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Welcome to OCEAN MEDICAL BENEFITS (the Scheme). This policy summary contains key information about the scheme, so please read it carefully.
Please note that this is only a policy summary; it does not contain full details of your cover.
About your cover
1. The insurer
(a) The insurance is provided under an agreement (the Agreement) between certain Underwriters at Lloyds (the Underwriters) and the company that pays for your membership (the Assured). Your cover is subject to the terms and conditions of that Agreement.
(b) There is no contractual agreement between you and the Underwriters covering your membership. Only the Assured and the Underwriters have legal rights under the Agreement, although the Underwriters will allow anyone covered under the Agreement access to their complaints process.
2. The type of insurance provided
(a) The scheme offers private medical insurance which aims to fund eligible private medical treatment only while in your main country of residence. The terms and conditions of your cover may change from time to time, particularly at renewal. Your Assured will be able to provide further details upon request.
(b) This insurance will pay up to a maximum benefit per Insured Person of US$ 100,000 per annum, subject to a lifetime limit per Insured Person of US$ 200,000.
(c) Benefits, per cause, are payable for a maximum of twelve months from the commencement of treatment, except as provided for herein.
3. Your entitlement and eligibility to join
(a) If you are an employee of the Assured you will be a Primary Insured Person and will be eligible for cover under this policy if:
1. you are under the age of 65 years on the effective date of cover, and
2. you have been entered in the schedule of insured persons by the Assured and the Assured has paid the appropriate premium.
(b) If you are the spouse of a Primary Insured Person of the Assured you will be eligible for cover under this policy if:
1. you are under the age of 65 years on the effective date of cover, and
2. you have been entered onto the schedule of insured persons by the Assured and the appropriate premium has been paid.
(c) If you are a dependant child of a Primary Insured Person of the Assured you will be eligible for cover under this policy if:
1. you are over the age of 30 days and under the age of 19 years,
2. you are residing at the domicile of a Primary Insured Person or eligible spouse, and
3. you have been entered onto the schedule of insured persons by the Assured and the appropriate premium has been paid.
4. The type of treatment covered
(a) You are only covered for eligible treatment. This means the Underwriters will pay benefits under the scheme for charges you or any covered dependant incur for medically necessary services and supplies, which must be ordered by a physician due to a sickness or injury.
(b) Medically necessary services and supplies, as determined by the Underwriters, are likely to be:
1. consistent with the symptom or diagnosis and treatment of the patient’s condition, disease, ailment or injury,
2. appropriate with regard to standards of acceptable medical practice,
3. not solely for the convenience of the Assured or yourself or covered dependant, the physician, the hospital, or other providers, and
4. the most appropriate supply or level of service which can safely be provided to the patient,
and the treatment, services or charges are not excluded under the terms and conditions of the Agreement between the Assured and the Underwriters. The fact that any physician may provide, order, recommend or approve a service does not, of itself, make such treatment medically necessary.
The Underwriters’ approval must be given for the treatment of non life-threatening conditions prior to any admission to an approved facility or for any surgical procedure.
5. Recognised practitioners and facilities
Your cover depends upon your using certain Underwriter- and Scheme-recognised medical practitioners and treatment facilities (an ‘approved facility’), where these are available. Whom you use and the facilities you can use can affect your eligibility for benefits you are covered for. Specific information on the use of the plan in your particular country can be obtained on the website for the administering company and/or your membership card. You can also contact the administering company directly at any time to receive detailed information regarding your cover and what to do if you need medical assistance in your particular country of residence. We encourage you to visit the website of the administering company on a regular basis, as information is subject to regular updates.
Contact details:
Marine Benefits Assistance Services Inc
Telephone No.: (+63) 2 753 4442
Telefax No.: (+63) 2 753 4443
Mobile No./SMS: (+63) 917 863 6126
In some countries there are also local numbers established which are routed directly to Marine Benefits Assistance Services Inc. These numbers are posted on the website mentioned above.
It is important to understand that you are insured and covered under the policy even if you are residing in a country where there is no particular network of approved facilities established or no local contact number. In these instances you should contact Marine Benefits Assistance Services Inc. on any of the above mentioned contact points to obtain guidance and assistance depending on your particular needs.
6. Summary of covered expenses
(a) A semi-private hospital room and board charges not to exceed the usual or customary charge for such accommodation.
(b) Surgical services wherever performed, including any required second opinion.
(c) Medical or consultation services by a physician for a sickness or injury.
(d) Medically necessary nursing care for up to 6 months by a licensed resident or daily nurse in the employ of an approved provider of medical services who is not an immediate family member.
(e) Anaesthesia services related to surgical, obstetric or other medically necessary services.
(f) Radiation therapy services for therapeutic treatment of benign or malignant conditions, including charges for X-rays, radium and radioactive isotopes and nuclear medicine procedures.
(g) Emergency local transportation by road ambulance, necessitated by a life-threatening condition, to the nearest available or appropriate hospital.
(h) Maternity services for prenatal treatment, delivery, postnatal treatment and infant’s routine care of a healthy new-born during the initial confinement.
(i) Infant’s routine care includes charges for:
1. physician’s initial examination;
2. treatment for acute sickness or injury;
3. immunization and/or regular testing;
4. routine nursery charges;
5. treatment consequent upon premature birth
incurred within the first 30 days following birth. On the 31st day following birth, continued cover of the infant will be subject to the eligibility conditions detailed above for dependent children.
Benefits are only payable for maternity services and infant routine care rendered to an insured person provided that their expected normal delivery date is at least one year after the date on which they are formally recognised by the scheme.
(j) Prescription drugs, dressings or use of surgical or medical appliances which are medically necessary and prescribed by a physician whilst the insured person is an inpatient in an approved facility only.
(k) Accident-related dental treatment and dental surgery, as necessary to restore or replace sound natural teeth lost or damaged in an accident.
(l) Services and supplies provided in connection with a covered transplant procedure.
7. Policy Excess
Underwriters will not pay charges arising from the initial visit for a general consultation for outpatient services if such consultation does not lead to treatment, diagnostic testing or diagnosis of an eligible condition.
8. Pre-existing medical conditions
(a) There is no pre-existing condition limitation in respect of Primary Insured Persons, provided they are actively at work or on a scheduled vacation at the time of their inclusion in the schedule.
(b) For Dependent Insured Persons, limited cover for pre-existing conditions will be provided after 1 year of continuous cover for a maximum benefit of 75% of covered expenses up to US$ 5,000 per Dependent Insured Person per annum.
Definition:
Pre-existing medical condition means any sickness or injury:
(1) for which the Insured Person is already receiving medical care or treatment (including prescription drugs) on the effective date, or
(2) that has been diagnosed but for which the Insured Person has not started to receive treatment on the effective date, or
(3) that would have induced a rational person to seek medical care or treatment.
9. What you are not covered for
(a) There are certain medical conditions and treatments for which you are not covered. If you need to know if a particular condition or treatment is covered, ask your Assured to make enquiries with the Underwriters.
(b) The excluded medical conditions and treatments include:
1. An injury or sickness caused by war, civil war, invasion, act of a foreign enemy, hostilities or warlike operations (whether war be declared or not).
2. An injury or sickness caused by any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the de jure or de facto government or to the influencing of such activities by terrorism or violence.
3. An injury or sickness caused by martial law or a state of siege, or any event or causes that determine the proclamation or maintenance of martial law or a state of siege.
4. Services and supplies that are not authorised by a physician or that are not medically necessary or appropriate to the treatment of sickness or injury as determined by the Underwriters.
5. Treatment provided outside the approved facility, where such facility exists, without prior written authorization by the Underwriters, except in the case of a life-threatening condition, as provided for herein.
6. Expenses that exceed the Underwriters’ definition of charges as usual or customary.
7. Routine examinations, routine health assessments or procedures or examinations undertaken at the request of the Insured Person that fail to lead to a diagnosis of injury or sickness or those requested by a third party e.g. examinations for insurance, school, employment, camp or annual physical examinations or examinations directed or requested by a court of law. This does not include examinations requested by the Underwriters or examinations undertaken during the course of pregnancy.
8. Neuroses, psychoneuroses, psychopathies, psychoses, stress, fatigue or mental or emotional diseases and disorders of any type.
9. Self-inflicted injury or sickness while sane or insane.
10.Congenital defect at birth of a dependent child, including special services associated with this event, such as incubators or other life-saving equipment.
11.Injury or sickness sustained while under the influence of intoxicating liquor or illicit drugs, other than drugs taken in accordance with treatment prescribed by a physician.
12.Injury or sickness caused through drug abuse, including the use of dirty needles or shared paraphernalia.
13.Sexually transmitted diseases including but not be limited to herpes, gonorrhea, syphilis and cytomegalovirus.
14.Hepatitis if it is medically determined to have been sexually contracted.
15.Human immunodeficiency virus (HIV) and/or related illness including acquired immune deficiency syndrome (AIDS), or any mutant derivative thereof.
16.Injury sustained while taking part in mountaineering where ropes or guides are normally used; aviation (except when travelling solely as a passenger); parachuting; winter sports; racing by horse, motor or motorcycle; underwater activities involving the use of breathing apparatus and water skiing, AND any professional sporting activity.
17.Elective cosmetic surgery and associated treatment.
18.Non-prescription drugs including but not limited to: vitamins, tonics, nutritional supplements, patent or baby foods, biochemical or herbal or homeopathic remedies and treatments.
19.Drugs, medications, bandages, syringes, instruments and or use of surgical or medical appliances unless prescribed by a physician while an inpatient in an approved facility.
20.Preparation or fitting of dentures, dental fillings, eyeglasses, contact lenses, or hearing aids, and any investigations and or examinations the purpose of which is to determine whether they are necessary.
21.Services provided for the treatment of educational or learning problems, health education, marriage counselling, or holistic medicine or other programs having the objective of providing enhanced personal fulfilment.
22.Treatment received while serving as a member of a military unit.
23.Treatment that has not been scientifically-proven or medically-recognized and any services or supplies regarded as experimental or research-oriented in nature, including but not limited to acupuncture.
24.Male or female sterilization, reversal of sterilization, fertility treatment, sex change or implantation. Treatment for sexual transformation, sexual dysfunctions or sexual inadequacies.
25.Any expenses, service, treatment or any form of food supplement or augmentation (unless necessary to sustain life in a critically-ill person), or any exercise program for weight control, whether for obesity or any other diagnosis, whether by diet, injection of any fluid or use of any medications or surgery of any kind.
26.Podiatric care including foot care in connection with corns, calluses, flat feet, weak arches, weak feet or symptomatic complaints of the feet and shoe inserts of any kind.
27.Custodial care or rest care.
28.Hospital admission on a Friday or Saturday, or in certain territories the last day of the working week, for surgery on Monday, or in certain territories the first day of the working week, unless the attending physician attests to the Underwriters in writing that it was medically necessary for the health and well being of the patient to be admitted early.
29.Services provided by a member of the Insured Person’s immediate family or anyone else living with the Insured Person.
30.Acquisition or procurement of the actual organ or tissue for a covered transplant.
10. How long your cover will last?
The Agreement is an annual one. Your cover is dependent on the Assured covering you under this Agreement, so your cover will generally be for 12 months. However, this may change depending on the Assured, on the you join the scheme, and where this falls within the annual period.
11. Getting further details
Should you require further details about any aspect of the scheme or your eligibility for cover, please contact your Assured. Alternatively, refer to the contact details on your Membership Card for further assistance.
12. How to make a claim
You will have been issued a Membership Card bearing an individual identification number and the telephone numbers and website details for the Assistance Company appointed by the Underwriters.
THE MEMBERSHIP CARD PLUS AN ADDITIONAL IDENTIFICATION DOCUMENT MUST BE PRESENTED TO THE APPROVED MEDICAL FACILITY AT THE TIME OF TREATMENT. FAILURE TO DO SO MAY RESULT IN TREATMENT BEING DENIED.
In the event that your Membership Card is lost or stolen you must report the loss to the Assured (your employer) who may impose, at their discretion, a charge for a replacement.
If treatment as an inpatient is necessary, the Underwriters must be informed:
(1) in the event of a non-life-threatening condition (including maternity), proposed admissions must be pre-authorised by the Underwriters;
(2) in the event of emergency admissions for a life-threatening condition, as soon as reasonably possible after admission to an approved facility and within 48 hours if to a non- approved facility. The Underwriters will arrange for the monitoring of treatment cost and, where possible, transfer the Insured Person to an approved facility, to be undertaken by the nominated Assistance Company.
13. How to complain
Our aim is to ensure that all aspects of your insurance are dealt with promptly, efficiently and fairly. We are committed to providing you with the highest standard of service at all times.
If you have any questions or concerns about your cover or the handling of a claim you should, in the first instance, contact your Assured.
If you are not satisfied with the way a complaint has been dealt with you may ask the Policyholder and the Market Assistance Department at Lloyd's to review your case without prejudice to your rights in law.
The address is:
Policyholder and Market Assistance
Lloyd's Market Services
One Lime Street
LONDON EC3M 7HA
Telephone: +44 (0)207 327 5693
Fax: +44 (0)207 327 5225
Complaints that cannot be resolved by the Complaints Department may be referred to the Financial Ombudsman Service.
Further details will be provided at the appropriate stage of the complaints process.
14. The Financial Services Compensation Scheme (FSCS)
The Underwriters are covered by the FSCS. In the unlikely event that we cannot meet our financial obligations you may be entitled to compensation from the Financial Services Compensation Scheme. More information is available from the FSCS by calling (+44) 207 892 7300 or on its website at www.fscs.org.uk.
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