Health Insurance Plan

Terms and Conditions

TABLE OF CONTENTS
INTRODUCTION ......................................................................................................... 4
BENEFITS ................................................................................................................... 5
1. Inpatient Benefits ........................................................................................... 5
2. Inpatient and Maternity Cash Benefits ......................................................... 5
3. Medical Benefits ............................................................................................. 6
4. Optical Benefits .............................................................................................. 6
5. Maternity Benefits .......................................................................................... 6
5.1. Ante-Natal Benefits ................................................................................... 6
5.2. Confinement Benefits ................................................................................ 6
5.3. Caesarean Delivery Benefits ..................................................................... 6
6. Dental Benefits ............................................................................................... 7
7. Hearing Benefits ............................................................................................. 7
8. Congenital Benefits ........................................................................................ 7
9. Funeral Benefits ............................................................................................. 7
10. Emergency Ambulance Benefits ................................................................... 7
11. Catastrophe Cover ......................................................................................... 7
PROVISIONS AND CONDITIONS ................................................................................. 8
1. Claims.............................................................................................................. 8
2. Premiums ........................................................................................................ 9
3. Policy When Void ......................................................................................... 10
4. Healthcare Insurance Membership Card .................................................... 10
5. Change of Address....................................................................................... 11
6. Termination ................................................................................................... 11
7. Renewal of Policy ......................................................................................... 11
GENERAL CONDITIONS ............................................................................................ 12
1. Benefit Section ............................................................................................. 12
3. Territorial Limits – Inpatient & Catastrophe Cover .................................... 13
4. Other General Conditions ............................................................................ 13

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 5. Waiting Period .............................................................................................. 14
EXCLUSIONS AND LIMITATIONS ............................................................................. 16
1. Exclusions .................................................................................................... 16
2. Other Exclusions and Limitations............................................................... 17
3. War, Civil War, Piracy and Terrorism Exclusion Clause ........................... 18
GENERAL PROVISIONS ............................................................................................ 19
DEFINITIONS / GLOSSARY OF TERMS ..................................................................... 20

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This policy is governed by “Livre III Titre Douzième Chapitre 3eme of the Mauritius Civil Code”
except to the extent the articles mentioned in Article 1983-12 are varied by terms and conditions
annexed herein.

The Policy consists of the Terms and Conditions appearing herein and the Schedule. These
documents shall be read together and any word or expression to which a specific meaning has been
attached therein shall bear such meaning wherever it may appear.

INTRODUCTION

NIC General Insurance Co. Ltd hereinafter referred to as “the Company” will pay benefits, as defined
in this Insurance Contract (hereinafter referred to as “the Policy”), to the Insured Persons or their
Dependants, requiring medical and/or surgical treatment or assistance as a result of injury or
sickness contracted during the Period of Insurance as per the Schedule of Benefits. The benefits are
subject to policy definitions, exclusions, limitations and conditions. The Company reserves the right
to interpret the terms and conditions of this Policy and to determine the benefits payable subject
to the Premium having been paid by the Policyholder/Insured Member in the manner provided by
and subject to the terms, conditions and limitations of the Policy.

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BENEFITS

Benefits and Conditions mentioned hereunder will apply to the Policyholder or the Insured
Members to the extent that these benefits are mentioned in the attached Schedule(s) under the
heading “Schedule of Benefits”. The Company shall compensate the Policyholder or the Insured
Persons as per details given on the Schedule of Benefits for any claim reported and admissible
under the Policy. The payment by the Company for any admissible claim reported under the Policy
will be limited to the overall limits shown on the Schedule of Benefits. Benefits mentioned
hereunder but not mentioned in the attached Schedule(s) will not apply to the
Policyholder/Insured Member.

1. Inpatient Benefits
Inpatient benefits refer to expenses incurred relating to any medical treatment or surgical
Procedure, excluding maternity and which requires the occupation of bed within a hospital. The
inpatient benefits also include expenses related to 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 Hospital fees pertaining to the operation. All costs incurred in relation to
maternity (pregnancy from conception to child birth and post-natal expenses) shall be exclusively
considered under the limit of the maternity benefits defined hereunder. The inpatient benefit will
include day care procedures/surgeries such as gastroscopy, colonoscopy, chalazion excision, etc.

2. Inpatient and Maternity Cash Benefits

Inpatient and Maternity cash benefits are exclusively payable when treatment and accommodation
for a medical condition or child delivery that would otherwise be covered under the Insured
Member’s health plan, is provided at the public hospital where no charges are billed.

To benefit from the aforesaid, notification to the Company by the Insured Member should be made
prior or during admission to public hospital, failing which the Company may opt not to effect any
payments or to restrict payments.

Subject to the above, cover is limited to the amount specified in the Schedule of Benefits and is
payable upon discharge from the public hospital and submission of a detailed medical report (with
mention of the exact diagnosis and treatment undergone) and other relevant documents
ascertaining admission such as length of stay, date and time admitted and discharged.

The Company reserves the right to engage its designated Doctor(s) to visit the Insured Member at
the public hospital prior payment of any cash benefit and in light of observations made, it may at
its sole discretion limit the number of days of cover based on treatment received and/or the
medical report received. Accordingly, the Company shall place a limit on the number of days for
which the cash benefit is offered during hospitalisation.

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After settlement of any cash benefit, the company reserves the right not to entertain claims under
the inpatient or maternity benefit if the said treatment is carried out in a private healthcare centre
within a period of 90 days from the previous public hospital treatment.

3. Medical Benefits
Medical benefits refer to expenses incurred relating to doctors’ and specialists’ services,
consultations, prescribed drugs, injections, therapies, clinical tests (e.g. X-ray). Medical benefits
cover other Hospital fees not involving a surgical Procedure. Medical benefits exclude expenses
related to maternity, optical, hearing and dental treatments.

4. Optical Benefits
Optical benefits refer to expenses incurred in connection to glasses, frames and consultations
relative thereto. The optical benefit is available every twelve (12) months for an eye test and every
twenty four (24) months for frames and lenses unless mentioned otherwise in your schedule of
benefits. Lenses include single vision, bifocal, and multifocal lenses. Any additional optical or
ophthalmological service such as Excimer laser / refractive eye surgery, photo chromatic lenses
(tinted), radium coating and sunglasses are excluded. Unless provided in the Schedule of Benefits,
contact lenses will be approved and refunded only in case of deterioration in sight certified by an
ophthalmologist/optometrist.

5. Maternity Benefits
Maternity benefits refer to expenses incurred in connection with pregnancy from conception until
child delivery including ante-natal, post-natal treatments and any complications of pregnancy.
These expenses will include any cost incurred on normal delivery, delivery by caesarean section or
surgical Procedures related to miscarriages. These benefits shall apply to the Insured Person and
Adult Dependants only. Child Dependants and Parent Dependants are excluded from this benefit.

5.1. Ante-Natal Benefits

Ante-natal benefits refer to expenses incurred in relation to treatments undergone from conception
until child delivery. These include doctors’ and specialists’ services, consultations, prescribed
drugs, injections, therapies, clinical tests and day-care treatments related to the pregnancy
condition.

5.2. Confinement Benefits

Confinement Benefits refer to expenses incurred in relation to normal vaginal delivery or surgical
procedures related to miscarriages. These include expenses related to specialists’ services, any
medical treatment or surgical Procedure (e.g. episiotomy) pertaining to childbirth or miscarriages.
These benefits exclude expenses related to delivery by caesarean section.

5.3. Caesarean Delivery Benefits

Caesarean Delivery Benefits refer to expenses incurred in relation to delivery by caesarean section.

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6. Dental Benefits
Dental benefits refer to expenses incurred relating to treatment of any dental and gum disease as
recommended by a recognised dentist including the following:-

a) Root canal treatment, fillings and crowns excluding the cost of precious metal restoration;
b) Tooth extractions and all other types of dental surgery, including those requiring
hospitalisation
c) Initial installation or repair of prosthetic appliances including bridges and full/partial
dentures;
d) Initial installation of orthodontic appliances.
e) Dental implant

7. Hearing Benefits
Hearing benefits refer to expenses incurred in relation to hearing diagnostics, hearing
rehabilitation, hearing aids, or any related treatment.

8. Congenital Benefits
Congenital benefits refer to expenses incurred in treatment of medical condition(s) or disorder(s)
that exist in neonates at or before birth. Such expenses related to this condition are restricted to
the congenital benefit and these benefits apply solely to neonates subject to:-

(a) the natural mother having been under this insurance cover and having fulfilled the waiting
period for maternity benefits.

(b) the neonate being insured at birth

9. Funeral Benefits
Funeral benefits are payable to designated beneficiary/ies on death of the Insured Person and/or
Adult Dependant during the policy period. For Individual Policyholder, in case no beneficiary/ies
are designated, the funeral benefit will be payable to the succession of the Policyholder.

10. Emergency Ambulance Benefits

Emergency Ambulance benefits refer to the costs incurred in the event of use of ambulance facilities
required exclusively for life-threatening emergency cases.

11. Catastrophe Cover

Catastrophe cover refers to expenses incurred relating to any major medical treatment or surgical
procedure resulting from illness or injury and which requires admission to a Hospital, provided
such expenses are incurred during the period this benefit is subscribed to and exceed the limits
under the Inpatient Benefit within the contractual term of the Policy. The Catastrophe cover

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excludes expenses related to dental, optical, hearing and maternity-related treatments and, medical
conditions treated conservatively (e.g. pain management, bronchitis, gastroenteritis, etc.).

Conditions for Catastrophe cover:

1. If the Catastrophe Cover is mentioned in the attached Schedule(s), the Catastrophe Cover takes
effect only after the Inpatient Benefit has been exhausted.
2. In addition to the conditions and benefits mentioned above, any treatment on congenital
problems, infirmities and malformations will be excluded from the scope of this cover.
3. Immediate notification should be given to the Company about claim under Catastrophe Cover
and claim documents should be submitted to the Company within 30 days from the date of
discharge from a Hospital.
4. Any excess applicable on the catastrophe benefit is specified on the catastrophe table of
benefits.

PROVISIONS AND CONDITIONS

1. Claims
1. Claims shall be made through Claim Forms to be furnished by the Company and shall contain
answers to every question asked to the claimant and physicians, as may be applicable.
2. Claims must be signed and certified as correct and must be submitted to the Company within
thirty (30) days following the date on which the service was rendered. The Company will notify
the claimant of any missing documents such as invoices, receipts, doctor’s prescription, doctor’s
report and other similar relevant documents within a maximum of thirty (30) days following
receipt of the claim. Claimants will be allowed thirty (30) days, from the date of notification, to
resubmit the missing documents. In the event the Company does not receive the relevant
documents within the prescribed timeframe, the claim will be rejected on the basis of
incomplete documentation.
3. All claims must be supported by original paid vouchers, information and evidence of any nature
which the Company considers necessary to determine whether an admissible claim exists, and
the amount of any such claim.
4. Admissible claims will be refunded to the policyholder in case of Individual Policyholders and
to the insured Person in case of Corporate Policyholders, up to the limits set out in the Schedule
of Benefits and subject to the Scale of Costs as enclosed within thirty (30) days of submission
of complete set of required documents, provided the premium payments are up to date and
once all the necessary verifications have been made.
5. Claims will be settled to the nearest Mauritian rupee.
6. Subject to paragraph 9 below, where the Company is of the opinion that an account, statement
or claim is erroneous or unacceptable for payment, it shall notify the Insured Person or any
relevant service provider within 30 days after receipt thereof and state the reasons for such an
opinion; the Company shall afford such Insured Person and/or service provider the

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 opportunity to resubmit such corrected claim within 30 days following the date from which it
was returned for correction.
7. Any unsatisfied Insured Person may, upon the rejection of his claim in whole or in part by the
Company, refer in writing within 30 days of such rejection, the case directly to the Company for
review. The Company’s final decision after examination of the complainant’s and/or the
Company’s arguments shall be binding upon all the parties concerned.
8. Should there be any doubt as to the admissibility of a claim:
a) The claimant may be asked to have a counter medical examination by another Doctor
nominated by the Company.
b) If need be, the dossier may then be referred to a panel of doctors nominated by the Company
and this panel will hear all of the parties concerned before casting its opinion on the
admissibility of the claim.
c) The Company reserves the right to carry out any investigation as it may deem necessary.
9. The Company shall not entertain any claim in the event of a fraud being detected in the
submission of the claim, misrepresentation, wrongful description or non-disclosure of any
material fact. Should a fraud be detected in the submission of a claim, the Company reserves
the right to cancel the cover offered under this Policy to the Insured Person and his/her
Dependants.
10. No lawsuit shall be brought against the Company under this Policy until ninety (90) days shall
have expired after the filing at the Company’s business premises (as stipulated in the annexed
Schedule) proofs of claim, including as part thereof, the finding and/or conclusion of any
inquiry, if held by the Company.
11. This Policy provides cover for medical treatment, related costs, services and/or supplies that
the Company determines to be medically necessary and appropriate to treat a patient’s
condition, illness or injury. However, the Company will only pay for medical costs according to
the Scale of Costs as enclosed or when no mention is made in the Scale of Costs, only such
medical costs which are fair and reasonable and at the level customarily charged on the market
and for the treatment provided, in accordance with standard and generally accepted medical
procedures. If a claim is deemed by the Company to be inappropriate, the Company reserves
the right to pay the amount deemed reasonable.

2. Premiums
1. Premiums shall be payable in accordance with the premium payment terms shown in the
Schedule of Premiums.
2. A moratorium of twenty-one (21) days may be allowed at the Company’s discretion for
payment of premiums.
3. On the expiry of any moratorium, the Company reserves the right to issue a Mise en Demeure
in accordance with Article 1983-21 of the Civil Code. If premiums are not settled within 20 days
following the issue of the Mise en Demeure, the Company shall suspend the insurance cover
and not entertain any claim under this Policy until the full amount of premiums due has been
paid and policy reinstated.
4. Article 1983-21 of the Civil Code provides as follows:

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“La prime est payable au domicile de l’assureur ou du mandataire désigné par lui a cet effet ou à tel
autre lieu convenu.

A défaut de paiement d’une prime ou d’une fraction de prime, la garantie ne peut être suspendue que
vingt jours après l’expédition, par lettre recommandée, de la mise en demeure de l’assure.

La garantie suspendue reprend pour l’avenir ses effets, à midi le lendemain du jour ou ont été payes a
l’assureur ou au mandataire désigné par lui a cet effet, la prime arriérée ainsi que, éventuellement, les
frais de poursuites et de recouvrement.

L’assureur a le droit de résilier le contrat dix jours après l’expiration du délai fixe par l’alinéa 2 du
présent article ou d’en poursuivre l’exécution en justice sous réserve des dispositions de l’article 1983-
84.

Est nulle toute clause réduisant les délais fixes par les dispositions du présent article ou dispensant
l’assureur de la mise en demeure”.

The Company reserves the right to apply the procedures of the Civil Code with effect from the due
date of each unpaid premium. If the said premium remains unpaid beyond the delay period
prescribed by the law (30 days following the Mise en demeure) , the Company reserves the right
either to terminate the contract or have recourse to judicial proceedings.

5. For all Insured Members admitted during the course of the Policy, premiums will be calculated
in proportion to the period of the membership from the Admission Date to the expiry date of
the Policy. This is equally applicable in respect of any change in benefits occurring during the
period of insurance.

3. Policy When Void

If the Policyholder/Insured Member has neglected and/or failed, as required by Article 1983-20
(2) of the Civil Code, to declare or disclose faithfully to the Company in the ‘proposition d’assurance’
all the circumstances known to him/her to enable the Company to appreciate and assess ‘en
connaissance de cause’ the risks which it takes in issuing this Policy, then, the present Policy shall
become null and void subject to Article 1983-30 of the Civil Code.

4. Healthcare Insurance Membership Card

1. Every Insured Person will be provided with a Membership Card which must be produced to the
service provider on request. It remains the property of the Company and should be returned to
the Company on termination of membership.
2. Any Insured Person who has lost his membership card must immediately notify the Company
in writing and on payment of the applicable fee, he/she will be supplied with a replacement
membership card.
3. The use of a membership card by any person other than the Insured Person or his registered
Dependants, with or without the knowledge or consent of the Insured Person or his

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 Dependants, is not permitted and is construed as an abuse of the terms and conditions of this
Policy. In such a case, the Company reserves the right to take any action that it deems
appropriate including termination of the Policy, notification to the Employer and claim
compensation from the Insured Person and/or Dependants in proportion to the damage that
has been caused to the Company.

5. Change of Address
It shall be the responsibility of the Policyholder to notify the Company in writing of any change of
address of the Policyholder to avoid non-delivery or late delivery of any communication from the
Company.

6. Termination
1. This Policy will terminate on the earlier happening of any one of the following:
a) Detection of a fraud in the submission of any claim under this Policy;
b) Termination of the Policy in accordance with Article 1983-21 of the Civil Code;
c) Cancellation of this Policy in accordance with Article 1983-35 of the Civil Code;
d) Expiry of this Policy as stipulated in the attached Schedule(s).
2. In the events set out in Article 1983-35 of the Mauritius Civil Code whenever a party purports
to cancel the present contract, he/she shall give notice thereof to the other party by way of a
registered letter (“avec demande d’avis de reception”) in accordance with the provisions of
Article 1983-36.

7. Renewal of Policy
1. This Policy shall expire on the expiry date mentioned on the Schedule(s) attached. In no cases,
shall the Policy be renewed by way of “tacite réconduction”.

This Policy is renewable at the end of the policy period only by mutual agreement in writing
between the Policyholder and the Company.

2. Renewal, if any, of the insurance cover shall be subject to underwriting requirements effective
at the date of renewal and shall at all-time be subject to paragraph 5 below.

The Company reserves the right to review the terms of the Policy, including applicable premiums,
in the event of Policy renewal. The Company may also include capping of benefit limits, apply
exclusions or any excess in light of the outcomes of medical underwriting and claims experience.
The Company does not guarantee, under any circumstance, that the premium rates applicable
under this Policy will be maintained on the renewed Policy. Premiums shall be subject to annual
reviews.

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3. Without prejudice to paragraph 1 above, the Company reserves the right not to renew the
Policy in the event that the claims history of the Policyholder is beyond acceptable ranges
and/or does not meet the underwriting policy of the Company effective at the time of renewal.
4. Without prejudice to paragraph 1 above, in the event that this Policy is renewed with the
Company, the latter reserves the right to exclude, from the renewed policy, those previously
insured members whose claim history are beyond ranges acceptable to the Company.
5. Without prejudice to paragraph 1 above, the premium rate applicable on policies being
renewed shall take into account the following:
a) The claims experience and claims ratio of the Policy being renewed;
b) The underwriting risk of the Insured Members;
c) Medical inflation, that shall be determined at least annually by the Company;
d) Premium rates effective at the date of renewal;
(e) Prevailing market conditions.

GENERAL CONDITIONS

1. Benefit Section
1. To the extent permitted by law and provided that no “bénéficiaire déterminé et irrévocable”
has been appointed by the Policyholder, the Policyholder may change the beneficiary by giving
us written notice, provided the new beneficiary can demonstrate insurable and/or fiduciary
interest.

2. If the age of an Insured Member falls outside the predetermined age limits for entering into a
contract as set in this Policy, no benefits shall be payable under this Policy and premiums paid
for that Insured Member shall be refunded on a prorated basis to the Policyholder deducting
processing and documentation charges.

3. The Company shall entertain the claims arising from an event in respect of which an Insured
Person or Dependant has received or is likely to receive compensation from any source
whatsoever, only to the portion not covered by the other source(s). These claims shall at all
times be subject to the excess applicable to the respective benefits of this Policy.

4. Insured Persons and their Dependants admitted during the course of the Policy are entitled to
the benefits set out in the relevant benefit(s) chosen, with the maximum benefits being adjusted
in proportion to the period of membership calculated from the Admission Date to the expiry
date of the Policy.

5. Upon payment of any claim, the Company shall be subrogated into all the rights, actions and
privileges of the Insured Person. The Company shall be entitled to take over and conduct in its
own name or in the name of the Insured Person, defence of any claim and to prosecute for its
own benefit any claim against any third party and shall have full discretion in the conduct of

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 any negotiation and proceedings in settlement of any claim and the Insured Person and
Policyholder hereby irrevocably agree to the same.

The Insured Person shall at the expense of the Company, do and concur in doing and permit to be
done all such acts and things as may be necessary or reasonably required by the Company for the
purpose of enforcing any rights and remedies or obtaining relief or indemnity from other parties
to which the Company shall or would become entitled or subrogated, upon paying for or making
good any loss or damage under this Policy, whether such acts and things shall become necessary or
required before or after Insured Person’s indemnification by the Company.

3. Territorial Limits – Inpatient & Catastrophe Cover

1. Territorial limits

Worldwide excluding USA and Canada.

2. Treatment overseas will only be considered by the Company if:

a) Such treatments are not available in Mauritius;
b) The Company has been given advance notice of the treatment being sought;
c) The Company has been provided with all medical reports at least 1 week prior to the
treatment being sought; and
d) The treatment has been approved in advance by the Company as being admissible based
on medical advice obtained from the Doctor designated by the Company.

3. Provided that the surgical and/ or medical intervention is performed overseas, as approved by
the Company, the return air fares in Economy class of the Insured Member, undergoing
treatment, shall be covered within the cover limit. Cover will be available for air ticket for the
Insured Person or Dependant undergoing treatment only. Any other travelling expense
including costs in relation to any accompanying person will be excluded.

4. Where surgery and/ or medical intervention is performed overseas, as approved by the

company, the reimbursement of expenses will be based on the cost of the surgery and/ or
medical intervention at the nearest renowned medical centre based in South Africa, Reunion
Island or India, should the surgery and/ or treatment be undergone elsewhere, whichever the
lesser.

5. Where treatment and operation is available in Mauritius, the Company may consider
reimbursement of expenses as per the Scale of Costs as enclosed or limited to the approximate
cost in force with clinics and doctors in Mauritius. Moreover, expenses incurred in relation to
cost of air tickets and accommodation costs shall not be refunded under policy.

4. Other General Conditions

1. Every notice, information and communication to the Company shall be in writing.

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2. The Policy and endorsements, if any, represent the entire contract. No change in the Policy or
endorsement is valid unless approved and endorsed by an authorised representative of the
Company. No other person, Insurance Agent, Insurance Broker or Insurance Salesperson can
change or waive any part of the Policy or endorsement or undertake any commitment for
claim’s payment (in part or full) on behalf of the Company.
3. Planned and non life-threatening Inpatient Treatments should be communicated to the
Company at least two (2) working days prior to admission. Failure to notify the Company about
any planned treatment may result in full or partial or no refund of the claim submitted for
reimbursement as the Company deems appropriate.
4. All membership changes in respect of additions and deletions applicable for the current month
must be communicated to the Company in writing, using the prescribed Endorsement Forms,
by the 5th of every month or the following business day as applicable.
5. Notification changes after the 5th of a particular month will only be effective as from the 1st of
the following month. The Company will only entertain claims relating to events which occur as
from the date of the Insured Member joining the insurance cover.
6. A new born of an insured person may be covered at birth subject to the following conditions:
- Submission of a written medical report from the treating Gynaecologist which states the
overall medical condition of both the mother and unborn baby between the 24th and 28th
week of gestation.
- One full month’s premium will apply during the month where the newborn is added as
member
7. For individual Policyholders, the company reserves the right to deduct any balance due on
premiums from any payable/ authorised claim(s) reported during the course of the policy.

5. Waiting Period

1. Subject to specific waiting periods mentioned elsewhere in this Policy, all benefits for any
illness will have a waiting period of ninety (90) days from Admission Date. However, this
limitation will not be applicable to accidents.

2. Expenses related to optical benefits, dental benefits and hearing benefits will have a waiting
period of six (6) months from Admission Date.

3. Expenses related to maternity benefits will have a waiting period of ten (10) months from
Admission Date.

4. The following conditions will have a waiting period of twenty-four (24) months of continuous
insurance coverage with the Company from the initial Admission Date:
a) Adenoidectomy
b) Joint pain of any kind including but not limited to Arthritis, Gout, Rheumatism
c) Spinal disorders
d) Varicose veins

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 e) Benign Prostatic Hypertrophy & TURP (Transurethral resection of prostate)
f) Cataract surgery
g) Dilatation and Curettage & evacuation of uterine cavity
h) Dialysis
i) Fistula, fissure in anus
j) Gastric and duodenal ulcers
k) Hernia
l) Haemorrhoids, Piles
m) Hydrocele
n) Hysterectomy, Myomectomy & any bleeding PV (per vaginum) related to fibroids
o) Myringotomy
p) Tumours, cysts, nodules, polyps, lumps or acne
q) Stone in urinary and biliary system
r) Surgery on tonsils
s) Sinusitis, FESS (Functional Endoscopic Sinus Surgery), Septoplasty
t) Gastroscopy, Colonoscopy, Mammography or Arthroscopy

5. Pre-existing condition
a) A pre-existing condition is a disease or sickness or injury which is known to an Insured
Member and/or diagnosed and in receipt of medical advice, consultation or treatment from
a Doctor during the twelve (12) months prior to the Admission Date or which in the opinion
of a Doctor exhibited or caused symptoms during the twelve (12) months prior to the
Admission Date, warranting to compel an ordinary and prudent person to seek medical
assistance or help.
b) Subject to paragraph 5(c)below, no pre-existing condition is covered under this Policy until
such time that the Insured Member would have completed the waiting period of forty-eight
(48) months of continuous insurance coverage with the Company.
c) The medical/surgical conditions appearing at paragraph 4(a) to 4(t) above will not be
covered under this Policy if they are pre-existing at the time Insured Member first joined
the insurance cover.
d) An Insured Member suffering from any physical defect or infirmity prior to taking a Policy
will be considered as person suffering from a pre-existing condition for the purpose of this
Policy.

6. Should an Insured Member wish to increase his/her limit at any time, a waiting period as
applicable for the relevant benefit as prescribed above will apply to the difference between the
increased and initial limits as from the date of approval by the Company of the increased limit

7. The age limit at entry is 65 years old.

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
EXCLUSIONS AND LIMITATIONS

The Company shall not be liable for expenses incurred in respect of the following exclusions and
limitations:-

1. Exclusions

1.1. General

1.2. External aids, unless related to the treatment being claimed for
1. Walking aids
2. Knee brace, crepe bandages, stockings or leggings
3. Lumbosacral belt, visco belts, abdominal belts or cervical collar
4. Band-aid
5. Alpha bed, air bed or water bed
6. Other aids related or similar to the above

1.3. Theatre and ward utilities

Disposable gowns, masks, caps or leggings, thermometer, glucometer, urometer, nebulizer

or BIPAP machine, boyle apparatus, pulseoxymeter, infusion pump, syringe pump charges
or monitors and other utilities related or similar shall not be covered.

1.4. Maternity and new-born related

1. Charges and utilities for newborn during and post delivery, including vaccination
charges, baby utilities, other charges/utilities or similar to the above.

1.5. Personnel related

1. Attendant bed, attendant food and attendant pass, any charge related to guest(s),
special attendant or special nursing charges and other charges related or similar to the
above.

1.6. Miscellaneous

1. Food charges and/or food supplements other than prescribed diet - not forming part
of treatment, blood grouping, cross matching of Donor samples.
2. Screening tests of any type not forming part of immediate and subsequent treatment,
Blood reservation charges and ante-natal booking charges, ward and theatre booking
charges, preventive treatment/procedures/blood test and Gender re assignment (also
known as sex change)

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
2. Other Exclusions and Limitations
1. Insured Member’s intentional self-injury, disease, poor drug compliance, any attempt at suicide,
insanity, duelling or fighting except in self-defence.
2. Routine physical, diagnostic or investigative examinations, medical check-ups, tests,
vaccination and immunization injections unless specified in the Schedule of Benefits.
3. Treatment for alcoholism, substance abuse, solvent abuse or addictive conditions of any kind
and treatment of any illness or injury arising directly or indirectly from any such abuse or
addiction.
4. Any routine or regular treatment or on-going medication given in connection with or given to
manage any Chronic Condition (such as, but not limited to, diabetes, hypertension, stroke,
coronary artery/heart disease, dyslipidemias, gastric problems, arthritis, asthma, cancer, spinal
problems/low back ache), pre-existing condition or permanent medical condition unless
specified in the Schedule of Benefits.
5. More than one month’s supply of any drug on any one prescription.
6. Slimming products and/or any investigation, treatment, surgery for hair loss, obesity or its
sequelae.
7. All costs for operations, medicines, treatment and/or procedures for cosmetic purposes,
including scaling, whitening creams, polishing, toiletries and beauty preparations. Treatment,
procedure, diagnosis and/or surgical procedure linked or related to sterilisation,
contraception, fertility or infertility, and including tubectomy or vasectomy, unless explicitly
covered in the Schedule of Benefits.
8. Expenses related to mental illness, psychiatric conditions/disorders including panic attack,
and/or related medication including sleeping pills.
9. Treatment or investigations for epilepsy, seizure disorders or fits, or any kind of illness/injury
arising directly or indirectly from any of the aforesaid.
10. Appliances and/or medication to prevent injuries during sport and/or recreational activities.
11. All expenses related to injuries arising from professional sport, power-driven vehicle sport,
scuba diving, bungee or parachute jumps.
12. Expenses on treatments taken at sanatoriums, resting centres for improving general state of
health, convalescence, general debility and/or spa activities.
13. Expenses on sun-screening agents, soaps, shampoos and/or anti-habit substances.
14. Expenses on treatments related to sexual dysfunction, impotence, aphrodisiacs and/or Trans
sexual surgery.
15. Expenses relating to transplants of organs not forming part of any treatment.
16. Expenses on treatments related to HIV/AIDS, Hepatitis B & C unless explicitly covered in the
Schedule of Benefits.
17. Expenses related to abortion.
18. Expenses on treatment on any congenital conditions, anomalies, malformations or any
complication arising therefrom, unless explicitly covered in the Schedule of Benefits.
19. Circumcision unless required for treatment.

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
20. Expenses on treatments and Medical Expenses related to experiments of research and
development and treatments, surgeries or procedures not approved by the World Health
Organization (WHO) and Food and Drug Administration (FDA)
21. Expenses on treatments related to Naturopathy, homemade remedies or alternative medicine.
22. Any direct or indirect consequence, loss or bodily injury or sickness relating to a disease
declared by the World Health Organization as pandemic.
23. Speech therapy, physiotherapy or occupational therapy, unless explicitly covered in the
Schedule of Benefits.
24. Costs for services rendered outside the borders of Mauritius, unless explicitly covered in the
Schedule of Benefits.
25. Sleep Apnea – all treatments for sleep Apnea and/or related studies including but not limited
to Polysomnograms.
26. Treatments, drugs, procedures and/or blood investigations related to a Chronic Condition
and/or any complication arising out of it.
27. The Company shall not be liable to pay for any tests not related to the medical condition/ chief
complaint of the Insured Member.

3. War, Civil War, Piracy and Terrorism Exclusion Clause

1. Notwithstanding any provision to the contrary within this Policy or any endorsement thereto
it is agreed that this Policy excludes any liability, injury, disease/sickness, loss, damage, cost or
expense of whatsoever nature directly or indirectly caused by, resulting from or in connection
with any of the following regardless of any other cause or event contributing concurrently or
in any other sequence of the loss:
a) War, invasion, act of foreign enemy, hostilities or warlike operations (whether war be
declared or not), civil war;
b) Permanent or temporary dispossession resulting from confiscation, nationalisation,
commandeering or requisition or destruction by or under the order of any lawfully
constituted authority;
c) Mutiny, civil commotion assuming the proportions of or amounting to a popular or military
uprising, insurrection, rebellion, revolution, military or usurped power, martial law or state
of siege or any of the events or causes which determine the proclamation or maintenance
of martial law or state of siege;
d) Acts of piracy, including piracy at sea;
e) Terrorist Activity as defined herein

“Terrorist Activity” shall mean any deliberate, unlawful act that;

i. is declared by any authorised governmental official to be or to involve terrorism, terrorist

activity or acts of terrorism; or
ii. includes, involves, or is associated with the use or threatened use of force, violence or harm
against any person, tangible or intangible property, the environment, or any natural
resource, where the act or threatened act is intended, in whole or in part; or

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
 iii. intimidates, coerces or forces a government, individuals or persons to modify their
behaviour or policies.
2. Notwithstanding any provision to the contrary within this Policy or any amendment thereto
the Insurer will not be liable for any claim arising as a direct or indirect consequence of:
a) The use of nuclear, biological or chemical weapons, or any radioactive contamination; or
b) Attacks on or sabotage of facilities (including, but not limited to, nuclear power plants,
reprocessing plants, final repository sites and research reactors) and/or storage depots,
which lead to the release of radioactivity or nuclear, biological or chemical warfare agents
which are capable of causing incapacitating disablement or death amongst people or
animals howsoever these may be distributed or combined.
3. If the Insurer alleges that by reason of this exclusion, any loss, damage, cost or expense is not
covered by this Policy the burden of proving the contrary shall be upon the Policyholder.

GENERAL PROVISIONS

1. Only the mandated authorised representatives of the company have the authority to make or
alter the terms and conditions of this Policy.
2. If, at the Policy Date, any provision of this Policy conflicts with the law of the country of issue,
that provision is understood to be amended to conform to that law.
3. This Policy does not participate in the profits of the Company.
4. If for any reason the Policyholder is not satisfied with this Policy, the Policyholder may return
it to the Company for cancellation within thirty (30) days from the date of receipt of the Policy,
in which case all premiums paid net of all claims already settled will be returned. Accordingly,
in the event that the claims settled exceed the premium already paid, the Policyholder shall
return the excess amount paid by the Company. The company will also deduct all processing
and documentation charges from the refund value.

5. Applicable for Individual Policyholder, the Company may cancel this policy by sending a
registered letter with thirty days’ notice to the Policyholder at the last known address. In such
a case, the Company will return to the Policyholder the premium paid net of claims already
settled, less pro rata portion thereof for the period the policy was in force and all processing
and documentation charges.

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
DEFINITIONS / GLOSSARY OF TERMS

Accident: An unforeseen and unplanned event or circumstance.

Admission Date: It is the date on which the Insured Member joins the Policy.

Adult Dependant: Lawfully married spouse of the Insured Person or a person of the opposite sex
who lives together with the Insured Person under the same roof as husband and wife. There cannot
be more than one Adult Dependant per Insured Person. Parents and/or other dependants of the
Insured Person are excluded.

Beneficiary: A person or an institution named to receive proceeds or benefits under a policy.

Child Dependant: Child, stepchild or lawfully adopted child, of the Insured Person, under the age
of 18 but may include children up to 23 years if dependant and pursuing full-time education and/or
unemployed. Child dependant excludes any married child or any child in full-time employment.

Chronic Condition:

Chronic disease is defined as a disease, illness or injury that has one or more of the following
characteristics:

- Needs ongoing or long-term monitoring, through consultations, medications,

examinations, check-ups and/ or tests.
- Needs ongoing or long-term control or relief of symptoms
- Requires rehabilitation or for someone to be specially trained to handle it
- Continues indefinitely
- Has no known cure
- Recurs or is likely to recur

Claim: A demand from the Insured Person or Dependant, directly or through the Policyholder, to
the Insurer for payment of benefits under the Policy.

Claim form: An application completed by Insured Person or Dependant for payment of benefits
under the Policy.

Claims Ratio: Claim Ratio is defined as (Total Claims Paid ADD Outstanding Claims) DIVIDED BY
Total Premiums Booked for the period of cover:

Total Claims Paid + Outstanding Claims

Claims Ratio = Total Premiums Booked

Outstanding Claims shall include claims reported for the period but not yet settled and a provision
of claims incurred but not yet reported to the Insurer.

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
Company: The word “Company” refers exclusively to NIC General Insurance Co. Ltd under the
terms and conditions of this contract and all subsequent documents related to this contract.

Congenital anomaly/problem: An anomaly that exists at and usually before birth.

Dependants: Dependants refer to Adult Dependants and/or Child Dependants defined herein.

Diagnosis: The process of determining and identifying the nature of a disease or disorder and
distinguishing it from other possible conditions.

Dialysis: It is a method of extra-corporal removal of waste products such as creatinine and urea, as
well as free water from the blood when the kidneys are in failure

Disease: It is an abnormal condition of the body and/or mind that causes discomfort, dysfunction,
or distress to the person afflicted. Sometimes, the term is used broadly to include injuries,
disabilities, syndromes, symptoms and deviant behaviours.

Doctor: A person, licensed or authorised by law to practise and duly registered with the Medical
Council of Mauritius or overseas equivalents, and who diagnoses physical and mental illnesses,
disorders, injuries, and prescribes medications and treatments to promote or restore good health.

Documentation fee: Fee charged by the Company for issuing the policy

Donor: A natural person that donates blood, biological tissues, sperm, ova and/or an organ of the
human body, for the purpose of saving or promoting health or life.

Drug abuse: Solvent abuse, alcohol abuse or any kind of chemical abuse leading to illness or injury.

Emergency: The sudden and, at the material time, unexpected onset of a health condition that
requires immediate medical or surgical treatment, where failure to provide treatment would result
in serious impairment to bodily functions or bodily organs, or would place the person’s life in
serious jeopardy.

Event: An occurrence of a health condition/ treatment/ surgery. If a benefit is payable per event
per year, any condition, treatment or surgery which is related to a condition, treatment or surgery
which has already occurred during a policy year, will be payable from the remaining limit of the
benefit.

Excess: Excess is an amount to be borne by the Insured Person and is not payable under the Policy.

Exclusions: Health care services or benefits that are not covered under this Policy.

Family: Refers to family members related by blood or marriage. This includes father, mother,
spouse, child, brother and sister.

Hospitalisation: It shall mean the necessary admission to a Hospital as an inpatient on the order
of and under the supervision of a Doctor. Necessary admission is admission which in the opinion of

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
a Doctor is required in terms of accepted medical practice for treatment of the injury or illness, but
excludes any Hospitalisation excluded under the Policy.

ID Fee: Fee charged for membership cards

Injury: Body wound resulting from physical trauma.

Inpatient treatment: Treatment that requires a justified admission into a private hospital/ clinic
for one or more days of overnight stay, as per available limits in line with the provisions of your
policy.

Insurance Agent: Insurance Agent means a person who with the authority of an Insurer and not
being an employee of the Insurer, acts on behalf of the Insurer in the initiation of the insurance
business, the receipt of proposals, the issue of policies, the collection of premiums or the settlement
of claims.

Insurance Broker: Insurance Broker means a person who arranges insurance business with
insurers on behalf of prospective Policyholders or as representatives of a Policyholder, and
includes a reinsurance broker carrying on reinsurance brokering for an insurer.

Insurance Salesperson: Insurance salesperson means a natural person who solicits proposals for
and negotiates insurance on behalf and with the authority of an insurer or an Insurance Agent, not
being its employee or officer.

Insured Member: Insured Person and Dependant(s) if any either for an Individual Policyholder or
Corporate Policyholder.

Insured Person: Any person included in the Schedule of Insured Members annexed to this Policy
and/or who is an employee of the Policyholder in case the Policyholder is a corporate.

Insurer: The word “Insurer” refers exclusively to NIC General Insurance Co. Ltd under the terms
and conditions of this contract and all subsequent documents related to this contract.

Levy fee: Fee imposed by the Financial Services Commission

Medical expenses: The cost of diagnosis, treatment for any illness, injury or disease. They include
pharmaceuticals, medical and surgical supplies, medical devices and equipment and other products
needed to support doctors, nurses and other service providers.

Naturopathy: Naturopathy is a system of treatment of any disease that avoids drugs and surgery
and emphasises use of natural agents like air, water and herbs as treatment.

Nurse: A person who cares for the sick and/or for someone who is physically or mentally disabled.
The person should be a licensed healthcare professional who practises independantly or is
supervised by a physician, surgeon, or dentist and who is skilled in promoting and maintaining
good health.

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
Nursing home: Nursing homes are residential healthcare facilities that provide nursing care and
supervision 24 hours a day. In addition to skilled nursing services, physical, occupational and
speech therapy are usually offered. These therapies are designed to enable residents to recover and
improve functional ability lost as a result of disease or injury.

Outpatient treatment: Treatment that does not require a patient (Insured Member) to stay
overnight at a Hospital.

Parent Dependant: Mother or father of the Insured Person.

Policy Benefits: Policy Benefits mean one or more sums of money, services or other benefits.

Policyholder: The corporate or person so designated in the Schedule(s) as owner of this Policy,
who has contracted the health cover and who is responsible for payment of the Premium to the
Company.

Post-natal: The first fifteen (15) days after child delivery.

Pregnancy: It is a process and series of changes that take place in a woman’s organs and tissues as
a result of a developing foetus. The entire process from fertilisation to birth takes about nine (9)
months.

Premium: It is the consideration given or to be given in return for an undertaking to provide Policy
Benefits under specified circumstances.

Private Hospital/ Clinic: It shall mean a facility which meets all of the following standards:

 It is operated pursuant to law;

 Its primary and continuous function is to provide, for a charge, medical, surgical and
diagnostic facilities for the medical care and treatment of sick or injured persons. The
facilities must be supervised by a staff of one or more Doctors. All such facilities must be on
the premises or available on a prearranged basis.
 It provides 24-hour nursing service. Such service must be performed and supervised by
Qualified Nurses.
 It keeps daily records.

Private hospital/ clinic does not include:

 Rest home
 Long term nursing care facility
 Home for the aged
 Any facility which primarily affords remedial, rehabilitative, or convalescent care
 Any facility primarily for the confinement or treatment of drug abuse or addiction or
alcoholism.

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018
Procedure: An activity directed at, or performed on an individual with the object of improving
health, treating disease or injury, or making a diagnosis.

Public Hospital: A public hospital is a hospital owned by the Government and where care/
treatments are available free of charge.

Root filling: Root filling involves removing damaged or dead nerves and filling the space. This
allows the dentist to repair the teeth that are left.

Risk: It means a possibility that a particular event may occur during the period for which an
insurance policy is in force.

Scale of Cost: It is the maximum cost the company will settle for listed procedures, surgeries, room
rents and doctor’s fees. The scale of cost shall be reviewed annually in line with the industry
practice and the last one issued shall always precede the others. The insured shall be notified of the
effective date of the new release.

Service Provider: A Private Hospital/ Clinic, Optician or Doctor .

Standard room: It means an individual air-conditioned room with attached bathroom. This room
may have a television, telephone and couch. This does not include deluxe room / suite or room with
additional facilities other than those stated herein

Surgeon: A Doctor who specialises in the treatment of injuries, diseases, and deformities through
surgical Procedures.

Tooth extraction: It is the removal of a tooth from its socket in the bone.

Transplant: The transfer of an organ from one person to another.

Waiting period: The time period before one is eligible to receive benefits under the Policy and is
also known as elimination period.

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Ref. & Version: G/HID/T001/V1.2 Released on: 01.10.2018