International Private Health Insurance Glossary of terms
1 Accident
An injury which is the result of an unexpected event independent of the will of the insured and which arises from a cause outside the individual’s control. The cause and symptoms must be medically and objectively definable, allow for a diagnosis and require therapy.
2 Accidental death
A single sudden and unexpected event which occurs at an identifiable time and place during the Policy Period and which causes unexpected bodily Injury at the time it occurs, and which solely and independently of any other cause results in the Death of the Insured Person upon its occurrence.
3 Accidental Dental Injury
A sudden unforeseen external blow to the face, teeth or jaws which occurs at an identifiable place and time resulting in dental injury.
4 Accommodation costs for one parent staying in hospital with an insured child
Hospital accommodation costs of one parent for the duration of the insured child’s admission to hospital for eligible treatment. If a suitable bed is not available in the hospital, we will contribute the equivalent of a 3 star hotel daily room rate towards any hotel costs incurred.
We will not, however, cover sundry expenses including, but not limited to meals, telephone calls or newspapers.5 Acute condition
A disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery.
6 Advice
Any consultation regarding any symptoms or abnormalities that you have experienced from a Medical Practitioner, Specialist, therapist or allied healthcare specialist, or otherwise.
7 Alcohol, drug and substance abuse
A condition, mental or physical, which is directly or indirectly related to alcohol, drug or substance abuse (unless the drug was prescribed by a General Practitioner or Specialist).
8 Appropriate
- a) The type, level, length of service, and setting needed to provide safe and adequate care.
- b) Rendered in accordance with generally accepted medical practice and professionally recognised standards.
- c) Not generally regarded as experimental, investigational or unproven by recognised medical professionals or appropriate government agencies.
- d) Specifically allowed by laws which apply to the provider who renders service.
Appropriateness shall be decided by our Chief Medical Officer.
9 Benefit
The maximum amount we will pay in any Policy year per insured person as shown on the Table of Benefits. The charges must be reasonable and customary.
10 Cancer
A malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.
11 Certificate of Insurance
The document accompanying this Policy which lists the Insured Persons, the Commencement Date and any endorsements.
12 Chronic condition
A disease, illness or injury which has at least one of the following characteristics:
- It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests;
- It needs ongoing or long-term control or relief of symptoms;
- It requires your rehabilitation or for you to be specially trained to cope with it;
- It continues indefinitely;
- It has no known cure;
13 Claim
The costs incurred relating to a course of treatment undergone in relation to a specific acute medical condition that we have pre-authorised in writing as an eligible benefit under the Policy.
14 Close family member
A Dependant, Parent, Step-parent, Parent-in-law, Grandparent, Grandchild, Brother, Sister, Brother-in-law, Sister-in-law, Son-in-law, Daughter-in-law or Legal guardian.
15 Commencement date
This is the date of the commencement of the contract with us, as stipulated in your Certificate of Insurance.
16 Compassionate emergency visit
This benefit covers the costs incurred by an insured person for an economy class return airfare from the country of residence to visit a close family member, up to the age of 70 years, in the event of a medical condition that results in that close family member being placed on a critical list, or his/her death. Limited to one return journey per insured person per plan.
17 Complementary treatment
Therapeutic and diagnostic treatment that exists outside the institutions where conventional medicine is taught. Such medicine includes chiropractic treatment, osteopathy, Chinese herbal medicine, homeopathy and acupuncture as practiced by approved therapists.
18 Complications of childbirth
Refers only to the following conditions that arise during childbirth and that require a recognised Obstetric procedures:
- Postpartum haemorrhage and retained placental membrane.
- Complications of childbirth are only payable where the cover also includes a routine maternity benefit. In this case, complications of childbirth shall also refer to medically necessary caesarean sections.
19 Complications of pregnancy
Covered as listed:
- Abnormal presentation;
- Ectopic pregnancy;
- Miscarriage;
- Missed abortion;
- Still birth;
- Post partum haemorrhage;
- Retained placental membrane
20 Co-payment
The percentage of the costs which the insured person must pay
21 Day-Patient
A patient who is admitted to a hospital or Day-Patient unit because they need a period of medically supervised recovery but does not occupy a bed overnight.
22 Dental prostheses
Includes crowns, inlays, on lays, adhesive reconstructions/restorations, bridges, dentures and implants as well as all necessary and ancillary treatment required.
23 Dental surgeryIncludes the extraction of teeth, apicoectomy, as well as the treatment of other oral problems such as congenital jaw deformities (e.g cleft jaw), fractures and tumours. Dental surgery does not cover any surgical treatment that is related to dental implants.
24 Dental treatment
Includes an annual dental check up, simple fillings related to cavities or decay and root canal treatment.
25 Dependant
Your husband, wife, partner or unmarried child included on your Policy. By partner we mean a person with whom you are cohabiting on a permanent basis. By child we mean you or your partner’s unmarried own, adopted or step children who are under 21 (or 25 if in full time education).
26 Diagnostic test
Investigations, such as X-rays or blood tests, to find or to help to find the cause of your symptoms.
27 Eating Disorder
Any psychological disorder such as anorexia nervosa or bulimia that involves insufficient or excessive food intake.
28 Emergency
Constitutes the onset of a sudden and unforeseen medical condition that requires urgent medical assistance. Only treatment commencing within 24 hours of the emergency event will be covered.
29 Emergency in-patient dental treatment
Acute emergency dental treatment due to a serious accident that requires hospitalisation.
The treatment must be received within 24 hours of the emergency event. Please note that cover under this benefit does not extend to follow-up dental treatment, dental surgery, dental prostheses, orthodontics or periodontics. If cover is provided for these benefits, it will be listed separately in the Table of Benefits.30 Emergency out-patient dental treatment
Treatment received in a dental surgery/hospital emergency room for the immediate relief of dental pain, including temporary fillings limited to 3 fillings per Policy period, and/or the repair of damage caused in an accident. The treatment must be received within 24 hours of the emergency event. This does not include any form of dental prostheses or root canal treatment.
31 Emergency out-patient treatment
Treatment received in a casualty ward/emergency room following an accident or sudden illness, where the insured does not, out of medical necessity, occupy a hospital bed. The treatment must be received within 24 hours of the emergency event.
32 Excess
The amount of money shown on the Insured’s Certificate of Insurance which you have agreed to pay towards the cost of each treatment.
33 Expenses for persons accompanying an evacuated/repatriated person
The cost of the persons travelling with the evacuated/repatriated person. If this cannot take place in the same transportation vehicle, transport at economy rates will be paid for. Following completion of treatment, we will also cover the cost of the return trip, at economy rates, for the accompanying person to return to the country from where the evacuation/repatriation originated. All costs must be preauthorised by us in writing and will be limited. This benefit is only applicable where the insured person has been placed on a critical list.
34 Experimental treatment
A diagnostic, medical or surgical procedure, treatment or drug therapy that is considered experimental or unproven based on generally accepted medical practice.
35 Fee for service
Fee for medical treatment with the cost not fixed in advance.
36 Full medical underwriting
The assessment of the health risk based on the detailed medical history questionnaire completed, where applicable, by you and from which the terms and conditions of our acceptance of the application are decided and applied to the Policy at the commencement date.
37 Home country
The country for which the insured person holds a current passport and to which the insured person would want to be repatriated.
38 Hospital
An establishment which is licensed as a medical or surgical hospital in the country where it operates and where the patient is permanently supervised by a medical practitioner. The following establishments are not considered hospitals: rest and nursing homes, spas, cure-centres and health resorts.
39 Hospital accommodation
A standard private or semi-private accommodation as indicated in the Table of Benefits. Deluxe, executive rooms and suites are not covered.
40 Hospital charges
Charges for accommodation, nursing, operating theatres, drugs, dressing, pathology, radiology and any other charges made by a hospital for treatment and within our fee schedule.
41 Infertility treatment
Treatment for both sexes including all invasive investigative procedures necessary to establish the cause for infertility such as hysterosalpingogram, laparoscopy or hysteroscopy. In the case of in vitro fertilisation (IVF), cover is limited to the amount specified in the Table of Benefits.
42 In-patient
A patient who is admitted to hospital and who occupies a bed overnight or longer, for medical reasons.
43 In-patient cash benefit
Payable when treatment and accommodation for a medical condition, that would otherwise be covered under the Policy, is provided in a hospital where no charges are billed. Cover is limited to the amount specified in the Table of Benefits and is payable upon discharge from hospital.44 Insured person/member
Anyone of the individuals specified on the Certificate of Insurance.
45 Laser eye treatment
Surgical improvement of the refractive quality of the cornea using laser technology, including necessary preoperative investigations.
46 Local ambulance
Ambulance transport required for an emergency or out of medical necessity, to the nearest available and appropriate hospital or licensed medical facility.
47 Long term care
Care over an extended period of time after the acute treatment has been completed, usually for a chronic condition or disability requiring periodic, intermittent or continuous care. Long term care can be provided at home, in the community, in a hospital or in a nursing home.
48 Material fact
A fact which may influence our decision regarding whether or not to accept your application or claim, or to accept it on special terms. If you are in doubt about whether or not a fact is material please tell us.
49 Medical condition
Any symptom, illness, disease or injury and/or any associated condition that is covered by this Policy.
50 Medical evacuation
Where the necessary treatment for which the insured person is covered and they are placed on a critical list or in our opinion adequate treatment is not available locally or if adequately screened blood is unavailable in the event of an emergency. We will evacuate the insured person to the nearest appropriate medical centre (which may or may not be located in the insured person’s home country) or we will, where appropriate, endeavour to locate and transport screened blood and sterile transfusion equipment. The medical evacuation will be carried out in the most economical way having regard to the medical condition.
Following completion of treatment, we will also cover the cost of the return trip, at economy rates, for the evacuated member to return to his/her principal country of residence. If medical necessity prevents the insured member from undertaking the evacuation or transportation following discharge from an in-patient episode of care, we will cover the reasonable cost of hotel accommodation up to a maximum of 7 days, comprising of a private room with en-suite facilities. We do not cover costs for hotel suites, 4 or 5 star hotel accommodation. Hotel accommodation for an accompanying person is not covered. Where an insured member has been evacuated to the nearest appropriate medical centre for ongoing treatment, we will agree to cover the reasonable cost of hotel accommodation comprising of a private room with en-suite facilities. The cost of such accommodation must be more economical than successive transportation costs to/from the nearest appropriate medical centre and the principal country of residence.
We will also cover the travel, accommodation and economy class return airfare expenses for preauthorised costs of a close business colleague or the insured person’s dependants having to accompany the insured person for an emergency medical evacuation, this benefit will only apply when the insured person is evacuated when placed on a critical list.
51 Medical necessity
Services or supplies which are:
- a) Appropriate for the signs, symptoms, diagnosis or treatment of the injury or disease.
- b) Provided for the diagnosis or direct care and treatment of the injury or disease.
- c) Within standards of good medical practice within an organised medical community.
- d) Not primarily for the convenience of the Insured Person or any other participating supplier providing appropriate covered services to the Insured Person.
- e) An appropriate supply and level of service needed to provide safe and adequate care.
Medical necessity shall be decided by our Chief Medical Officer.
52 Medical practitioner
A physician who is licensed to practice medicine under the law of the country in which treatment is given and where he/she is practising within the limits of his/her licence.
53 Medical practitioner fees
A non-surgical treatment performed or administered by a medical practitioner.
54 Medical repatriation
This benefit means that if the necessary treatment for which you are covered is not available locally, you can choose to be medically evacuated to your home country for treatment, instead of to the nearest appropriate medical centre. This only applies when your home country is located within your geographical area of cover. Following completion of treatment, we will also cover the cost of the return trip, at economy rates, to your principal country of residence. The return journey must be made within one month after treatment has been completed.
55 Midwife fees
Fees incurred by a midwife or birth assistant, who, according to the law of the country in which treatment is given, has fulfilled the necessary training and passed the necessary state examinations.
56 Moratorium
The period during which we will not pay benefits for pre-existing conditions.
57 Newborn care
Customary examinations required to assess the integrity and basic function of the child’s organs and skeletal structures. These essential examinations are carried out immediately following birth.
Further preventive diagnostic procedures, such as routine swabs, blood typing and hearing tests, are not covered. Any medically necessary follow-up investigations and treatment are covered under the newborn’s own Policy.
58 Nursing at home or in a convalescent home
Skilled nursing services given by a qualified nurse at your home, immediately after qualifying In-Patient treatment. The nursing must be under the supervision of a specialist and for medical not domestic purposes.
59 Obesity
Diagnosed when a person has a BMI (Body Mass Index) of over 30.
60 Occupational therapy
Treatment that addresses the individual’s development of fine motor skills, sensory integration, coordination, balance and other skills such as dressing, eating, grooming, etc. in order to aid daily living and improve interactions with the physical and social world.
61 Oncology
Specialist fees, diagnostic tests, radiotherapy, chemotherapy and hospital charges incurred in relation to the planning and carrying out treatment for cancer, from the point of diagnosis.
62 Oral surgical procedures
Surgical procedures, such as, but not limited to, the removal of impacted wisdom teeth, when carried out in a hospital by an oral or maxillofacial surgeon.
63 Organ transplant
A surgical procedure in performing the following organ and/or tissue transplants: heart, heart/ valve, heart/lung, liver, pancreas, pancreas/kidney, kidney, bone marrow, parathyroid, muscular/skeletal and cornea transplants. Expenses incurred in the acquisition of organs are not reimbursable.
64 Orthodontics
The use of devices to correct malocclusion and restore the teeth to proper alignment and function.
65 Orthomolecular treatment
Treatment which aims to restore the optimum ecological environment for the body’s cells by correcting deficiencies on the molecular level based on individual biochemistry. It uses natural substances such as vitamins, minerals, enzymes, hormones, etc.
66 Out-patient surgery
A surgical procedure performed in a surgery, hospital, day-care facility or out-patient department that does not require the patient to stay overnight out of medical necessity.
67 Out-patient
A patient who attends a hospital, consulting room, or Out-Patient clinic and is not admitted as a Day- Patient or an In-Patient.
68 Palliative care
Any treatment given for the sole purpose of relieving symptoms rather than attempting cure of a medical condition.
69 Patient
The person being treated for disease, illness or injury.
70 Periodontics
Dental treatment related to gum disease.
71 Phobia
A persistent, irrational, intense fear of a specific object, activity or situation.
72 Policy
The Application Form, Declaration, Policy Document, Reasonable and Customary Fees, Certificate of Insurance, Table of Benefits, Definitions, and any endorsements.
73 Policy period
The period between the commencement date and the expiry date shown on the Certificate of Insurance.
74 Post-natal care
Routine post-partum medical care to be received by the mother up to six weeks after delivery.
75 Pre-authorisation
A process through which an Insured Person seeks approval from us prior to undertaking treatment or incurring costs. If pre-authorisation is not obtained we will only cover 50% of the costs that would have been agreed if the correct procedure had been taken.
76 Pre-existing conditions
Any disease, illness or injury for which:
- You have received medication, advice or treatment; or
- You have experienced symptoms;
Whether the condition has been diagnosed or not in the two years before the start of your cover.
77 Pregnancy
The period of time, from the date of the first diagnosis, until delivery.
78 Premiums
The amount you must pay us each year as a premium for the insurance and this will include Insurance Premium Tax dependant on the local legislation.
79 Pre-natal care
Common screening and follow-up tests, as required during a pregnancy. For women aged 35 and over, this includes Triple/Bart’s, Quadruple or Spina Bifida tests, amniocentesis and DNA-analysis, if directly linked to an eligible amniocentesis.
80 Prescribed medical aids
Any instrument, apparatus or device which is medically prescribed as an aid to the function or capacity of the insured person, such as hearing aids, speaking aids (electronic larynx), crutches or wheelchairs, orthopaedic supports/braces, artificial limbs, stoma supplies, graduated compression stockings as well as orthopaedic arch-supports. Costs for medical aids that form part of palliative care or long term care are not covered.
81 Prescribed Physiotherapy
Treatment by a registered physiotherapist following referral by a medical practitioner. Physiotherapy is initially restricted to six sessions per condition, after which the treatment must be reviewed by the referring medical practitioner. Should further sessions be required, a progress report must be submitted to us, which indicates the medical necessity for any further treatment. Physiotherapy does not include therapies such as Rolfing, Massage, Pilates, Fango and Milta therapy.
82 Prescription drugs
Products, including, but not limited to, insulin, hypodermic needles or syringes, which require a prescription for the treatment of a confirmed diagnosis or medical condition or to compensate vital bodily substances. The prescription drugs must be clinically proven to be effective and recognised by the pharmaceutical regulator in a given country.
83 Preventive treatment
Treatment that is undertaken without any clinical symptoms being present at the time of treatment. An example of such treatment is the removal of a precancerous growth (e.g. mole on the skin).
84 Principal country of residence
The country where you and your dependants live for more than six months of the year.
85 Professional Sport
Professional sporting activities of any kind where a fee is received.
86 Psychiatry and Psychotherapy
Treatment of a mental, nervous or eating disorder carried out by a clinical psychiatrist or clinical Psychologist. The disorder must be associated with present distress, or substantial impairment of the individual’s ability to function in a major life activity (e.g. employment. The aforementioned condition must be clinically significant and not merely an expected response to a particular event such as bereavement, relationship or academic problems and acculturation. The disorder must meet the criteria for classification under an international classification system such as the Diagnostic and Statistical Manual (DSM-IV) or the International Classification of Diseases (ICD-10).
87 Rehabilitation
Treatment aimed at the restoration of a normal form and/or function after an acute illness or injury. The rehabilitation benefit is payable only for treatment that starts immediately after the acute medical treatment ceases. Treatment must take place in a licensed rehabilitation facility.
88 Related condition
Any condition, symptom, sign, disease, illness or injury which is medically considered to be associated with another condition, symptom, sign, disease, illness or injury.
89 Repatriation
If the necessary treatment for is not available locally, repatriation benefit will enable the insured members to return to their home country for treatment, rather than to the nearest appropriate medical centre. This only applies when the home country is located within the chosen geographical area of cover. Following completion of treatment, we will also cover the cost of the return trip, at economy rates, to the insured members principal country of residence as long as the return journey is made within one month of completion of treatment. Travelling, accommodation and economy class return airfare expenses for pre-authorised costs of a close business colleague, or the insured person’s dependants, or in the case of the insured person being a dependant, a parent or close family member, having to accompany the insured person for an emergency medical repatriation.
90 Repatriation of mortal remains
The transportation of the deceased’s mortal remains from the principal country of residence to the country of burial. Covered expenses include, but are not limited to, expenses for embalming, a container legally appropriate for transportation, shipping costs and the necessary government authorisations. Cremation costs will only be covered in the event that this is required for legal purposes. Costs incurred by any accompanying persons are not covered. All covered expenses in connection with the repatriation of mortal remains must be preapproved by us.
91 Routine health checks
Tests/screenings that are undertaken without any clinical symptoms being present. Such tests include the following examinations performed, at an appropriate age interval, for the early detection of illness or disease:- Vital signs (blood pressure, cholesterol, pulse, respiration, temperature, etc
- Cardiovascular exam
- Neurological exam
- Cancer screening
- Well child test (for children up to the age of 6 years, up to a maximum of 15 visits per lifetime).
92 Routine maternity
Any medically necessary costs incurred during pregnancy and childbirth, including hospital charges, specialist fees, the mother’s pre- and post-natal care, midwife fees as well as newborn care. Costs related to complications of pregnancy and childbirth are not payable under routine maternity.
93 Specialist
A qualified and licensed medical physician possessing the necessary additional qualifications and expertise to practice as a recognised specialist of diagnostic techniques, treatment and prevention in a particular field of medicine. This benefit does not include cover for psychiatrist or psychologist fees. Where covered, a separate benefit for psychiatry and psychotherapy will appear in the Table of Benefits.
94 Specialist fees
Non-surgical treatment performed or administered by a Specialist.
95 Speech therapy
Treatment carried out by a qualified speech therapist to treat diagnosed physical impairments, including but not limited to nasal obstruction, neurogenic impairment (e.g. lingual paresis, brain injury) or articulation disorders involving the oral structure (eg cleft palate).
96 Surgical appliances and prostheses
Artificial body parts or devices, which are an integral part of a surgical procedure or part of any medically necessary treatment following surgery.
97 Therapist
A chiropractor, osteopath, Chinese herbalist, homeopath, acupuncturist, physiotherapist, speech therapist, occupational therapist or oculomotor therapist, who is qualified and licensed under the law of the country in which treatment is being given.
98 Third party opinion
Obtaining an alternative opinion of a medical condition from a second Specialist chosen by Freedom Healthnet Limited.
99 Treatment
Surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury.
100 Treatment Charges
We will pay for eligible In-Patient, Day-Patient and Out-Patient Treatment for an acute condition if charges and fees are reasonable and customary.
101 Vaccinations
All basic immunisations and booster injections required under regulation of the country in which treatment is being given, any medically necessary travel vaccinations and malaria prophylaxis. The cost of consultation for administering the vaccine as well as the cost of the drug is covered.
102 Waiting period
A period of time commencing on your Policy start date (or effective date if you are a dependant), during which you are not entitled to cover for particular benefits. Your Table of Benefits will indicate which benefits are subject to waiting periods.
103 We/Our/Us
The Appointed agents (Freedom Healthnet Ltd) acting on behalf of Guardian Life of the Caribbean Limited.
104 You/Your
The Policyholder and each Insured Person who is listed on the Certificate of Insurance.
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