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General Clause and Exclusions on the Retail Plan.

 

    1. A waiting period of 2 weeks apply before enrolees can access medical care
    2. Within the first year of policy purchase, Antenatal care, delivery, post-natal care, pre-existing medical conditions and chronic illnesses are not covered

 

The following treatments and procedures are also excluded from this policy

 

    1. Cosmetic Surgery or treatment are not covered
    2. Teeth Whitening
    3. Dental Prosthesis
    4. Domiciliary/Hospice Care
    5. Alternative/ Unorthodox medicine is not covered
    6. Neonatal care not listed under neonatal services
    7. Self-inflicted injuries
    8. Congenital abnormalities are not covered
    9. Conditions caused by an act of war, an epidemic or enrollee participating in a riot
    10. Services primarily for weight reduction or treatment of obesity
    11. Treatment of substance abuse
    12. Infertility - All investigations and treatment
    13. Orthodontics
    14. Advanced radiological investigations (e.g. C.T. scan, Myelogram, EEG)
    15. Advanced and Complex investigations (e.g. Marrow biopsy, skeletal survey)
    16. Prosthetic devices such as cardiac pacemaker, orthopaedic implants
    17. Management of Chronic Renal Failure (Dialysis and Transplant Surgery)
    18. Induced Abortion
    19. Laser Treatments
    20. Transplants
    21. Complex major Surgeries (e.g. Heart, Brain and Great blood vessels)
    22. Neurological surgeries
    23. Management of Cancers
    24. Professional sports, wilful exposure to danger
    25. Infectious and contagious diseases in an epidemic
    26. All procedures, management and investigations not covered by the plans

Cover Limit: : The overall cover limit refers to the maximum annual reimbursement by AXA Mansard Health to cater for the care and treatment of an Enrolee. These limits are plan and provider category specific. Specific monetary or benefit limits may apply for specific services such as optical, dental and surgical procedures. In addition, some services are capped or restricted based on length of stay or number of procedures dispensed.

 

Waiting period: The standard waiting period is 14 days and during this period, you will have no access to the covered services and the plan purchased will only become active 14 days after completion of registration.

 

Right to cancel Policy: AXA Mansard Health is at liberty to cancel the cover of an Enrolee who has misled it or breached any term of the health insurance policy, given incorrect, incomplete or misleading information, failed to provide any reasonable information which AXA Mansard Health has requested for, conspired with a third party to obtain undue benefit from this Policy, or submitted a claim which is in any respect fraudulent or unfounded. In any of these circumstances, AXA Mansard Health shall have the right to cancel the Enrolee’s cover from the date of commencement (without refund of any portion of the unused premium) and shall recover from the Enrolee any benefit it might have paid in relation to such claim

 

Cancellation/Termination by an Enrolee is only possible within the first 30 days of the commencement of the policy. An Enrolee that decides to cancel/terminate this Health Insurance Policy must notify AXA Mansard Health in writing and the Enrolee shall be entitled to a refund of the premium paid less (1) any amounts incurred on their behalf as medical and other expenses (2) an administrative charge of 20% of the premium paid. No refund shall apply in case of termination/cancellation made by an Enrollee after 30 days of the commencement of the policy.

 

Cancellation/Termination by AXA Mansard: AXA Mansard Health may terminate the Policy by sending 30 days' notice by registered letter to an Enrolee at their last known address or to their known e-mail address. In such event, AXA Mansard Health will refund to the Enrolee an amount equal to the pro-rata value of their unused premium. Unused premium refers to the difference between the premium paid and the medical cost incurred as at the effective date of termination which includes amounts reported and amounts yet to be reported but which were incurred prior to the date of termination.

 

Treatment prior to Date of Commencement: AXA Mansard Health will not cover or pay for any treatment that was given before an Enrolee’s commencement date of cover or after cancellation/termination of cover or during any period for which AXA Mansard Health is yet to receive premiums.

 

Treatment that is not covered under the Benefit Schedule: AXA Mansard Health will not cover or pay for any treatment that is not specifically covered under the Benefit Schedule of the Policy. Similarly, all plans do not cover Consultations with unrecognized/un-orthodox consultants, hospitals, family doctors, therapists, dental practitioners or complementary medicines practitioners. In the same vein, complications from such unrecognized/un-orthodox places are not covered under any of the plans.

 

Transferability: The plans are person specific and non-transferable.

 

Confidentiality: AXA Mansard Health is committed to protecting the information of its Enrolees and it is bound by law and regulatory standards to maintain the privacy of its Enrolees’ medical information and records. AXA Mansard Health also holds its employees, providers and consultants and business associates to strict policies and procedures protecting Enrolee’s information. The Information collected from an Enrolee at enrolment and other transactions would include an Enrolee’s biodata as well as an Enrolee’s medical information through claims and utilization data submitted from healthcare providers. AXA Mansard Health can also access an Enrolee’s medical records in furtherance of its role under the health plans and you hereby consent to our access of your medical records and information accordingly.

 

Categorization of Healthcare facilities: Healthcare Providers are categorized by AXA Mansard Health for the benefit of ease of access to care by its Enrolees. AXA Mansard Health reserves the right to review this categorization from time to time without prior recourse to an Enrolee. This could include (but not limited to) the addition and deletion of healthcare providers from the general list and/or from a specific plan provider list. At the point of filling your proposal form, you shall be required to select your preferred hospital(s) from the list of in-network hospitals accessible on your plan. PLEASE NOTE that we will not be liable to pay for care accessed from an in-network hospital that is not available on the list of hospitals associated with your plan. In the event we choose to make payment for care received from an in-network hospital not on your plan, our payment shall be limited only to what it would have cost us to pay if you had accessed the services from an in-network hospital accessible on your plan.

 

Liability: AXA Mansard Health shall not be liable for any damages or losses that may arise from an Enrollee’s failure to pay premiums as and when due.

 

Refunds: Enrollees are required to access care within AXA Mansard Health’s network of Providers and not pay out of pocket for covered services. Reimbursement may only apply for extreme cases of emergency requiring enrollee to access care in a non-network Hospital, AXA Mansard Health should be notified of such emergencies within 72hrs of occurrence for approval through its contact centre. refund will be made by AXA Mansard Health upon the Enrollee providing the following documents within 30 days of encounter:
(1) copy of medical report from the Healthcare practitioner indicating history of the medical condition, diagnosis and treatment administered
(2) Original Receipt for having made payment indicating the costs separately for consultation, each investigation, each procedure and each Drug and the quantity dispensed.
(3)Pre-authorisation number received from AXA Mansard Health.
All refunds will be made only into the principal Enrollees designated account based only on medical emergency as might be reviewed by AXA Mansard Health's in-house medical practitioners and only at AXA Mansard Health's designated/customary rate irrespective of the cost of care. Also, refunds are only applicable where same is processed and paid before receipt by AXA Mansard Health of the notice to terminate or expiration of a plan.

 

Supply of drugs & medication: all Enrolees are covered for drugs recommended during their treatment for covered services except for excluded items.

 

Notices or Demands: . Any notices or demands required to be given under this Agreement, or given in connection with it, shall be in writing and shall be given by electronic means. Should the Enrollee require or where AXA Mansard Health deems same expedient, such notice can also be issued in hard copy and delivered by personal delivery or courier service delivery to the last known address of the other party. Changes in address has to be communicated to the other party otherwise, notifications will continue to be delivered to the last known address and remain legally enforceable. AXA Mansard Health can be contacted at any time through its Call Centre: 0700 AXAMANSARD (07002926267273); or send an email to HealthCare@axamansard.com

 

 

General Clause and Exclusions on the EasyCare Plan.

 

    1. Pre-Existing or Chronic Conditions
    2. Complex & Advanced Investigations
    3. Chronic diseases or conditions
    4. Intensive Care
    5. Special Baby Care Unit
    6. Renal dialysis
    7. Cancer care
    8. Additional immunization for 0-5 years (e.g. Hepatitis B, Rotavirus, Pneumococcal)
    9. Fertility Services & Family Planning
    10. An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia)
    11. Ophthalmological & optical services
    12. Dental & Surgical Implant
    13. Within the first year of policy purchase, Antenatal care and delivery isn’t covered
    14. All procedures, management and investigation not covered/slated by the plan

 

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