Terms & Conditions

Operative from 01 March 2018

Terms and Conditions must be read in conjunction with the Rules of Association.

1. BENEFITS
1.1. The benefits provided by the scheme are described in the Appendix and the limits payable are indicated in the Tables of Benefits.
1.2. The treatment for which the benefit is claimed must have been recommended by a medical practitioner, duly registered with the Medical or Dental Council of Mauritius, or a registered optometrist. Treatment with a Special Therapist is refunded if duly prescribed by a registered medical practitioner
1.3. Doctors and Clinic Fees will be refunded as per Scale of cost applicable by the medical industry.

2 .DEPENDANTS
2.1. Dependants of employees/pensioners are :
(i) Spouse or any living-in partner of employee/pensioner (concubinage)

(ii) Child, stepchild or adopted child, under the age of 18, or a full time student who is under the age of 25 years, unmarried and unemployed.
2.2. An employee shall register all children as dependants as defined by article 2.1(ii), unless such dependant(s) is already covered in a medical scheme.
Decision to accept or reject any application to the Scheme rest at the Management Committee level

2.3. The Managing Committee may, at its discretion and without prejudice, request evidence of health or an affidavit regarding any aspect as may be required.

3. WIDOWS AND WIDOWER
Provided a spouse has been a member of the Association for at least 5 years, a widow/widower may retain membership of the Association for herself/himself and dependants, provided her/his membership would cease upon her/his re-marriage or upon her/his becoming eligible for another scheme by virtue of her/his employment.
Such contributions would still be paid through the Corporate member for the decease spouse.

4. WAITING PERIOD

Benefits become payable as follows:

4.1(a) Existing employee and or dependants

Pregnancy related treatment 9 months
3 Months for any other cases

4.1(b) tsNew Recruits and or dependan

No Waiting Period apply after enrolment
Pregnancy related treatment 9 MONTHS

4.1(c) New Born

No Waiting period for the In Patient and Outpatient Benefits if enrolled during the month of birth.
Catastrophe covers however, becomes payable 3 MONTHS after enrolment.

4.1(d) Change of cover at Renewal
No waiting period will apply, except for pregnancy related treatment where 9 months will apply.

5. EXCLUSIONS

5.1 Personal injury (not sickness) benefits are excluded for persons in active performance of duty falling within the following trades or professions:

  •  Aviators
  • Stevedores
  • Jockeys
  • Taxi drivers
  • Seamen
  • Window cleaners
  • Members of armed forces
  • Threshing and woodworking machinists

5.2 Benefits shall not be payable for

1.(a) Aids, patent foods, food supplements, baby foods, contraceptives, domestic, biochemical remedies

Purchase of Equipment such as wheelchair, iron lung, apnoea aid machine, nebulizer except where specially provided for

1.(b) Patent medicines as advertised to the public and tonics, in a proportion exceeding the one proposed by the Vidal Dictionary.

2. Cosmetic or elective surgery or treatment or any adverse consequence, in connection with or attributable to same, except in case of post-surgeryr accident or reconstruction following an illness / accident .

3. Illness or accident attributable to use of alcohol or use of non-prescribed drugs.

4. Illness or accident arising out of self-inflicted injury.

5. Obesity consultations or treatments.

6. Treatments, investigations or procedures for fertility or infertility, vasectomy or sterilisation, artificial insemination. Except where Specifically provided for.

7. Professional sport, all sports in the air, duration tests or races of any kind (other than athletics and sailing within the Mauritian coral belt).

8. Certifiable mental disease or senile illness, Nervous disorder Including (Mental illness, anxiety , stress, depressive illness, psychological or psychiatric illnesses, Schizophrenia )

9. Convalescent treatment.

10. Venereal disease

11. Injury or disability directly or indirectly related to War, Civil War, Nuclear fission or fusion contamination by radioactivity. Act of Terrorism.

12. Chronic Illness – Except where provided specifically for.

For the purpose of this exclusion, a chronic illness shall be defined as follows:

• Has no known cure
• Does not respond effectively to treatment
• Needs prolonged supervision or monitoring
• Leads to permanent disability
• Is caused by changes to the body that cannot be reserved

13. Preventive Treatment (including vaccines and routine/general check-ups) – Except where specifically provided for.

14. Expenses recoverable from another Scheme or Insurer and from any other third party.

15. Congenital defects and deformities. Except where specifically provided for

16. Persons over 60 years of age, unless satisfactory evidence of good health is produced.

17. Cost of sunglasses, broken lenses/ frames and repairs

5.3 For new entrants or for new benefits or for additional limits subscribed to under an existing benefit, cover is excluded for any pre-existing conditions.

6. BONUS / MALUS MECHANISM
A Bonus / Malus mechanism will apply to Members on a yearly basis on all non- catastrophe benefits rates as per calculation in place.

7. CLAIMS PROCEDURE
Claims must be submitted within three months from the date the services are rendered.

7.1(a) Physical Claims Submission

Claims shall be submitted to the Administrator on the Personalised Claim Form available from the On Line Member’s Portal and accompanied by the Original Invoice/s, Original Receipt/s, Prescription/s and/ or Medical Reports

7.1(b) Electronic Claim Submission

Claims submitted to the Administrator via the Online Member Portal shall consist of scanned copies of the Personalised Claim Form, Original Receipt/s, Original Invoice/ s, Prescription/ s and/ or Medical Reports.

7.1(c) Snap and Send

Claims submitted to the Administrator via the Medscheme Touch mobile application shall consist of photos of Original Invoice/ s, Prescription/ s and/ or Medical Reports.

For 7.1(b) and 7.1(c), the Administrator reserves the rights to request for original documents before, during and after the claim have been processed and/ or paid.

7.2 All claims will be refunded, provided the Corporate Member’s Contributions are up to date, once all the necessary verifications have been made, normally within 20 working days. Refunds will be made to the nearest rupee.

Any returned claims from the Administrator requesting for additional information should be resubmitted within one month from the date of the letter or within three months of the Occurrence date, whichever date is the latest, failing which the claim will be rejected.

7.3 Should there be any doubt as to the receivabilty of a claim:

1. The claimant shall be asked to have a counter medical examination by another practitioner nominated by the Administrators.

2. If need be, the dossier can then be referred to a panel of doctors nominated by the Administrators and this panel will hear all the parties concerned before casting their opinion on the receivabilty of the claim.

7.4. Should a fraud be detected in the submission of a claim, the Association reserve the right of evicting the beneficiarie(s) or taking any appropriate legal action.

8.TERRITORIAL LIMITS
The geographical area(s) or place(s) where the occurrence e.g. an Illness or Accident giving rise to a claim under the Policy should happen for the insurance Policy to operate.

Option 1 Mauritius
Option 2 Worldwide excluding U.S.A. & Canada

IMPORTANT: The Territorial Limits clause should be read in conjunction with the Geographical Treatment Limits clause.

9. GEOGRAPHICAL TREATMENT LIMITS

The only geographical areas where the Insured Person can undergo Treatment which would be recoverable under the Policy, subject to other Policy terms and conditions.

Option 1 Mauritius

Option 2 (a) Where Treatment is unavailable in Mauritius, the nearest regional Overseas Medical Centre to which the Company consents in writing

Option 2 (b) Where Treatment is not available either in Mauritius or in the nearest regional Overseas Medical Centre, an overseas centre to which the Company consents in writing excluding U.S.A & Canada.

IMPORTANT: The choice of the Overseas Medical Centre shall remain at Our discretion Benefits are payable for cost of treatment/surgery incurred anywhere in the world except USA and Canada and if recommended jointly by the beneficiary’s physician/surgeon and by a physician/surgeon appointed by the Managing Committee.

10. OVERSEAS TRAVEL UNPLANNED OR EMERGENCY TREATMENT
Where an Insured Person, whilst travelling abroad, has to undergo unplanned or Emergency Treatment, the reimbursement of the said Treatment expenses incurred shall not exceed the amount equivalent to the cost of such Treatment in Mauritius.
The recoverable amount shall be calculated strictly in accordance with the prevailing Scale of Costs agreement in force with Doctors and Clinics in Mauritius, except if otherwise expressly mentioned in the Policy and/ or in Policy Endorsement.
11. GENERAL NOTES
The Committee has delegated to Medscheme (Mtius) Ltd the day to day administration and all communications should therefore be addressed to them at:
Medscheme (Mtius) Ltd
1st Floor, One Cybercity,
Tower A,
Ebene

Mosante dedicated Telephone number: 403-5060

CUSTOMER SERVICE CONTACT DETAILS

Membership
Customer Hotline : (230) 403 50 98
Email: [email protected]

Claims
Customer Hotline : (230) 403 5091
Email : [email protected]

APPENDIX
DESCRIPTION OF BENEFITS
1. SURGICAL OPERATIONS:
Surgical Operations including surgeons’, assistants’ and anaesthetists’ fees, deep X-ray therapy and approved physiotherapy, blood transfusions, serum, pathological and radiological services, theatre room, oxygen and drugs for the operation and other clinic fees pertinent to the operation.
A Surgical Operation shall mean the treatment of deformity (except congenital deformities), disease or injury by manual or instrumental means or operations such as the attempted restoration or removal of the diseased part or tissue by cutting, cautery, ligature and the like, but excluding simple intra muscular or intravenous injections.
This Benefit is extended to include caesarean delivery and Endoscopy when it involves Biopsy or any other surgical procedure.

2. MEDICAL BENEFITS:
Doctors’ and specialists’ services, consultations and prescribed drugs. Injections and therapy, clinical tests (e.g. X-ray, analysis). Other Clinic fees not involving an operation. This Benefit is extended to include Endoscopy when it is performed for investigative purposes only. Soles (when duly prescribed)

3. EYE TREATMENT:
Glasses, frames, contact lenses and consultations relative thereto. Replacement of frames and/ or lenses of identical power shall be considered after a period of 3 years

4. PREGNANCY:
Expenses incurred in connection with normal childbirth (including ante-natal and post-natal treatment, which are not covered under the medical benefit).

5. DENTAL TREATMENT:
(i) Treatment of any dental disease as recommended by a recognised dentist including the following: –
(a) Fillings and crowns including the cost of precious metal restoration only where the teeth cannot be restored with an ordinary filling material.
(b) Extractions and all other types of dental surgery performed in a dentist cabinet .
(c) Periodontal treatment.
(d) Initial installation or repair (and replacement if qualitative or quantitative changes are prescribed) of prosthetic appliances including bridges and full and partial dentures.
(ii) Initial installation of orthodontic appliances.

6. PREVENTIVE /CHECK UP
Routine check-up as detailed in the table of benefits.

7. CHRONIC ILLNESS
Diseases as per described in the table of benefits

8. HEARING AID
Prescribed apparatus for deafness.

9. INPATIENT
Any medical treatment or surgical procedure which requires the occupation of a clinic bed – extended to delivery.

10. INFERTILITY TREATMENT – LIFETIME COVER
Includes in-vitro fertilisation and Endometriosis
Excludes outpatient consultation/ treatment

11. CONGENITAL TREATMENTS – LIFETIME COVER
Covers deformity/anomaly apparent or diagnosed before the age of 10 of enlisted beneficiary.

12. ORTHOPAEDIC AID – LIFETIME COVER
Includes the cost of purchase or rent pf wheel chair, crutches etc. as a result of hospitalisation.

13. CATASTROPHE
Expenses relating to any one Illness or Accident incurred, provided such expenses exceed the deductible within the first twelve months of treatment, and are incurred during the period this benefit is subscribed to.

14. FUNERAL GRANT
Payable upon production of death certificate.