SERVICES
WELLNESS WEBSITE ACCESS
1110
Travel Security ServicesAs the world continues to witness an increase in security threats we provide services that enable you tomanage your personal risk conveniently and effectively The Travel Security Services offer access to a richpool of professional advice and support that is available whenever you need it via phone email orwebsite This service where provided will be shown in the Table of Benefits
Travel Security Services offer 247 access to personal security information and advice for all your travelsafety queries This includes
To access the service please contact us
+44 207 741 2185This is not a free phone number
allianzcustomerenquiriesworldawarecom
httpsmyworldawarecomawcRegister by entering your policy number (indicated in your Insurance Certificate)
Download lsquoTravelKitrsquo app from App store or Google Play
All Security Support Services are provided in English Interpreter services are available where required
The Travel Security Services are made available by WorldAware LTD subject to your acceptance of our terms and conditionsYou understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health amp Life Services Limited are notresponsible or liable for any claim loss or damage directly or indirectly resulting from your use of the Travel Security Services
EMERGENCY SECURITY ASSISTANCE HOTLINETalk to a security specialist for any safety concerns associated with a traveldestination or if immediate assistance is needed while travelling
COUNTRY INTELLIGENCE AND SECURITY ADVICESecurity information for a number of countries worldwide as well as comprehensivesecurity advice
DAILY SECURITY NEWS UPDATES AND TRAVEL SAFETY ALERTSWeekly newsletter and email alert notifications of high-risk events includingterrorism civil unrest and severe weather risks in or near your current location
1312
Is your family growing We have you coveredAre you getting married or going to have a baby Congratulations
You can add your spouse or partner to your policy by simply completing our Application Form availableat
wwwallianzworldwidecarecomapplication
To add a new born child to your policy simply send an email to our underwriting team including a copyof the birth certificate When adding a new born child to your policy make sure to send your requestwithin four weeks of the date of birth to ensure that the child is accepted for cover without medicalunderwriting and for cover to start from birth For further information in how to add a dependantincluding important information in how to add multiple babies adopted and foster children please referto the ldquoAdding dependantsrdquo section of this guide
What am I covered forYou are covered for all benefits indicated in your Table of Benefits Pre-existing conditions (including anypre-existing chronic conditions) are generally covered unless we indicate otherwise in your policydocuments If in doubt please refer to the ldquoNotesrdquo section of your Table of Benefits to confirm if pre-existing conditions are covered
Where can I receive treatmentYou can avail of treatment in any country within your area of cover (which is indicated in your InsuranceCertificate)
If the treatment you require is available locally but you choose to travel to another country within yourarea of cover we will reimburse all eligible medical costs incurred within the terms of your policy apartfrom your travel expenses However if the eligible treatment is not available locally and ldquoMedicalevacuationrdquo is included in your cover travel costs to the nearest centre of excellence are also covered Inorder to seek reimbursement for medical and travel expenses incurred you will need to complete andsubmit the Treatment Guarantee Form before travelling
What are benefit limitsYour cover may be subject to a maximum plan benefit This is the maximum we will pay in total for allbenefits included in the plan Although many benefits included in your Table of Benefits are covered infull some are capped to a specific amount (eg euro30000) This specific amount is a benefit limit
For further information on benefit limits please refer to the ldquoBenefit limitsrdquo section of this guide
COVER OVERVIEWWe understand the importance of your own and your familyrsquos health Below is a summaryto help you understand the scope of your health cover
1514
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Travel Security ServicesAs the world continues to witness an increase in security threats we provide services that enable you tomanage your personal risk conveniently and effectively The Travel Security Services offer access to a richpool of professional advice and support that is available whenever you need it via phone email orwebsite This service where provided will be shown in the Table of Benefits
Travel Security Services offer 247 access to personal security information and advice for all your travelsafety queries This includes
To access the service please contact us
+44 207 741 2185This is not a free phone number
allianzcustomerenquiriesworldawarecom
httpsmyworldawarecomawcRegister by entering your policy number (indicated in your Insurance Certificate)
Download lsquoTravelKitrsquo app from App store or Google Play
All Security Support Services are provided in English Interpreter services are available where required
The Travel Security Services are made available by WorldAware LTD subject to your acceptance of our terms and conditionsYou understand and agree that AWP Health amp Life SA ndash Irish Branch andor AWP Health amp Life Services Limited are notresponsible or liable for any claim loss or damage directly or indirectly resulting from your use of the Travel Security Services
EMERGENCY SECURITY ASSISTANCE HOTLINETalk to a security specialist for any safety concerns associated with a traveldestination or if immediate assistance is needed while travelling
COUNTRY INTELLIGENCE AND SECURITY ADVICESecurity information for a number of countries worldwide as well as comprehensivesecurity advice
DAILY SECURITY NEWS UPDATES AND TRAVEL SAFETY ALERTSWeekly newsletter and email alert notifications of high-risk events includingterrorism civil unrest and severe weather risks in or near your current location
1312
Is your family growing We have you coveredAre you getting married or going to have a baby Congratulations
You can add your spouse or partner to your policy by simply completing our Application Form availableat
wwwallianzworldwidecarecomapplication
To add a new born child to your policy simply send an email to our underwriting team including a copyof the birth certificate When adding a new born child to your policy make sure to send your requestwithin four weeks of the date of birth to ensure that the child is accepted for cover without medicalunderwriting and for cover to start from birth For further information in how to add a dependantincluding important information in how to add multiple babies adopted and foster children please referto the ldquoAdding dependantsrdquo section of this guide
What am I covered forYou are covered for all benefits indicated in your Table of Benefits Pre-existing conditions (including anypre-existing chronic conditions) are generally covered unless we indicate otherwise in your policydocuments If in doubt please refer to the ldquoNotesrdquo section of your Table of Benefits to confirm if pre-existing conditions are covered
Where can I receive treatmentYou can avail of treatment in any country within your area of cover (which is indicated in your InsuranceCertificate)
If the treatment you require is available locally but you choose to travel to another country within yourarea of cover we will reimburse all eligible medical costs incurred within the terms of your policy apartfrom your travel expenses However if the eligible treatment is not available locally and ldquoMedicalevacuationrdquo is included in your cover travel costs to the nearest centre of excellence are also covered Inorder to seek reimbursement for medical and travel expenses incurred you will need to complete andsubmit the Treatment Guarantee Form before travelling
What are benefit limitsYour cover may be subject to a maximum plan benefit This is the maximum we will pay in total for allbenefits included in the plan Although many benefits included in your Table of Benefits are covered infull some are capped to a specific amount (eg euro30000) This specific amount is a benefit limit
For further information on benefit limits please refer to the ldquoBenefit limitsrdquo section of this guide
COVER OVERVIEWWe understand the importance of your own and your familyrsquos health Below is a summaryto help you understand the scope of your health cover
1514
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Is your family growing We have you coveredAre you getting married or going to have a baby Congratulations
You can add your spouse or partner to your policy by simply completing our Application Form availableat
wwwallianzworldwidecarecomapplication
To add a new born child to your policy simply send an email to our underwriting team including a copyof the birth certificate When adding a new born child to your policy make sure to send your requestwithin four weeks of the date of birth to ensure that the child is accepted for cover without medicalunderwriting and for cover to start from birth For further information in how to add a dependantincluding important information in how to add multiple babies adopted and foster children please referto the ldquoAdding dependantsrdquo section of this guide
What am I covered forYou are covered for all benefits indicated in your Table of Benefits Pre-existing conditions (including anypre-existing chronic conditions) are generally covered unless we indicate otherwise in your policydocuments If in doubt please refer to the ldquoNotesrdquo section of your Table of Benefits to confirm if pre-existing conditions are covered
Where can I receive treatmentYou can avail of treatment in any country within your area of cover (which is indicated in your InsuranceCertificate)
If the treatment you require is available locally but you choose to travel to another country within yourarea of cover we will reimburse all eligible medical costs incurred within the terms of your policy apartfrom your travel expenses However if the eligible treatment is not available locally and ldquoMedicalevacuationrdquo is included in your cover travel costs to the nearest centre of excellence are also covered Inorder to seek reimbursement for medical and travel expenses incurred you will need to complete andsubmit the Treatment Guarantee Form before travelling
What are benefit limitsYour cover may be subject to a maximum plan benefit This is the maximum we will pay in total for allbenefits included in the plan Although many benefits included in your Table of Benefits are covered infull some are capped to a specific amount (eg euro30000) This specific amount is a benefit limit
For further information on benefit limits please refer to the ldquoBenefit limitsrdquo section of this guide
COVER OVERVIEWWe understand the importance of your own and your familyrsquos health Below is a summaryto help you understand the scope of your health cover
1514
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
A deductible is a fixed amount that the insured person must pay per period of cover (when paying fortheir medical bills) before we begin to pay for the medical expenses In the following example Johnneeds to receive medical treatment throughout the year His plan includes a euro450 deductible
Treatment invoice 1 = euro400
Treatment invoice 2 = euro400
Treatment invoice 3 = euro400
Treatment invoice 4 = euro400
John pays the medical bill in full
(euro400)
We pay euro0
John pays euro50
We pay the remaining euro350
John pays euro0
John pays euro0
We pay the medical bill in
full (euro400)
We pay the medical bill in
full (euro400)
End of the Insurance Year
Start of the Insurance Year
What are deductibles and co-paymentsSome plans and benefits may be subject to co-payments andor a deductible If your plan includes anythis will be confirmed in your Table of Benefits
A co-payment is when you pay a percentage of the medical costs In the following example Maryrequires several dental treatments throughout the year Her dental treatment benefit has a 20 co-payment which means that we will refund 80 The total amount payable by us may be subject to amaximum plan benefit limit
Treatment invoice 1
Treatment invoice 2
Mary pays 20 We pay
80
Mary pays 20
We pay 80
End of the Insurance Year
Start of the Insurance Year
Mary pays 20
We pay 80
Treatment invoice 3
1716
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
If itrsquos an emergencyGet the emergency treatment you need and call us if you need any advice or support
Either you your physician one of your dependants or a colleague needs to call ourHelpline (within 48 hours of the emergency) to inform us of the hospitalisationTreatment Guarantee Form details can be taken over the phone when you call us
Check your level of coverFirst check that your plan covers the treatment you are seeking Your Table of Benefits will confirm whichbenefits are available to you however you can always call our Helpline if you have any queries
Some treatments require pre-authorisationYour Table of Benefits will indicate what treatments are subject to pre-authorisation through submissionof a Treatment Guarantee Form Usually these are in-patient and high cost treatments The TreatmentGuarantee process helps us to assess each case organise everything with the hospital before yourarrival and facilitate direct payment of your hospital bill where possible
Getting in-patient treatment(pre-authorisation applies)
We can also take Treatment Guarantee Form details over the phone if treatment is taking place within 72 hours Please notethat we may decline your claim if Treatment Guarantee is not obtained Full details of our Treatment Guarantee process canbe found in the Terms and Conditions section of this document
SEEKING TREATMENTWe understand that seeking treatment can be stressful By following the process belowwe can look after the administration and you can concentrate on getting better
Download a Treatment Guarantee Form from our websitewwwallianzworldwidecarecommembers
Send the completed form to us at least five working days before treatment Scan andemail fax or post (details on the form)
We contact your medical provider directly to arrange settlement of your bills (wherepossible)
1918
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Claiming for your out-patient dental and other expensesIf your treatment does not require pre-authorisation just pay the bill and claim the expenses from us Inthis case simply follow these steps
As an alternative to MyHealth app you can also claim your treatment costs by completing andsubmitting a Claim Form downloadable at
wwwallianzworldwidecarecommembers
You will need to complete section 5 and 6 of the Claim Form only if the information requested in thosesections is not already provided on your medical invoice
Please send the Claim Form and all supporting documentation invoices and receipts to us by email faxor post (details on the form)
Please refer to ldquoMedical Claimsrdquo in the Terms and conditions of your cover section of this guide foradditional information about our claims process
Receive your medical treatment and pay the medical provider
Get an invoice from your medical providerThis should state your name treatment date(s) the diagnosismedical condition that you receivedtreatment for the date of onset of symptoms the nature of the treatment and the fees charged
Claim back your eligible costs via our MyHealth appSimply provide a few key details take a photo of your invoice(s) and press lsquosubmitrsquo
Quick claim processingWe can process a claim and issue payment instructions to your bank within48 hours when all required information has been submitted Howeverwithout the diagnosis we cannot process your claim promptly as we willneed to request these details from you or your doctor Please make sureyou include the diagnosis on your claim
We will email or write to you to let you know when the claim has beenprocessed
2120
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Evacuations and repatriationsAt the first indication that a medical evacuationrepatriation is required please call our 24 hour Helplineand we will take care of everything Given the urgency of an evacuationrepatriation we would advisethat you call us however you can also contact us by email
When emailing please include ldquoUrgent ndash EvacuationRepatriationrdquo in the subject line Please contact usbefore talking to any alternative providers even if approached by them to avoid potentially inflatedcharges or unnecessary delays in the evacuation process In the event that evacuationrepatriationservices are not organised by us we reserve the right to decline the costs
+353 1 630 1301
medicalservicesallianzworldwidecarecom
2322
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
You can also apply for a discount pharmacy card from Olympuswhich can be used any time your prescription is not covered byyour healthcare policy To register and obtain your discountpharmacy card simply go to the following website and click onldquoPrint Discount Cardrdquo
httpmembersomhccomawcprescriptionshtml
And if I need treatment in the USAIf you have ldquoWorldwiderdquo cover and wish to locate a medical provider in the USA simply go to
wwwallianzworldwidecarecomolympus
If you have a query about a medical provider or if you have selected a provider and wish to arrange anappointment please call us
(+1) 800 541 1983(toll-free from the USA)
2524
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
TERMS ANDCONDITIONSOF YOURCOVER
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Your health insurance policy is an annual contract between the insured person(s) named on theInsurance Certificate and us The contract is composed of
The Benefit Guide (this document) which sets out the standard benefits and rules of your healthbullinsurance policy and should be read in conjunction with your Insurance Certificate and Table ofBenefitsThe Insurance Certificate This states the plan(s) chosen the start date and renewal date of the policybull(and effective dates of when dependants were added) as well as the geographical area of cover Anyfurther special terms unique to your cover will be indicated in the Insurance Certificate (and will havebeen detailed on a Special Conditions Form issued prior to the inception of your policy) Please notethat we will send you a new Insurance Certificate if you request (and we accept) a change such asadding a dependant or if we apply a change which we are entitled to makeThe Table of Benefits This shows the plan(s) selected the associated benefits available to you andbullspecifies which benefitstreatments require submission of a Treatment Guarantee Form It alsoconfirms any benefits to which specific benefit limits waiting periods deductibles andor co-payments applyInformation provided to us by or on behalf of the insured person(s) in the signed Application Formbullsubmitted Online Application Form Confirmation of Health Status Form or others (hereafter referredto collectively as the ldquorelevant application formrdquo) or other supporting medical information
TERMS AND CONDITIONSThis section describes the standard benefits and rules of your health insurance policy
2928
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Benefit limitsThere are two kinds of benefit limits shown in the Table of Benefits
The maximum plan benefit which applies to certain plans is the maximum we will pay for all benefitsbullin total per member per Insurance Year under that particular planSome benefits also have a specific benefit limit which may be provided on a ldquoper Insurance Yearrdquobullbasis a ldquoper lifetimerdquo basis or on a ldquoper eventrdquo basis such as per trip per visit or per pregnancy Insome instances we will pay a percentage of the costs for the specific benefit eg ldquo65 refund up topound4150euro5000US$6750CHF 6500rdquo
Where a specific benefit limit applies or where the term ldquoFull refundrdquo appears next to certain benefitsthe refund is subject to the maximum plan benefit if one applies to your plan(s) All limits are permember per Insurance Year unless otherwise stated in your Table of Benefits
If you are covered for maternity benefits these will be stated in your Table of Benefits along with anybenefit limit andor waiting period that applies Benefit limits for ldquoRoutine maternityrdquo and ldquoComplicationsof pregnancy and childbirthrdquo are payable on either a ldquoper pregnancyrdquo or ldquoper Insurance Yearrdquo basis (thiswill be confirmed in your Table of Benefits) If your benefit is payable on a ldquoper pregnancyrdquo basis and apregnancy spans two Insurance Years please note that if a change is applied to the benefit limit atpolicy renewal the following will apply
All eligible expenses incurred in the first year will be subject to the benefit limit that applies in yearbulloneAll eligible expenses incurred in the second year will be subject to the updated benefit limit thatbullapplies in year two less the total benefit amount reimbursed in year oneIn the event that the benefit limit decreases in year two and this updated amount has been reachedbullor exceeded by eligible costs incurred in year one no additional benefit amount will be payable
For multiple birth babies born as a result of medically assisted reproduction in-patient treatment islimited to pound24900euro30000US$40500CHF39000 per child for the first three months following birthOut-patient treatment is paid within the terms of the Out-patient Plan
Your benefits are also subject to
Policy definitions and exclusions (also available in this document)bullAny special conditions indicated on your Insurance Certificate (and on the Special Condition Formbullissued prior to policy inception where relevant)
What we coverThe extent of your cover is determined by your Table of Benefits the Insurance Certificate any policya)endorsements these policy terms and conditions as well as any other legal requirements We willreimburse in accordance with your Table of Benefits and individual terms and conditions medicalcosts arising from the occurrence or worsening of a medical condition
This policy provides cover for medical treatment related costs services andor supplies that web)determine to be medically necessary and appropriate to treat a patientrsquos condition illness or injuryTreatments and procedures are only covered if they have a palliative curative andor diagnosticpurpose are medically necessary appropriate and performed by a licensed physician dentist ortherapist Claimscosts will be paidreimbursed if the medical diagnosis andor prescribed treatmentare fair and reasonable and at the level customarily charged in the specific country and for thetreatment provided in accordance with standard and generally accepted medical procedures If aclaim is deemed by us to be inappropriate we reserve the right to reduce or decline the amountpayable by us
This policy may not provide any cover or benefit to the extent that either the cover or benefit wouldc)violate any applicable sanction law or regulations of the United Nations the European Union or anyother applicable economic or trade sanction law or regulations
When cover starts for you and your dependantsOur acceptance of your application for cover is confirmed when we issue your Insurance Certificate andyour cover is valid from the start date shown on the certificate Please note that no benefit will bepayable under your policy until the initial premium has been paid with subsequent premiums being paidwhen due
If any other person is included as a dependant under your membership their membership will start onthe effective date as shown on your most recent Insurance Certificate which lists them as a dependantTheir membership may continue for as long as you remain the policyholder and as long as any childdependants remain under the defined age limit Child dependants can be covered under your policy upuntil the day before their 18th birthday or up until the day before their 24th birthday if they are in full timeeducation At that time they may apply for cover in their own right should they wish to do so
YOUR COVER EXPLAINEDThe plans that you selected are indicated in your Table of Benefits which lists all thebenefits you are covered for and any applicable limits For an explanation of how yourbenefit limits apply to your plan please see the ldquoBenefit limitsrdquo paragraph below
3130
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Medical claimsIn relation to medical claims please note that
All claims should be submitted (via our MyHealth app or Claim Form) no later than six months aftera)the end of the Insurance Year If cover is cancelled during the Insurance Year claims should besubmitted no later than six months after the date that your cover ended Beyond this time we are notobliged to settle the claim
Submission of a separate claim (via our MyHealth app or Claim Form) is required for each personb)claiming and for each medical condition being claimed for Please note that as well as our hard andsoft copy claim forms members can avail of our MyHealth app for fast and easy claims submission
It is your responsibility to retain any original supporting documentation (eg medical receipts) wherec)copies are submitted to us as we reserve the right to request original supportingdocumentationreceipts up to 12 months after claims settlement for auditing purposes We alsoreserve the right to request a proof of payment by you (eg bank or credit card statement) in respectof your medical receipts We advise that you keep copies of all correspondence with us as we cannotbe held responsible for correspondence that does not reach us for any reason that is outside of ourreasonable control
If the amount to be claimed is less than the deductible figure under your plan keep collecting all out-d)patient receipts and Claim Forms until you reach an amount in excess of your plan deductible thenforward to us all completed Claim Forms together with supporting receiptsinvoices
Please specify on the Claim Form the currency in which you wish to be paid Unfortunately on raree)occasions we may not be able to make a payment in the currency you requested on the Claim Formdue to international banking regulations In this instance we will review each case individually toidentify a suitable alternative currency option If we have to make a conversion from one currency toanother we will use the exchange rate that applies on the date on which the invoices were issued orwe will use the exchange rate that applies on the date that claims payment is made Please notethat we reserve the right to choose which currency exchange rate to apply
Only costs incurred as a result of eligible treatment will be reimbursed within the limits of your policyf)after taking into consideration any Treatment Guarantee requirements Any deductibles or co-payments outlined in the Table of Benefits will be taken into account when calculating the amount tobe reimbursed
If you are required to pay a deposit in advance of any medical treatment the cost incurred will onlyg)be reimbursed after treatment has taken place
You and your dependants agree to assist us in obtaining all necessary information to process ah)claim We have the right to access all medical records and to have direct discussions with themedical provider or the treating physician We may at our own expense request a medicalexamination by our medical representative when we deem this to be necessary All information willbe treated in strict confidence We reserve the right to withhold benefits if you or your dependantshave not honoured these obligations
CLAIMS AND TREATMENT GUARANTEEPROCESS
3332
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
All in-patient benefitssup1 listed (where you need to stay overnight in a hospital)bullDay-care treatmentsup2bullExpenses for one person accompanying an evacuatedrepatriated personsup2bullKidney dialysissup2bullLong term caresup2bullMedical evacuationsup2 (or repatriationsup2 where covered)bullMRI (Magnetic Resonance Imaging) scan Treatment Guarantee is not needed for MRI scans unlessbullyou wish to have direct settlementNursing at home or in a convalescent homesup2bullOccupational therapysup2 (only out-patient treatment requires pre-authorisation)bullOncologysup2 (only in-patient or day-care treatment requires pre-authorisation)bullOut-patient surgerysup2bullPalliative caresup2bullPETsup2 (Positron Emission Tomography) and CT-PETsup2 scansbullPreventative surgerysup2bullRehabilitation treatmentsup2bullRepatriation of mortal remainssup2bullRoutine maternitysup2 complications of pregnancy and childbirthsup2 (only in-patient treatment requiresbullpre-authorisation)Travel costs of insured family members in the event of an evacuationsup2 (or repatriation wherebullcovered)Travel costs of insured family members in the event of the repatriation of mortal remainssup2bullTravel costs to another Channel Island the UK or to Francesup2bull
Use of the Treatment Guarantee Form helps us to assess each case and facilitate direct settlement withthe hospital
If Treatment Guarantee is not obtained the following will apply
If the treatment received is subsequently proven to be medically unnecessary we reserve the right tobulldecline your claimFor the benefits listed with a 1 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 80 of the eligible benefitFor the benefits listed with a 2 we reserve the right to decline your claim If the respective treatmentbullis subsequently proven to be medically necessary we will pay only 50 of the eligible benefit
Claims for accidental deathIf the ldquoAccidental deathrdquo benefit is provided on the healthcare plan selected please note that claimsmust be reported within 90 working days following the date of death and the following documents mustbe provided
A fully completed Life and Accidental Death Benefit Application FormbullA death certificatebullA medical report indicating the cause of deathbullA written statement outlining the date location and circumstances of the accidentbullOfficial documentation proving the insured personrsquos family status and for the beneficiaries proof ofbullidentity as well as proof of relationship to the insured person
Beneficiaries are unless otherwise specified by the insured
The insured personrsquos spouse if not legally separatedbullFailing the spouse the insured personrsquos surviving children including step-children adopted or fosterbullchildren and children born less than 300 days from the date of the insured personrsquos death in equalshares among themFailing the children the insured personrsquos father and mother in equal shares between them or to thebullsurvivor of themFailing them the insured personrsquos estatebull
If you wish to nominate a beneficiary other than those listed above please contact our Helpline
Please note that in the specific case of the death of the insured person and one or all of thebeneficiaries in the same occurrence the insured person shall be considered the last deceased
Treatment needed as a result of somebody elsersquos faultIf you are claiming for treatment that is needed when somebody else is at fault you must write and tellus as soon as possible eg if you need treatment for an injury suffered in a road accident in which youare a victim Please take any reasonable steps we ask of you to obtain the insurance details of theperson at fault so that we can recover from the other insurer the cost of the treatment paid for by us Ifyou are able to recover the cost of any treatment for which we have paid you must repay that amount(and any interest) to us
Treatment GuaranteeSome of the benefits available to you require pre-authorisation through submission of a TreatmentGuarantee Form In your Table of Benefits these are usually marked with a 1 or a 2
For your convenience see below the treatmentsbenefits which normally require pre-authorisationthrough submission of a Treatment Guarantee Form (this may vary depending on the cover selected foryou so please check your Table of Benefits to confirm)
3534
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Paying other chargesIn addition to paying premiums you also have to pay us the amount of any Insurance Premium Tax (IPT)taxes levies or charges relating to your membership (or new taxes levies or charges that may beimposed after you join) that we are required by law to pay or to collect from you The amount of any IPTor taxes levies or charges that you have to pay us is shown on your invoice
Please note that we may change the amount you have to pay us in respect of Insurance Premium Tax(IPT) or other taxes levies or charges at any time if there is a change in the rate of IPT or any new taxlevy or charge is introduced or changed
Premiums for each Insurance Year are based on each memberrsquos age on the first day of the InsuranceYear their region of cover the policyholderrsquos country of residence the premium rates in effect and otherrisk factors which may materially affect the insurance
By accepting cover you have agreed to pay the premium amount shown on your quotation by thepayment method stated You are required to pay the premium due to us in advance for the duration ofyour membership The initialfirst premium instalment is payable immediately after our acceptance ofyour application Subsequent premiums are due on the first day of the chosen payment period You maychoose between monthly quarterly half-yearly or annual payments depending on the payment methodyou choose Please note that if there is any difference between the agreed quotation and your invoiceyou should contact us immediately We are not responsible for payments made through third parties
Your premium should be paid in the currency you selected when applying for cover If you are unable topay your premium for any reason please contact us on
+353 1 630 1301
Changes in payment terms can be made at policy renewal via written instructions which must bereceived by us a minimum of 30 days prior to the renewal date Failure to pay an initial premium orsubsequent premium on time may result in loss of insurance cover
If the initial premium is not paid in time we are entitled to withdraw from the contract for as long as thepayment remains outstanding The insurance contract is deemed to be null and void unless we assert aclaim to the premium in court within three months of the commencement date the policy start date orthe conclusion of the insurance contract If a subsequent premium is not paid in time we may in writingand at the policyholderrsquos expense set a time limit of not less than two weeks for the policyholder to paythe amount due Thereafter we may terminate the contract in writing with immediate effect and shallthereby be exempt to pay benefits
The effects of termination shall cease if the policyholder makes a payment within one month after thetermination or if the termination was combined with the setting of a time limit within one month afterthe expiration of the time for payment provided that no claims have been incurred in the interveningperiod
PAYING PREMIUMS
3736
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
to do this within 28 days we will at our discretion not add any further special restrictions or exclusionsapplicable to them in addition to those which already applied to them at the time of the policyholderrsquosdeath
If a dependant dies they will be taken off the policy and a pro rata repayment of the current yearrsquospremium for that member will be made if no claims have been filed (please note that we reserve theright to request a death certificate before a refund is issued)
Changing your level of coverIf you want to change your level of cover please contact us before your policy renewal date to discussyour options as changes to cover can only be made at policy renewal If you want to increase your levelof cover we may ask you to complete a medical history questionnaire andor to agree to certainexclusions or restrictions to any additional cover before we accept your application If an increase incover is accepted an additional premium amount will be payable and waiting periods may apply
Changing country of residenceIt is important that you advise us when you change your country of residence as it may impact the coveror premium even if you are moving to a country within your geographical area of cover If you move to acountry outside of your geographical area of cover your existing cover will not be valid there Pleasenote that cover in some countries is subject to local health insurance restrictions particularly for residentsof that country It is your responsibility to ensure that your healthcare cover is legally appropriate If youare in any doubt please seek independent legal advice as we may no longer be able to provide youwith cover The cover we provide is not a substitute for local compulsory health insurance
Changing your addressemail addressAll correspondence will be sent to the details we have on record for you unless requested otherwise Anychange in your home business or email address should be communicated to us in writing as soon aspossible
CorrespondenceWritten correspondence between us must be sent by email or post (with the postage paid) We do notusually return original documents to you unless you specifically request us to do so at the time ofsubmission
Renewing membershipSubject to the provisions on ldquoReasons your membership would endrdquo your annual policy is automaticallyrenewed for the next Insurance Year provided that the planplan combination selected is still availablewe can continue to provide cover in your country of residence all premiums due to us have been paidand the payment details we have for you are still valid on the renewal date Please update us if you geta newreplacement credit card or if your bank account details have changed
Adding dependantsYou may apply to include any of your family members on the policy by completing the relevantapplication form
Newborn infants (with the exception of multiple birth babies adopted and fostered babies) will beaccepted for cover from birth without medical underwriting provided that we are notified within fourweeks of the date of birth and the birth parent or intended parent (in the case of surrogacy) has beeninsured with us for a minimum of six continuous months To notify us of your intention to have yournewborn child included on your policy please email your request with a copy of the birth certificate toour Underwriting Team at
underwritingallianzworldwidecarecom
Notification of the birth after four weeks will result in newborn children being underwritten and cover willonly commence from the date of acceptance Please note that all multiple birth babies adopted andfostered children will be subject to full medical underwriting and cover will only commence from the dateof acceptance
Following acceptance by our Underwriting team we will issue a new Insurance Certificate to reflect theaddition of a dependant and this certificate will replace any earlier version(s) you may have from thestart date shown on the new Insurance Certificate
Changes to policyholderIf a request is made at renewal to change the policyholder the proposed replacement policyholder willbe required to complete an application form and full medical underwriting will apply (Please refer tothe section on ldquoDeath of the policyholder or a dependantrdquo if this requested change is due to the death ofthe policyholder)
Death of the policyholder or a dependantWe hope you will never need to refer to this section however if a policyholder or a dependant diesplease inform us in writing within 28 days
If the policyholder dies the policy will be terminated and a pro rata repayment of the current yearrsquospremium will be made if no claims have been filed (please note that we reserve the right to request adeath certificate before a refund is issued) Alternatively if they wish to the next named dependant onthe Insurance Certificate may apply to become the policyholder in hisher own right (if they meet theminimum age requirements) and include the other dependants under hisher membership If they apply
ADMINISTRATION OF YOUR POLICY
3938
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
If you do not pay any of your premiums on or before the date they are due However we may allowbullyour membership to continue without you having to complete a Confirmation of Health Status Formif you pay the outstanding premiums within 30 days after the due dateIf you do not pay the amount of any IPT taxes levies or charges that you have to pay under yourbullagreement with us on or before the due dateUpon the death of the policyholder Please see the section on ldquoDeath of the policyholder or abulldependantrdquo for further detailsIf there is reasonable evidence that the policyholder or any dependants misled or attempted tobullmislead us ie giving false information withholding pertinent information from us or working withanother party to give us false information either intentionally or carelessly which may influence uswhen deciding whether they can join the scheme the applicable premium to pay or whether we haveto pay a claim Please see the section on ldquoAdditional termsrdquo for further detailsIf you choose to cancel your policy after giving us written notice within 30 days of receiving the fullbullterms and conditions or from the startrenewal date of your policy whichever is later Please seesection on ldquoYour right to cancelrdquo for further details
If your membership ends for reasons other than for fraudnon-disclosure we will refund any premiumsyou have paid which relate to a period after your membership has ended subject to the deduction ofany money which you owe us
Please note that if your membership ceases your dependantrsquos cover will also end
Policy expiryPlease note that upon the expiry of your policy your right to reimbursement ends Any eligible expensesincurred during the period of cover shall be reimbursed up to six months after the expiry date of thepolicy However any on-going or further treatment that is required after the expiry date of your policywill no longer be covered
As part of this automatic process one month before the renewal date you will receive a new InsuranceCertificate along with details of any policy changes If you do not receive your Insurance Certificate onemonth before your renewal date it is important that you notify us
Changes that we may apply at renewalWe have the right to apply revised policy terms and conditions effective from the renewal date Thepolicy terms and conditions and the Table of Benefits that exist at renewal will apply for the duration ofthe Insurance Year We may change the premium benefits and rules of your membership on yourrenewal date including how we calculatedetermine premiums andor the method or frequency ofpayment These changes will only apply from your renewal date regardless of when the change is madeand we will not add any restrictions or exclusions which are personal to a memberrsquos cover in relation tomedical conditions that started after their policyrsquos inception provided that they gave us the informationwe asked them for before incepting and they have not applied for an increase in their level of cover
We will write to tell you about any changes If you do not accept any of the changes we make you canend your membership and we will treat the changes as not having been made if you end yourmembership within 30 days of the date on which the changes take effect or within 30 days of us tellingyou about the changes whichever is later
Your right to cancelYou can cancel the contract in relation to all insured persons or only in relation to one or moredependants within 30 days of receiving the full terms and conditions of your policy or from thestartrenewal date of your policy whichever is later Please note that you cannot backdate thecancellation of your membership
Should you wish to cancel please complete the ldquoRight to change your mindrdquo form which was included inyour welcomerenewal pack This form can be sent to us via email
underwritingallianzworldwidecarecom
Alternatively you can post this form to the Client Services Team using the address provided at the backof this guide
If you cancel your contract within this 30 day period you will be entitled to a full refund of the cancelledmember(s) premiums paid for the new Insurance Year provided that no claims have been made If youchoose not to cancel (or amend) your policy within this 30 day period the insurance contract will bebinding on both parties and the full premium owing for the selected Insurance Year will be due forpayment according to the payment frequency selected by you
Reasons your membership would endPlease remember that your membership (and that of all the other people listed on the InsuranceCertificate) will end
4140
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Fraud7
Incorrect disclosurenon-disclosure of any material facts by you or your dependants which maya)affect our assessment of the risk including but not limited to those material facts declared on therelevant application form will render the contract void from the commencement date unless weconfirm otherwise in writing Conditions arising between completing the relevant application formand the start date of the policy will be deemed to be pre-existing and will not be covered if notdisclosed If the applicant is not sure whether something is material the applicant is obliged toinform us If the contract is rendered void due to incorrect disclosure or non-disclosure of any materialfacts we will refund the premium amount(s) paid to date minus the cost of any medical claimsalready paid If the cost of claims exceeds the balance of the premium we will seek reimbursementof this amount from the principal member
If a claim is in any respect false fraudulent intentionally exaggerated or if fraudulentb)meansdevices have been used by you or your dependants or anyone acting on your or their behalfto obtain benefit under this policy we will not pay any benefits for that claim The amount of anyclaim settlement made to you before the fraudulent act or omission was discovered will becomeimmediately due and owing to us If the contract is rendered void due to false fraudulentintentionally exaggerated claims or if fraudulent meansdevices have been used premium will notbe refunded in part or in whole and any pending claims settlements will be forfeited In the event offraudulent claims the contract will be cancelled from the date of our discovery of the fraudulentevent
Cancellation We will cancel the policy where you have not paid the full premium due and owing We8shall notify you of this cancellation and the contract shall be deemed cancelled from the date thatthe premium payment became due and payable However if the premium is paid within 30 daysafter the due date the insurance cover will be reinstated and we will cover any claims whichoccurred during the period of delay If the outstanding premium is paid after the 30-day limit youmust complete a Confirmation of Health Status Form before your policy can be reinstated subject tounderwriting
Making contact with dependants In order to administer your policy in accordance with the insurance9contract there may be circumstances when we will need to request further information If we need tomake contact in relation to a dependant on a policy (eg when we need to collect an email addressfor an adult dependant) the policyholder acting for and on behalf of the dependant may becontacted by us and asked to provide the relevant information provided that these are non-sensitivemedical information relating to a dependant Similarly any non-medical information in relation to aperson covered by the insurance policy for the purposes of administering claims may be sent directlyto the policyholder
Use of Medi24 Please note that the Medi24 and its health-related information and resources are not10intended to be a substitute for professional medical advice or for the care that patients receive fromtheir doctors It is not intended to be used for medical diagnosis or treatment and information shouldnot be relied upon for that purpose Always seek the advice of your doctor before beginning any newtreatment or if you have any questions regarding a medical condition You understand and agreethat we are not responsible or liable for any claim loss or damage directly or indirectly resulting fromyour use of this advice line or the information or the resources provided through this service Calls tothe Medi24 will be recorded and may be monitored for training quality and regulatory purposes
Applicable law1
If you live in the European Economic Area Your policy is governed by the laws and courts of yourbullcountry of residence unless otherwise required by lawIf you live outside of the European Economic Area Your policy is governed by the laws and courts ofbullIreland unless otherwise required by law
Economic sanctions This policy does not provide any cover or benefit for any business or activity to2the extent that either the cover benefit the underlying business or activity would violate anyapplicable sanction law or regulations of the United Nations the European Union or any otherapplicable economic or trade sanction law or regulations
Liability Our liability to the insured person is limited to the amounts indicated in the Table of Benefits3and any subsequent policy endorsements In no event will the amount of reimbursement whetherunder this policy public medical scheme or any other insurance exceed the amount of the invoice
Other parties No other person (except an appointed representative) is allowed to make or confirm4any changes to your membership on your behalf or decide not to enforce any of our rights Nochange to your membership will be valid unless it is confirmed in writing by us
Third party liability If you or any of your dependants are eligible to claim benefits under a public5scheme or any other insurance policy or from any other third party which pertains to a claimsubmitted to us we reserve the right to decline to pay benefits You must inform us and provide allnecessary information if and when you are entitled to claim benefits under a public scheme or anyother insurance policy or from any other third party You and the third party may not agree any finalsettlement or waive our right to recover outlays without our prior written agreement Otherwise weare entitled to recover the amounts paid from you and to cancel the policy We have full rights ofsubrogation and may institute proceedings in your name but at our expense to recover for ourbenefit the amount of any payment made or due under a public scheme or any other insurancepolicy or made by or due from any other third party We will not make any contribution wholly or inpart to any third-party insurer if any claim under this insurance is also covered wholly or in partunder any other insurance except in respect of any excess beyond the amount which would havebeen covered under such other insurance had this insurance not been effected
Force majeure We shall not be liable for any failure or delay in the performance of our obligations6under the terms of this policy caused by or resulting from force majeure which shall include but isnot limited to events which are unpredictable unforeseeable or unavoidable such as extremelysevere weather floods landslides earthquakes storms lightning fire subsidence epidemics acts ofterrorism outbreaks of military hostilities (whether or not war is declared) riots explosions strikes orother labour unrest civil disturbances sabotage expropriation by governmental authorities and anyother act or event that is outside of our reasonable control
ADDITIONAL TERMSThe following are important additional terms that apply to your policy with us
4342
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Our Data Protection Notice explains how we protect your privacy This is an important notice whichoutlines how we will process your personal data and should be read by you before the submission of anypersonal data to us To read our Data Protection Notice visit
wwwallianzworldwidecarecomenprivacy
Alternatively you can contact us on the phone to request a paper copy of our full Data ProtectionNotice
+353 1 630 1301
If you have any queries about how we use your personal data you can always contact us by email
APEU1DataPrivacyOfficerallianzcom
DATA PROTECTION AND RELEASE OFMEDICAL RECORDS
4544
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
other Party has failed to participate in the mediation (provided that the right to issue proceedings isnot prejudiced by a delay) The mediation will take place in the country of the Applicable Law TheMediation Agreement referred to in the Model Procedure shall be governed by and construed andtake effect in accordance with the laws of the country of the Applicable Law The Courts of thecountry of the Applicable Law shall have exclusive jurisdiction to settle any claim dispute or matterof difference which may arise out of or in connection with the mediation
Any dispute controversy or claim which isc)
Arising out of or relating to this Agreement (or the breach termination or invalidity thereof) with a-value in excess of euro500000 or
Referred to mediation pursuant to Clause ldquobrdquo but not voluntarily settled by mediation within three-months of the ADR Notice date
shall be determined exclusively by the Courts of the country of the Applicable Law and the partieswill submit to the exclusive jurisdiction of those courts Any proceedings brought pursuant to thisClause ldquocrdquo shall be issued within nine calendar months of the expiration date of the aforementionedthree month period
Legal actionYou shall not institute any legal proceedings to recover any amount under the policy until at least 60days after the claim has been submitted to us and not more than two years from the date of thissubmission unless otherwise required by mandatory legal regulations
Making a complaintOur Helpline is always the first number to call if you have any comments or complaints If we have notbeen able to resolve the problem on the telephone please email or write to us at
+353 1 630 1301
clientservicesallianzworldwidecarecom
Customer Advocacy Team Allianz Care 15 Joyce Way Park West Business Campus Nangor RoadDublin 12 Ireland
We will handle your complaint according to our internal complaint management procedure detailed at
wwwallianzworldwidecarecomcomplaints-procedure
You can also contact our Helpline to obtain a copy of this procedure
MediationAny differences in respect of medical opinion in connection with the results of an accident or medicala)condition must be notified to us within nine weeks of the decision Such differences will be settledbetween two medical experts appointed by you and us in writing
If differences cannot be resolved in accordance with Clause ldquoardquo above the parties shall attempt tob)settle by mediation in accordance with the Centre for Effective Dispute Resolution (CEDR) ModelMediation Procedure any dispute controversy or claim arising out of or relating to this Agreement orthe breach termination or invalidity thereof where the value is euro500000 or less and which cannot besettled amicably between the parties The parties shall endeavour to agree on the appointment ofan agreed Mediator Should the parties fail to agree the appointment of an agreed Mediator within14 days either party upon written notice to the other party may apply to CEDR for the appointmentof a Mediator
To initiate the mediation a party must give notice in writing (Alternative Dispute Resolution (ADR)Notice) to the other Party to the dispute requesting mediation A copy of the request should be sentto CEDR The mediation will start no later than 14 days after the date of the ADR notice No Partymay commence court proceedingsarbitration relating to any dispute pursuant to this Clause ldquobrdquo untilit has attempted to settle the dispute by mediation and either the mediation has terminated or the
COMPLAINTS AND DISPUTERESOLUTION PROCEDURE
4746
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
AAccident is a sudden unexpected event which causes injuryand is due to a cause external to the insured person The causeand symptoms of the injury must be medically and objectivelydefinable allow for a diagnosis and require therapy
Accidental death benefit refers to an amount shown in theTable of Benefits which shall become payable if an insuredperson (aged 18 to 70) passes away during the period ofinsurance as a result of an accident (including industrial injury)
Accommodation costs for one parent staying in hospitalwith an insured child refers to the hospital accommodationcosts of one parent for the duration of the insured childrsquosadmission to hospital for eligible treatment If a suitable bed isnot available in the hospital we will contribute the equivalentof a three star hotel daily room rate towards any hotel costsincurred We will not however cover sundry expensesincluding but not limited to meals telephone calls ornewspapers Please check your Table of Benefits to confirmwhether an age limit applies with regard to your child
Acute refers to sudden onset
CChronic condition is defined as a sickness illness disease orinjury that either lasts longer than six months or requiresmedical attention (check-up or treatment) at least once a yearIt also has one or more of the following characteristics
Is recurrent in naturebullIs without a known generally recognised curebullIs not generally deemed to respond well to treatmentbullRequires palliative treatmentbullRequires prolonged supervision or monitoringbullLeads to permanent disabilitybull
Please refer to the ldquoNotesrdquo section of your Table of Benefits toconfirm whether chronic conditions are covered
Complementary treatment refers to therapeutic anddiagnostic treatment that exists outside the institutions whereconventional Western medicine is taught Please refer to yourTable of Benefits to confirm whether any of the followingcomplementary treatment methods are covered chiropractictreatment osteopathy Chinese herbal medicine homeopathyacupuncture and podiatry as practiced by approvedtherapists
Complications of childbirth refer only to the followingconditions that arise during childbirth and that require a
recognised obstetric procedure post-partum haemorrhageand retained placental membrane Complications of childbirthare only payable where your cover also includes a routinematernity benefit Where your cover includes a routinematernity benefit complications of childbirth shall also refer tomedically necessary caesarean sections
Complications of pregnancy relate to the health of themother Only the following complications that arise during thepre-natal stages of pregnancy are covered ectopic pregnancygestational diabetes pre-eclampsia miscarriage threatenedmiscarriage stillbirth and hydatidiform mole
Co-payment is the percentage of the costs which the insuredperson must pay These apply per person per Insurance Yearunless indicated otherwise in the Table of Benefits Some plansmay include a maximum co-payment per insured person perInsurance Year and if so the amount will be capped at theamount stated in your Table of Benefits Co-payments mayapply individually to the Core Out-patient Maternity Dentalor Repatriation Plans or to a combination of these plans
DDay-care treatment is planned treatment received in ahospital or day-care facility during the day including ahospital room and nursing that does not medically require thepatient to stay overnight and where a discharge note is issued
Deductible is that part of the cost which remains payable byyou and which has to be deducted from the reimbursable sumWhere applied deductibles are payable per person perInsurance Year unless indicated otherwise in the Table ofBenefits Deductibles may apply individually to the Core Out-patient Maternity Dental or Repatriation Plans or to acombination of these plans
Dental prescription drugs are those prescribed by a dentistfor the treatment of a dental inflammation or infection Theprescription drugs must be proven to be effective for thecondition and recognised by the pharmaceutical regulator in agiven country This does not include mouthwashes fluorideproducts antiseptic gels and toothpastes
Dental prostheses include crowns inlays onlays adhesivereconstructionsrestorations bridges dentures and implants aswell as all necessary and ancillary treatment required
Dental surgery includes the surgical extraction of teeth aswell as other tooth related surgical procedures such asapicoectomy and dental prescription drugs All investigativeprocedures necessary to establish the need for dental surgerysuch as laboratory tests X-rays CT scans and MRI(s) areincluded under this benefit Dental surgery does not cover anysurgical treatment that is related to dental implants
DEFINITIONSThe following definitions apply to the benefits included in our range of HealthcarePlans and to some other commonly used terms The benefits you are covered for arelisted in your Table of Benefits If any unique benefits apply to your plan(s) thedefinition will appear in the ldquoNotesrdquo section at the end of your Table of BenefitsWherever the following wordsphrases appear in your policy documents they willalways be defined as follows
4948
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Annual pap smear-Mammogram (every two years for women aged 45+ or-earlier where a family history exists)Prostate screening (yearly for men aged 50+ or earlier-where a family history exists)Colonoscopy (every five years for members aged 50+ or-40+ where a family history exists)Annual faecal occult blood test-
Bone densitometry (every five years for women aged 50+)bullWell child test (for children up to the age of six years up tobulla maximum of 15 visits per lifetime)BRCA1 and BRCA2 genetic test (where a direct familybullhistory exists and where included in your Table of Benefits)
Home country is a country for which the insured person holdsa current passport or is their principal country of residence
Hospital is any establishment which is licensed as a medical orsurgical hospital in the country where it operates and wherethe patient is permanently supervised by a medicalpractitioner The following establishments are not consideredhospitals rest and nursing homes spas cure-centres andhealth resorts
Hospital accommodation refers to standard private or semi-private accommodation as indicated in the Table of BenefitsDeluxe executive rooms and suites are not covered Pleasenote that the hospital accommodation benefit only applieswhere no other benefit included in your plan covers therequired in-patient treatment In this case hospitalaccommodation costs will be covered under the more specificin-patient benefit up to the benefit limit stated Psychiatry andpsychotherapy organ transplant oncology routine maternitypalliative care and long term care are examples of in-patientbenefits which include cover for hospital accommodationcosts up to the benefit limit stated where included in yourplan
IInfertility treatment refers to treatment for the insured personincluding all invasive investigative procedures necessary toestablish the cause for infertility such as hysterosalpingogramlaparoscopy or hysteroscopy If your Table of Benefits does nothave a specific benefit for infertility treatment cover is limitedto non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan (if selected) and this doesnot apply to members of the Channel Islands Plan for whominvestigation into infertility is excluded If however there is aspecific benefit for infertility treatment the cost for infertilitytreatment will be covered for the insured member whoreceives the treatment up to the limit indicated in the Table ofBenefits Any costs exceeding the benefit limit cannot beclaimed under the cover of the spousepartner (if included inthe policy) In the case of InVitro Fertilisation (IVF) cover islimited to the amount specified in the Table of Benefits Pleasenote that for multiple birth babies born as a result of medically
assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
In-patient cash benefit is payable when treatment andaccommodation for a medical condition that would otherwisebe covered under the insuredrsquos plan is provided in a hospitalwhere no charges are billed Cover is limited to the amountand maximum number of nights specified in the Table ofBenefits and is payable upon discharge from hospital
In-patient treatment refers to treatment received in a hospitalwhere an overnight stay is medically necessary
Insurance Certificate is a document outlining the details ofyour cover and is issued by us It confirms that an insurancerelationship exists between you and us
Insurance Year applies from the effective date of theinsurance as indicated on the Insurance Certificate and endsexactly one year later
Insured person is you and your dependants as stated on yourInsurance Certificate
LLaser eye treatment refers to the surgical improvement of therefractive quality of the cornea using laser technologyincluding necessary pre-operative investigations
Local ambulance is ambulance transport required for anemergency or out of medical necessity to the nearestavailable and appropriate hospital or licensed medical facility
Long term care refers to care over an extended period of timeafter the acute treatment has been completed usually for achronic condition or disability requiring periodic intermittentor continuous care Long term care can be provided at homein the community in a hospital or in a nursing home
MMaternitypaternity cash benefit applies to the ChannelIslands Plan only and if provided under your plan an amountwill be paid to each parent insured with us following the birthof a child dependant This benefit is only payable wheretreatment is received free of charge and the amount payablewill be indicated in your Table of Benefits To claim thematernitypaternity cash benefit please send us a copy of thebabyrsquos birth certificate within three months of the birth To beeligible for this benefit the motherfather must be coveredunder our Healthcare Plan for the Channel Islands for aminimum of 10 continuous months before the baby is born
Dental treatment includes an annual check up simple fillingsrelated to cavities or decay root canal treatment and dentalprescription drugs
Dependant is your spouse or partner (including same sexpartner) andor unmarried children (including any stepfostered or adopted children) financially dependant on thepolicyholder up to the day before their 18th birthday or up tothe day before their 24th birthday if in full time education andalso named in your Insurance Certificate as one of yourdependants
Diagnostic tests are investigations such as x-rays or bloodtests undertaken in order to determine the cause of thepresented symptoms
Dietician fees relate to charges for dietary or nutritionaladvice provided by a health professional who is registered andqualified to practice in the country where the treatment isreceived If included in your plan cover is only provided inrespect of eligible diagnosed medical conditions
Direct family history exists where a parent grandparentsibling or child has been previously diagnosed with themedical condition in question
EEmergency constitutes the onset of a sudden and unforeseenmedical condition that requires urgent medical assistanceOnly treatment commencing within 24 hours of the emergencyevent will be covered
Emergency in-patient dental treatment refers to acuteemergency dental treatment due to a serious accidentrequiring hospitalisation The treatment must be receivedwithin 24 hours of the emergency event Please note thatcover under this benefit does not extend to follow-up dentaltreatment dental surgery dental prostheses orthodontics orperiodontics If cover is provided for these benefits it will belisted separately in the Table of Benefits
Emergency out-patient dental treatment is treatmentreceived in a dental surgeryhospital emergency room for theimmediate relief of dental pain caused by an accident or aninjury to a sound natural tooth including pulpotomy orpulpectomy and the subsequent temporary fillings limited tothree fillings per Insurance Year The treatment must bereceived within 24 hours of the emergency event This does notinclude any form of dental prostheses permanent restorationsor the continuation of root canal treatment If a Dental Planwas selected you will be covered under the terms of this planfor dental treatment in excess of the (Core Plan) emergencyout-patient dental treatment benefit limit
Emergency out-patient treatment is treatment received in acasualty wardemergency room within 24 hours of an accidentor sudden illness where the insured does not out of medical
necessity occupy a hospital bed If an Out-patient Plan wasselected you are covered under the terms of this plan for out-patient treatment in excess of the (Core Plan) emergencyout-patient treatment benefit limit
Emergency treatment outside area of cover is treatment formedical emergencies which occur during business or holidaytrips outside your area of cover Cover is provided up to amaximum period of six weeks per trip within the maximumbenefit amount and includes treatment required in the eventof an accident or the sudden beginning or worsening of asevere illness which presents an immediate threat to yourhealth Treatment by a physician medical practitioner orspecialist must commence within 24 hours of the emergencyevent Cover is not provided for any curative or follow-up non-emergency treatment even if you are deemed unable to travelto a country within your geographical area of cover nor does itcover charges relating to maternity pregnancy childbirth orany complications of pregnancy or childbirth Please advise usif you are moving outside your area of cover for more than sixweeks
Expenses for one person accompanying anevacuatedrepatriated person refer to the cost of one persontravelling with the evacuatedrepatriated person If this cannottake place in the same transportation vehicle transport ateconomy rates will be paid for Following completion oftreatment we will also cover the cost of the return trip ateconomy rates for the accompanying person to return to thecountry from where the evacuationrepatriation originatedCover does not extend to hotel accommodation or otherrelated expenses
FFamily history exists where a parent grandparent siblingchild aunt or uncle has been previously diagnosed with themedical condition in question
HHealth and wellbeing checks including screening for theearly detection of illness or disease are health checks testsand examination performed at an appropriate age intervalthat are undertaken without any clinical symptoms beingpresent Checks are limited to
Physical examinationbullBlood tests (full blood count biochemistry lipid profilebullthyroid function test liver function test kidney function test)Cardiovascular examination (physical examinationbullelectrocardiogram blood pressure)Neurological examination (physical examination)bullCancer screeningbull
5150
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
diagnostic procedures such as routine swabs blood typingand hearing tests are not covered Any medically necessaryfollow-up investigations and treatment are covered under thenewbornrsquos own policy Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
Non-prescribed physiotherapy refers to treatment by aregistered physiotherapist where referral by a medicalpractitioner has not been obtained prior to undergoingtreatment Where this benefit applies cover is limited to thenumber of sessions indicated in your Table of BenefitsAdditional sessions required over and above this limit must beprescribed in order for cover to continue these sessions will besubject to the prescribed physiotherapy benefit limitPhysiotherapy (either prescribed or a combination of non-prescribed and prescribed treatment) is initially restricted to 12sessions per condition after which the treatment must bereviewed by the referring medical practitioner Should furthersessions be required a progress report must be submitted tous which indicates the medical necessity for any furthertreatment Physiotherapy does not include therapies such asRolfing Massage Pilates Fango and Milta therapy
Nursing at home or in a convalescent home refers to nursingreceived immediately after or instead of eligible in-patient orday-care treatment We will only pay the benefit listed in theTable of Benefits where the treating doctor decides (and ourMedical Director agrees) that it is medically necessary for theinsured person to stay in a convalescent home or have a nursein attendance at home Cover is not provided for spas curecentres and health resorts or in relation to palliative care orlong term care (see palliative care and long term caredefinitions)
OObesity is diagnosed when a person has a Body Mass Index(BMI) of over 30 (a BMI calculator can be found on ourwebsite wwwallianzworldwidecarecommembers)
Occupational therapy refers to treatment that addresses theindividualrsquos development of fine and gross motor skills sensoryintegration coordination balance and other skills such asdressing eating grooming etc in order to aid daily living andimprove interactions with the physical and social world Aprogress report is required after 20 sessions
Oculomotor therapy is a specific type of occupational therapythat aims to synchronise eye movement in cases where there isa lack of coordination between the muscles of the eye
Oncology refers to specialist fees diagnostic testsradiotherapy chemotherapy and hospital charges incurred inrelation to the planning and carrying out of treatment for
cancer from the point of diagnosis We will also cover the costof an external prosthetic device for cosmetic purpose forexample a wig in the event of hair loss or a prosthetic bra as aresult of cancer treatment
Oral and maxillofacial surgical procedures refer to surgicaltreatment performed by an oral and maxillofacial surgeon ina hospital as a treatment for oral pathologytemporomandibular joint disorders facial bone fracturescongenital jaw deformities salivary gland diseases andtumours Please note that surgical removal of impacted teeththe surgical removal of cysts and orthognathic surgeries forthe correction of malocclusion even if performed by an oraland maxillofacial surgeon are not covered unless a DentalPlan has also been selected
Organ transplant is the surgical procedure in performing thefollowing organ andor tissue transplants heart heartvalveheartlung liver pancreas pancreaskidney kidney bonemarrow parathyroid muscularskeletal and corneatransplants Expenses incurred in the acquisition of organs arenot reimbursable
Orthodontics is the use of devices to correct malocclusion andrestore the teeth to proper alignment and functionOrthodontic treatment is covered only in cases of medicalnecessity and for this reason at the point of claiming we willask you to submit supporting information to determine thatyour treatment is medically necessary and therefore eligiblefor cover The supporting information required (depending onyour case) may include but is not limited to the followingdocuments
Medical report issued by the specialist stating thebulldiagnosis (type of malocclusion) and a description of thepatientrsquos symptoms caused by the orthodontic problemTreatment plan indicating the estimated treatmentbullduration estimated cost and typematerial of theappliance usedThe payment arrangement agreed with the medicalbullprovider Proof that payment has been made in respect of thebullorthodontic treatment Photographs of both jaws clearly showing dentition prior tobulltreatmentClinical photographs of the jaws in central occlusion frombullfrontal and lateral viewsOrthopantomogram (panoramic x-ray) bullProfile x-ray (cephalometric x-ray)bull
Please note that we will only cover orthodontic treatmentwhere the standard metallic braces andor standardremovable appliances are used Cosmetic appliances such aslingual braces and invisible aligners are covered up to the costof metallic braces subject to the ldquoOrthodontic treatment anddental prosthesesrdquo benefit limit
Orthomolecular treatment refers to treatment which aims torestore the optimum ecological environment for the bodyrsquoscells by correcting deficiencies on the molecular level based
Medical evacuation applies where the necessary treatmentfor which the insured person is covered is not available locallyor if adequately screened blood is unavailable in the event ofan emergency We will evacuate the insured person to thenearest appropriate medical centre (which may or may not belocated in the insured personrsquos home country) by ambulancehelicopter or aeroplane The medical evacuation which shouldbe requested by your physician will be carried out in the mosteconomical way having regard to the medical conditionFollowing completion of treatment we will also cover the costof the return trip at economy rates for the evacuated memberto return to hisher principal country of residence
If medical necessity prevents the insured person fromundertaking the evacuation or transportation followingdischarge from an in-patient episode of care we will coverthe reasonable cost of hotel accommodation up to amaximum of seven days comprising of a private room with en-suite facilities We do not cover costs for hotel suites four orfive star hotel accommodation or hotel accommodation for anaccompanying person
Where an insured person has been evacuated to the nearestappropriate medical centre for ongoing treatment we willagree to cover the reasonable cost of hotel accommodationcomprising of a private room with en-suite facilities The cost ofsuch accommodation must be more economical thansuccessive transportation costs tofrom the nearestappropriate medical centre and the principal country ofresidence Hotel accommodation for an accompanying personis not covered
Where adequately screened blood is not available locally wewill where appropriate endeavour to locate and transportscreened blood and sterile transfusion equipment where thisis advised by the treating physician We will also endeavour todo this when our medical experts so advise Neither we nor ouragents accept any liability in the event that such endeavoursare unsuccessful or in the event that contaminated blood orequipment is used by the treating authority
Members must contact us at the first indication that anevacuation is required From this point onwards we willorganise and coordinate all stages of the evacuation until theinsured person is safely received into care at their destinationIn the event that evacuation services are not organised by uswe reserve the right to decline all costs incurred
Medical necessity refers to medical treatment services orsupplies that are determined to be medically necessary andappropriate They must be
Essential to identify or treat a patientrsquos condition illness ora)injuryConsistent with the patientrsquos symptoms diagnosis orb)treatment of the underlying conditionIn accordance with generally accepted medical practicec)and professional standards of medical care in the medicalcommunity at the time This does not apply tocomplementary treatment methods if they form part ofyour cover
Required for reasons other than the comfort ord)convenience of the patient or hisher physicianProven and demonstrated to have medical value Thise)does not apply to complementary treatment methods ifthey form part of your coverConsidered to be the most appropriate type and level off)service or supplyProvided at an appropriate facility in an appropriateg)setting and at an appropriate level of care for thetreatment of a patientrsquos medical conditionProvided only for an appropriate duration of timeh)
In this definition the term ldquoappropriaterdquo means taking patientsafety and cost effectiveness into consideration Whenspecifically applied to in-patient treatment medicallynecessary also means that diagnosis cannot be made ortreatment cannot be safely and effectively provided on an out-patient basis
Medical practitioner is a physician who is licensed to practicemedicine under the law of the country in which treatment isgiven and where heshe is practising within the limits of hisherlicence
Medical practitioner fees refer to non-surgical treatmentperformed or administered by a medical practitioner
Medical repatriation is an optional level of cover and whereprovided will be shown in the Table of Benefits This benefitmeans that if the necessary treatment for which you arecovered is not available locally you can choose to bemedically evacuated to your home country for treatmentinstead of to the nearest appropriate medical centre This onlyapplies when your home country is located within yourgeographical area of cover Following completion oftreatment we will also cover the cost of the return trip ateconomy rates to your principal country of residence Thereturn journey must be made within one month aftertreatment has been completed
Members must contact us at the first indication thatrepatriation is required From this point onwards we willorganise and coordinate all stages of the repatriation until theinsured person is safely received into care at their destinationIn the event that repatriation services are not organised by uswe reserve the right to decline all costs incurred
Midwife fees refer to fees charged by a midwife or birthassistant who according to the law of the country in whichtreatment is given has fulfilled the necessary training andpassed the necessary state examinations
NNewborn care includes customary examinations required toassess the integrity and basic function of the childrsquos organsand skeletal structures These essential examinations arecarried out immediately following birth Further preventive
5352
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Genetic testing has established the presence of abullhereditary cancer syndrome
Preventive treatment refers to treatment that is undertakenwithout any clinical symptoms being present at the time oftreatment An example of such treatment is the removal of apre-cancerous growth
Principal country of residence is the country where you andyour dependants (if applicable) live for more than six monthsof the year
Psychiatry and psychotherapy is the treatment of mentaldisorders carried out by a psychiatrist or clinical psychologistThe condition must be clinically significant and not related tobereavement relationship or academic problemsacculturation difficulties or work pressure All day-care or in-patient admissions must include prescription medicationrelated to the condition Psychotherapy treatment (on an in-patient or out-patient basis) is only covered where you or yourdependants are initially diagnosed by a psychiatrist andreferred to a clinical psychologist for further treatment Inaddition out-patient psychotherapy treatment (wherecovered) is initially restricted to 10 sessions per condition afterwhich treatment must be reviewed by the referring psychiatristShould further sessions be required a progress report must besubmitted to us which indicates the medical necessity for anyfurther treatment
RRehabilitation is treatment in the form of a combination oftherapies such as physical occupational and speech therapyand is aimed at the restoration of a normal form andorfunction after an acute illness injury or surgery Therehabilitation benefit is only payable for treatment that startswithin 14 days of discharge after the acute medical andorsurgical treatment ceases and where it takes place in alicensed rehabilitation facility
Repatriation of mortal remains is the transportation of theinsured personrsquos mortal remains from the principal country ofresidence to the country of burial Covered expenses includebut are not limited to expenses for embalming a containerlegally appropriate for transportation shipping costs and thenecessary government authorisations Cremation costs willonly be covered in the event that this is required for legalpurposes Costs incurred by any accompanying persons arenot covered unless this is listed as a specific benefit in yourTable of Benefits
Routine maternity refers to any medically necessary costsincurred during pregnancy and childbirth including hospitalcharges specialist fees the motherrsquos pre- and post-natal caremidwife fees (during labour only) as well as newborn careCosts related to complications of pregnancy or complicationsof childbirth are not payable under routine maternity Inaddition any non-medically necessary caesarean sections will
be covered up to the cost of a routine delivery in the samehospital subject to any benefit limit in place If the homedelivery benefit is included in your plan a lump sum up to theamount specified in the Table of Benefits will be paid in theevent of a home delivery Please note that for multiple birthbabies born as a result of medically assisted reproduction in-patient treatment is limited topound24900euro30000US$40500CHF39000 per child for the firstthree months following birth Out-patient treatment is paidwithin the terms of the Out-patient Plan
SSpecialist is a qualified and licensed medical physicianpossessing the necessary additional qualifications andexpertise to practice as a recognised specialist of diagnostictechniques treatment and prevention in a particular field ofmedicine This benefit does not include cover for psychiatrist orpsychologist fees Where covered a separate benefit forpsychiatry and psychotherapy will appear in the Table ofBenefits
Specialist fees refer to non-surgical treatment performed oradministered by a specialist
Speech therapy refers to treatment carried out by a qualifiedspeech therapist to treat diagnosed physical impairmentsincluding but not limited to nasal obstruction neurogenicimpairment (eg lingual paresis brain injury) or articulationdisorders involving the oral structure (eg cleft palate)
Surgical appliances and materials are those which arerequired for the surgical procedure These include artificialbody parts or devices such as joint replacement materialsbone screws and plates valve replacement appliancesendovascular stents implantable defibrillators andpacemakers
TTherapist is a chiropractor osteopath Chinese herbalisthomeopath acupuncturist physiotherapist speech therapistoccupational therapist or oculomotor therapist who isqualified and licensed under the law of the country in whichtreatment is being given
Travel costs is a benefit covered under the Channel IslandsPlan only We will pay up to the amount specified in your Tableof Benefits for each return journey if you need private hospitalday-care post-operative out-patient consultations or in-patient treatment for which you are covered under your planand your doctor has confirmed to us in writing that it ismedically necessary for you to travel to another ChannelIsland to the UK or to France to receive such treatment Youwill need to obtain written confirmation from the Department
on individual biochemistry It uses natural substances such asvitamins minerals enzymes hormones etc
Out-patient surgery is a surgical procedure performed in asurgery hospital day-care facility or out-patient departmentthat does not require the patient to stay overnight out ofmedical necessity
Out-patient treatment refers to treatment provided in thepractice or surgery of a medical practitioner therapist orspecialist that does not require the patient to be admitted tohospital
PPalliative care refers to ongoing treatment aimed atalleviating the physicalpsychological suffering associatedwith progressive incurable illness and maintaining quality oflife It includes in-patient day-care or out-patient treatmentfollowing the diagnosis that the condition is terminal andtreatment can no longer be expected to cure the conditionWe will also pay for physical care psychological care as wellas hospital or hospice accommodation nursing care andprescription drugs
Periodontics refers to dental treatment related to gumdisease
Podiatry Refers to medically necessary treatment carried outby a State Registered podiatrist
Post-natal care refers to the routine post-partum medical carereceived by the mother up to six weeks after delivery
Pre-existing conditions are medical conditions or any relatedconditions for which one or more symptoms have beendisplayed at some point during your lifetime irrespective ofwhether any medical treatment or advice was sought Anysuch condition or related condition about which you or yourdependants could reasonably have been assumed to haveknown will be deemed to be pre-existing Pre-existingconditions which have not been declared on the relevantapplication form are not covered Plus conditions arisingbetween completing the relevant application form and thestart date of the policy will equally be deemed to be pre-existing Such pre-existing conditions will also be subject tomedical underwriting and if not disclosed they will not becovered Please refer to the ldquoNotesrdquo section of your Table ofBenefits to confirm if pre-existing conditions are covered
Pregnancy refers to the period of time from the date of firstdiagnosis until delivery
Pre-natal care includes common screening and follow up testsas required during a pregnancy For women aged 35 and overthis includes TripleBartrsquos Quadruple and Spina Bifida testsamniocentesis and DNA-analysis if directly linked to aneligible amniocentesis
Prescribed drugs refers to products prescribed by a physicianfor the treatment of a confirmed diagnosis or medicalcondition or to compensate vital bodily substances includingbut not limited to insulin hypodermic needles or syringes Theprescribed drugs must be clinically proven to be effective forthe condition and recognised by the pharmaceutical regulatorin a given country Prescribed drugs do not legally have to beprescribed by a physician in order to be purchased in thecountry where the insured person is located however aprescription must be obtained for these costs to be consideredeligible
Prescribed glasses and contact lenses including eyeexamination refers to cover for a routine eye examinationcarried out by an optometrist or ophthalmologist (one perInsurance Year) and for lenses or glasses to correct vision
Prescribed medical aids refers to any device which isprescribed and medically necessary to enable the insuredperson to function to a capacity consistent with everyday livingwhere reasonably possible This includes
Biochemical aids such as insulin pumps glucose metersbulland peritoneal dialysis machinesMotion aids such as crutches wheelchairs orthopaedicbullsupportsbraces artificial limbs and prosthesesHearing and speaking aids such as an electronic larynxbullMedically graduated compression stockings bullLong term wound aids such as dressings and stomabullsupplies
Costs for medical aids that form part of palliative care or longterm care (see palliative care and long term care definitions)are not covered
Prescribed physiotherapy refers to treatment by a registeredphysiotherapist following referral by a medical practitionerPhysiotherapy is initially restricted to 12 sessions per conditionafter which the treatment must be reviewed by the referringmedical practitioner Should further sessions be required anew progress report must be submitted to us after every set of12 sessions which indicates the medical necessity for anyfurther treatment Physiotherapy does not include therapiessuch as Rolfing Massage Pilates Fango and Milta therapy
Prescription drugs refers to products including but notlimited to insulin hypodermic needles or syringes whichrequire a prescription for the treatment of a confirmeddiagnosis or medical condition or to compensate vital bodilysubstances The prescription drugs must be clinically proven tobe effective for the condition and recognised by thepharmaceutical regulator in a given country
Preventative surgery refers to prophylactic mastectomy orprophylactic oophorectomy We will pay for preventativesurgery when an insured person
Has a direct family history of a disease which is part of abullhereditary cancer syndrome for example breast cancer orovarian cancer and
5554
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
of Health that you are not entitled to a travelling allowancegrant in respect of travel and escort costs We will only pay forthe following travel costs under this benefit
Standard rate air fares from one Channel Island to anotherbullChannel Island to the UK or to FranceStandard rate train underground and bus faresbullA maximum of pound25euro30 per taxi tripbullTravel costs for one parent to accompany a child under 18bullup to the amount specified in your Table of BenefitsIf medically necessary we may also pay a contribution ofbullup to pound125euro150 per trip towards the cost of nursing carerequired during the journey
Travel costs of insured family members in the event of anevacuationrepatriation refer to the reasonabletransportation costs of all insured family members of theevacuated or repatriated person including but not limited tominors who might otherwise be left unattended If this cannottake place in the same transportation vehicle round triptransport at economy rates will be paid for In the event of aninsured personrsquos repatriation the reasonable transportationcosts of insured family members will only be covered if therelevant Repatriation Plan benefit forms part of your coverCover does not extend to hotel accommodation or otherrelated expenses
Travel costs of insured family members in the event of therepatriation of mortal remains refer to reasonabletransportation costs of any insured family members who hadbeen residing abroad with the deceased insured person toreturn to the home countrychosen country of burial of thedeceased Cover does not extend to hotel accommodation orother related expenses
Travel costs of insured members to be with a family memberwho is at peril of death or who has died refer to thereasonable transportation costs (up to the amount specified inyour Table of Benefits) so that insured family members cantravel to the location of a first degree relative who is at peril ofdeath or who has died A first degree relative is a spouseparent brother sister or child including adopted childrenfostered children or step children Claims are to beaccompanied by a death certificate or doctorrsquos certificatesupporting the reason for travel as well as copies of the flighttickets and cover will be limited to one claim per lifetime ofthe policy Cover does not extend to hotel accommodation orother related expenses
Treatment refers to a medical procedure needed to cure orrelieve illness or injury
VVaccinations refer to all basic immunisations and boosterinjections required under regulation of the country in whichtreatment is being given any medically necessary travelvaccinations and malaria prophylaxis The cost of consultation
for administering the vaccine as well as the cost of the drug iscovered
WWaiting period is a period of time commencing on your policystart date (or effective date if you are a dependant) duringwhich you are not entitled to cover for particular benefits YourTable of Benefits will indicate which benefits are subject towaiting periods
WeOurUs Is Allianz Care
YYouYour refers to the eligible individual stated on theInsurance Certificate
5756
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
a) The following exclusions apply to all our plans unless stated otherwise
Acquisition of an organExpenses for the acquisition of an organ including but not limited to donor search typingharvesting transport and administration costs
Behavioural and personality disordersTreatment for conditions such as conduct disorder attention deficit hyperactivity disorder autismspectrum disorder oppositional defiant disorder antisocial behaviour obsessive-compulsivedisorder phobic disorders attachment disorders adjustment disorders eating disorderspersonality disorders or treatments that encourage positive social-emotional relationships suchas family therapy unless indicated otherwise in the Table of Benefits
Chemical contamination and radioactivityTreatment for any medical conditions arising directly or indirectly from chemical contaminationradioactivity or any nuclear material whatsoever including the combustion of nuclear fuel
Complementary treatmentComplementary treatment with the exception of those treatments indicated in the Table ofBenefits
Complications caused by conditions not covered under your planExpenses incurred because of complications directly caused by an illness injury or treatment forwhich cover is excluded or limited under your plan
Consultations performed by you or a family memberConsultations performed as well as any drugs or treatments prescribed by you your spouseparents or children
Dental veneersDental veneers and related procedures unless medically necessary
Developmental delay Developmental delay unless a child has not attained developmental milestones expected for achild of that age in cognitive or physical development We do not cover conditions in which achild is slightly or temporarily lagging in development The developmental delay must have beenquantitatively measured by qualified personnel and documented as a 12 month delay incognitive andor physical development
Drug addiction or alcoholism Care andor treatment of drug addiction or alcoholism (including detoxification programmes andtreatments related to the cessation of smoking) instances of death or the treatment of anycondition that in our reasonable opinion is related to or a direct consequence of alcoholism oraddiction (eg organ failure or dementia)
EXCLUSIONSAlthough we cover most medically necessary treatment expenses incurred for thefollowing treatments medical conditions procedures behaviours or accidents arenot covered under the policy unless confirmed otherwise in the Table of Benefits orin any written policy endorsement
5958
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Medical errorTreatment required as a result of medical error
Obesity treatmentInvestigations into and treatment of obesity
Orthomolecular treatmentFor the orthomolecular treatment please refer to Orthomolecular definition
Participation in war or criminal actsTreatment for any illnesses diseases or injuries as well as instances of death resulting from activeparticipation in war riots civil disturbances terrorism criminal acts illegal acts or acts against anyforeign hostility whether war has been declared or not
Plastic surgeryAny treatment carried out by a plastic surgeon whether or not for medicalpsychologicalpurposes and any cosmetic or aesthetic treatment to enhance your appearance even whenmedically prescribed The only exception is reconstructive surgery necessary to restore function orappearance after a disfiguring accident or as a result of surgery for cancer if the accident orsurgery occurs during your membership
Pre- and post-natal Pre- and post-natal classes
Products sold without prescriptionsProducts that can be purchased without a doctorrsquos prescription except where a specific benefitcovering these costs appears in the Table of Benefits
Sex change Sex change operations and related treatments
Sleep disordersTreatment of sleep disorders including insomnia obstructive sleep apnoea narcolepsy snoringand bruxism
Stays in a cure centreStays in a cure centre bath centre spa health resort and recovery centre even if the stay ismedically prescribed
Sterilisation sexual dysfunction and contraception Investigations into treatment of and complications arising from sterilisation sexual dysfunction(unless this condition is as a result of total prostatectomy following surgery for cancer) andcontraception including the insertion and removal of contraceptive devices and all othercontraceptives even if prescribed for medical reasons The only exception in relation to costs forcontraception is where contraceptives are prescribed by a dermatologist for the treatment ofacne This exclusion extends to include infertility within the Channel Islands Plan
Experimental or unproven treatment or drug therapyAny form of treatment or drug therapy which in our reasonable opinion is experimental orunproven based on generally accepted medical practice
Failure to seek or follow medical advice Treatment required as a result of failure to seek or follow medical advice
Family therapy and counsellingCosts in respect of a family therapist or counsellor for out-patient psychotherapy treatment
Fees for the completion of a Claim Form Medical practitioner fees for the completion of a Claim Form or other administration charges
Genetic testing Genetic testing except
where specific genetic tests are included within your plana)
where DNA tests are directly linked to an eligible amniocentesis ie in the case of women agedb)35 or over
testing for genetic receptor of tumours which is coveredc)
Home visitsHome visits unless they are necessary following the sudden onset of an acute illness whichrenders the insured incapable of visiting their medical practitioner physician or therapist
Infertility treatment Infertility treatment including medically assisted reproduction or any adverse consequencesthereof unless you have a specific benefit for infertility treatment or have selected an Out-patientPlan (whereby you are covered for non-invasive investigations into the cause of infertility withinthe limits of your Out-patient Plan) These exceptions do not apply to members of the ChannelIslands Plan for whom investigation into infertility is excluded
Injuries caused by professional sportsTreatment or diagnostic procedures for injuries arising from an engagement in professional sports
Intentionally caused diseases or self-inflicted injuries Care andor treatment of intentionally caused diseases or self-inflicted injuries including a suicideattempt
Loss of hair and hair replacement Investigations into and treatment of loss of hair and any hair replacement unless the loss of hairis due to cancer treatment
6160
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Expenses for one person accompanying an evacuatedrepatriated personbullHealth and wellbeing checks including screening for the early detection of illness or diseasebullHome deliverybullInfertility treatment bullIn-patient psychiatry and psychotherapy treatmentbullLaser eye treatmentbullMedical repatriationbullOrgan transplantbullOut-patient psychiatry and psychotherapy treatment bullOut-patient treatment bullPrescribed glasses and contact lenses including eye examinationbullPrescribed medical aids bullPreventive treatment bullRehabilitation treatmentbullRoutine maternity and complications of childbirthbullTravel costs of insured family members in the event of an evacuationrepatriationbullTravel costs of insured family members in the event of the repatriation of mortal remainsbullTravel costs of insured members to be with a family member who is at peril of death or who hasbulldied Vaccinationsbull
Accidental death benefitAccidental death benefit in circumstances where the death of an insured person has been causedeither directly or indirectly by
Active participation in war riots civil disturbances terrorism criminal acts illegal acts or actsbullagainst any foreign hostility whether war has been declared or notIntentionally caused diseases or self-inflicted injuries including suicide within one year of thebullenrolment date of the policy Active participation in undergroundunderwater activity such as underground mining or deepbullsea divingAbove water activity (such as oil platforms oil rigs) and aerial activity unless otherwisebullspecifiedChemical or biological contamination radioactivity or any nuclear material contaminationbullincluding the combustion of nuclear fuelPassive war riskbull
Being in a country where the British government has recommended their citizens to leave-(this criteria will apply regardless of the insured personrsquos nationality) and advised against lsquoalltravelrsquo to that location orTravelling to or staying for a period of more than 28 days per stay in a country or an area-where the British government advises ldquoagainst all but essential travelrdquo
The passive war risk exclusion applies regardless of whether the claim arises directly orindirectly as a consequence of war riots civil disturbances terrorism criminal acts illegal actsor acts against any foreign hostility whether war has been declared or notBeing under the influence of drugs or alcoholbullDeath that takes place more than 365 days after the occurrence of the accidentbullDeliberate exposure to danger except in an attempt to save human life bull
Surrogacy Treatment directly related to surrogacy whether you are acting as surrogate or are the intendedparent
Termination of pregnancy Termination of pregnancy except in the event of danger to the life of the pregnant woman
Treatment in the USA Treatment in the USA if we know or suspect that cover was acquired for the purpose of travellingto the USA to receive treatment for a condition when the symptoms of the condition wereapparent to the insured person prior to acquiring cover If any claims have been paid by us inthese circumstances we reserve the right to seek reimbursement from the insured person of anyamounts which have already been paid in claims
Treatment outside the geographical area of cover Treatment outside the geographical area of cover unless for emergencies or authorised by us
TripleBartrsquos Quadruple or Spina Bifida testsTripleBartrsquos Quadruple or Spina Bifida tests except for women aged 35 or over
Tumour marker testing Tumour marker testing unless you have previously been diagnosed with the specific cancer inquestion in which case cover will be provided under the Oncology benefit
Vessel at sea Medical evacuationrepatriation from a vessel at sea to a medical facility on land
Vitamins or minerals Products classified as vitamins or minerals (except during pregnancy or to treat diagnosedclinically significant vitamin deficiency syndromes) and supplements including but not limited tospecial infant formula and cosmetic products even if medically recommended prescribed oracknowledged as having therapeutic effects Costs incurred as a result of nutritional or dietaryconsultations are not covered unless a specific benefit is included within your Table of BenefitsFor members of the Channel Islands Plan this exclusion extends to include the period ofpregnancy
Treatments not indicated in your Table of BenefitsThe following treatments expenses procedures or any adverse consequences or complicationsrelating to them unless otherwise indicated in your Table of Benefits
Complications of pregnancybullDental treatment dental surgery periodontics orthodontics and dental prostheses with thebullexception of oral and maxillofacial surgical procedures which are covered within the overalllimit of your Core PlanDietician feesbullEmergency dental treatmentbull
6362
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
Dental surgery dental prostheses periodontics and orthodontic treatmentDental surgery dental prostheses periodontics and orthodontic treatment with the exception ofdental treatment as per its definition
HIVHuman Immuno-deficiency Virus infection AIDS or any associated psychiatric condition
Organ transplant
Pre-existing conditions
Prescription drugs and dressingsPrescription drugs and dressings unless prescribed for use whilst an in-patient or day-patient
Travel benefitTravel benefit is not available
For any travel costs which are above normal standard faresbullFor a parent to accompany a child who is 18 years of age or olderbullFor incidental costs of travel eg hotel accommodation or mealsbullWhen costs are covered by the Department of HealthbullWhen the treatment is not covered under your planbullWhen travelling has not been recommended by your consultantbullWhen we have not agreed to all costs of travel prior to the journeybull
Travel costsTravel costs related to out-patient consultations except for post-operative consultations thatcannot be carried out locally by a consultant
Travel costs when treatment is available locallyTravel costs to another Channel Island the UK and France for hospital in-patient or day-caretreatment if the proposed treatment or any alternative treatment is available locally Howeverplease note that medical costs incurred will be refunded within the terms of your policy
The following benefitsMedical evacuation or repatriationbullOculomotor therapybullRepairs to spectaclesbullRepatriation of mortal remainsbullSpeech therapybull
Intentional inhalation of gas or intentional ingestion of poisons or legally prohibited drugsbullFlying in an aircraft including helicopters unless the insured person is a passenger and thebullpilot is legally licensed or is a military pilot and has filed a scheduled flight plan when requiredby local regulationsActive participation in extreme or professional sports including but not limited to bull
Mountain sports such as abseiling mountaineering and racing of any kind (other than on-foot)Snow sports such as bobsleigh luge mountaineering skeleton skiing off-piste and-snowboarding off-pisteEquestrian sports such as hunting on horseback horse jumping polo steeple chasing or-horse-racing of any kindWater sports such as potholing (solo caving) or cave diving scuba diving to a depth of more-than 10 metres high diving white water rafting and canyoningCar and motorcycle sports such as motorcycle riding and quad biking-Combative sports-Air sports such as flying with a microlight ballooning hang gliding paragliding-parascending and parachute jumpingVarious other sports such as bungee jumping-
b) The following additional exclusions apply to all plans with the exception of the ChannelIslands Plan (this plan has its own additional exclusions listed below and on the following page)
Pre-existing conditionsPre-existing conditions (including any pre-existing chronic conditions) which are indicated on aSpecial Conditions Form that is issued prior to policy inception (if relevant) and conditions whichhave not been declared on the relevant application form In addition conditions arising betweencompleting the relevant application form and the start date of the policy will equally be deemedto be pre-existing Such pre-existing conditions will also be subject to medical underwriting and ifnot disclosed they will not be covered
Speech therapy Speech therapy related to developmental delay dyslexia dyspraxia or expressive languagedisorder
Travel costsTravel costs to and from medical facilities (including parking costs) for eligible treatment exceptany travel costs covered under local ambulance medical evacuation and medical repatriationbenefits
c) The following exclusions apply solely to our Channel Islands Plan
Chronic conditionsChronic conditions with the exception of short term treatment of acute episodes of a chroniccondition the aim of which is to return you to the state of health you were in immediately beforesuffering the episode or which leads you to full recovery We strongly advise you to contact ourHelpline to establish the extent of your cover in your particular circumstances before incurring anytreatment costs
6564
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
NOTES
6766
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-
DOC-IBG-en-UK-1218
AWP Health amp Life SA is regulated by the French Prudential Supervisory Authority located at 4 place de Budapest CS 92459 75 436 Paris Cedex 09
AWP Health amp Life SA acting through its Irish Branch is a limited company governed by the French Insurance Code Registered in France No 401 154 679 RCS Bobigny Irish Branch registeredin the Irish Companies Registration Office registered No 907619 address 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland Allianz Care and Allianz Partners areregistered business names of AWP Health amp Life SA
Talk to us we love to helpIf you have any queries please do not hesitate to contact us
247 Helpline for general enquiries and emergency assistance
English +353 1 630 1301German +353 1 630 1302French +353 1 630 1303Spanish +353 1 630 1304Italian +353 1 630 1305Portuguese +353 1 645 4040
Toll free numbers wwwallianzworldwidecarecomtoll-free-numbersPlease note that in some instances the toll-free numbers are not accessible from a mobile phone In this case please dialone of the Helpline numbers listed above
Calls to our Helpline will be recorded and may be monitored for training quality and regulatory purposes Please notethat only the policyholder (or an appointed representative) can make changes to the policy Security questions will beasked of all callers to verify their identity
Email clientservicesallianzworldwidecarecom
Fax + 353 1 630 1306
Address Allianz Care 15 Joyce Way Park West Business Campus Nangor Road Dublin 12 Ireland
wwwallianz-carecom
wwwfacebookcomallianzcare
plusgooglecom+allianzworldwidecare
wwwyoutubecomuserallianzworldwide
wwwlinkedincomcompanyallianz-care
- HOW TO USE YOUR COVER
-
- Member services
- Cover overview
- Seeking treatment
-
- TERMS AND CONDITIONS OF YOUR COVER
-
- Your cover explained
- Claims and Treatment Guarantee process
- Paying premiums
- Administration of your policy
- Additional terms
- Data protection and release of medical records
- Complaints and dispute resolution procedure
- Definitions
- Exclusions
-