PRESTIGE GLOBAL HEALTH OPTIONS - Great Eastern … · OAC is a general insurance company regulated...

PRESTIGE GLOBAL HEALTH OPTIONSYour trusted and comprehensive medical plan

Lifestyle

2

TAILOR A HEALTH

INSURANCE PLAN TO

MEET THE NEEDS OF

YOU AND YOUR FAMILY.

Plan administration from Cigna, a leader in global healthcare

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INTERNATIONAL HEALTH INSURANCE

The Overseas Assurance Corporation Limited (OAC) has partnered with Cigna to bring you Prestige

Global Health Options, insured by OAC, and administered by Cigna.

OAC is a general insurance company regulated by the Monetary Authority of Singapore and is a wholly-owned

subsidiary of Great Eastern Holdings Limited, the oldest and most established life insurance group in Singapore

and Malaysia.

As the administrator of your plan, Cigna has offices all around the world, and a wide international network of

trusted hospitals, physicians and other healthcare professionals. Cigna has provided global health insurance for

many years. Today they have 86 million customer relationships in over 200 countries and jurisdictions. Looking

after them is an international workforce of 37,000 people, plus a medical network comprising of over 1 million

partnerships, including 89,000 behavioural health care professionals, and 11,400 facilities and clinics.

With Prestige Global Health Options, you can create the policy that’s right for you and your family. We offer three

distinct levels of cover, with a host of optional additional benefits. Read on to find out more about what we have

to offer.

CONTENTSWhy choose a Prestige Global Health Options plan 4

How to create your plan 5

How deductible, cost share and out of pocket maximum work 7

Benefits in detail 9

We have you covered 32

What you can expect from us 33

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WHY CHOOSE A PRESTIGE

GLOBAL HEALTH OPTIONS PLAN

Why choose us

Our customers choose us because Prestige Global Health Options gives them all of the following:

> Access to our network of trusted hospitals, physicians and other healthcare professionals.

> The flexibility to tailor a cost-eEective plan to suit their individual needs.

> Making sure our Customer Care Team is always available to speak with you day and night.

> The reassurance of our experience in delivering international healthcare.

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HOW TO CREATE YOUR PLAN

Creating a comprehensive, tailored plan with OAC is

simple. It’s flexible, so you can choose and pay for only

the cover you need. Our plans comprise of three levels

of cover: Silver, Gold and Platinum. Each plan includes

International Medical Insurance. Choose from two

areas of coverage, depending on needs and location:

Worldwide including USA and Worldwide excluding

USA.

In addition, you can select optional modules, including:

International Outpatient; International Medical

Evacuation; International Health and Wellbeing; and

International Vision and Dental which enables you the

flexibility to create a health insurance plan that suits

your unique needs.

As well as this, we offer a wide range of cost share and

deductible options on International Medical Insurance

and International Outpatient, allowing you to tailor a

plan to suit your budget and needs.

The diagram on the next page shows you how Prestige

Global Health Options plans work.

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International Outpatient More extensive outpatient care for

treatments that don’t require an overnight

stay in hospital. Including prescribed

outpatient drugs and dressings and

much more.

International Health & Wellbeing Proactively manage your

own health. Screen against disease,

test against common illnesses and get

reassurance with routine physical exams.

International Medical Evacuation Medical evacuation in the event that

treatment is not available locally in an

emergency, as well as repatriation, allowing the

beneficiary to return to their country of habitual

residence or nationality.

International Vision & Dental Vision care including an eye test and a

wide range of preventative, routine and

major dental treatments.

SELECT YOUR CORE PLAN - INTERNATIONAL MEDICAL INSURANCE

Start with one of our core inpatient plans, which

covers you for essential hospital stays and

treatments, such as:

> Surgeon & consultation fees

> Hospital accommodation

> Cancer treatment

ADD OPTIONAL MODULES

PAY FOR YOUR PLAN4

Choose if you would like to add a deductible or cost share*. Please see page 7 for a full description and example of how the deductible and cost

share work.

*the voluntary amount you have chosen to pay that’s not covered by your plan.

Premiums will be paid on an annual basis. Payments can be made by cash or cheque, at any OCBC

branch into OAC USD account or by bank transfer (overseas TT or local bank transfer).

Annual bene6tsUp to the maximum amount per beneficiary per period of cover

2

1

SILVER: USD1,000,000

GOLD: USD2,000,000

PLATINUM: USD3,000,000

Creating a comprehensive, tailored plan with Prestige Global Health Options is simple.

MANAGE YOUR PREMIUM3

Choose from two areas of coverage:

> Worldwide including USA or

> Worldwide excluding USA

g

on

ng the

t

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Our wide range of deductible and cost share options

allow you to tailor your plan to suit your needs.

You can choose to have a deductible and/or cost

share on the International Medical Insurance

and/or International Outpatient option. No deductible

applies to inpatient cash benefits or newborn care

benefits.

You will be responsible for paying the amount of any

deductible and cost share directly to the hospital,

clinic or medical practitioner. We will let you know

what this amount is. If you select both a deductible

and a cost share, the amount you will need to

pay due to the deductible is calculated before the

amount you will need to pay due to the cost share.

The out of pocket maximum is the maximum

amount of cost share any beneficiary would have to

pay per period of cover.

The following examples show how the deductible,

cost share and out of pocket maximum work.

This is the amount of money you pay towards

your medical expenses per period of cover.

Claim value: USD1,200

Deductible: USD500

HOW THE DEDUCTIBLE, COST SHARE AND OUT

OF POCKET MAXIMUM WORK

YOU PAY..

Deductible of

USD500

WE PAY...

USD700

EXAMPLE 1: DEDUCTIBLE

(also known as ‘excess’)

WHAT THIS MEANS FOR YOU... You only pay the deductible amount and

we pay the rest.

Cost share is the percentage of every claim you

will pay. Out of pocket is the maximum amount

you would have to pay in cost share per period of

cover.


Deductible: USD0

20% cost share: USD1,000

Out of pocket maximum: USD2,000

YOU PAY..

The 20% cost share

of USD1,000

WE PAY...

USD4,000

EXAMPLE 2: COST SHARE AND

OUT OF POCKET MAXIMUM AFTER

DEDUCTIBLE

(when your cost share after deductible amount is

under the out of pocket maximum)

WHAT THIS MEANS FOR YOU... Your cost share is 20% of USD5,000 (USD1,000).

This is less than your out of pocket maximum, so

you pay USD1,000 and we cover the rest.

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cover.


Deductible: USD0



YOU PAY..

The out of pocket

maximum of

USD2,000

WE PAY...

USD18,000

EXAMPLE 3: COST SHARE AND

OUT OF POCKET MAXIMUM AFTER

DEDUCTIBLE


over the out of pocket maximum)

WHAT THIS MEANS FOR YOU... Your cost share is 20% of USD20,000 (USD4,000).

This is more than your out of pocket maximum, so

you only pay USD2,000 and we cover the rest.




cover.


Deductible: USD375



YOU PAY..

The deductible of

USD375 and the

cost share of

USD3,925

WE PAY...

USD15,700

EXAMPLE 4: DEDUCTIBLE, COST

SHARE AND OUT OF POCKET

MAXIMUM AFTER DEDUCTIBLE


under the out of pocket maximum)

WHAT THIS MEANS FOR YOU... After you paid your deductible of USD375, your cost

share is 20% of USD19,625 (USD3,925). This is not

more than your out of pocket maximum, so you pay

the USD3,925 towards satisfying the out of pocket

maximum for the cost share (and the initial USD375

deductible that you paid at the outset) and we cover

the rest.

Please note: The deductible, cost share after deductible, and out of pocket maximum is determined separately for each

beneficiary and each period of cover.

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Hospital charges for:Nursing and accommodation for inpatient and

daypatient treatment and recovery room.

Silver Gold Platinum

Paid in full for a

semi-private room

Paid in full for a

private room

Paid in full for a

private room

• We will pay for nursing care and accommodation whilst a

beneficiary is receiving inpatient or daypatient treatment;

or the cost of a treatment room while a beneficiary is

undergoing outpatient surgery, if one is required.

• We will only pay these costs if:

• it is medically necessary for the beneficiary to be

treated on an inpatient or daypatient basis;

• they stay in hospital for a medically appropriate period

of time;

• the treatment which they receive is provided or

managed by a specialist; and

• they stay in a standard single room with a private

bathroom or equivalent (applicable on the Gold and

Platinum plans only).

• they stay in a semi-private room with shared

bathroom (applicable on the Silver plan only).

• If a hospital’s fees vary depending on the type of room

which the beneficiary stays in, then the maximum

amount which we will pay is the amount which would

have been charged if the beneficiary had stayed in

a standard single room with a private bathroom or

equivalent (applicable on the Gold and Platinum plans

only), or a semi-private room with shared bathroom or

equivalent (applicable on the Silver plan only).

• If the treating medical practitioner decides that the

beneficiary needs to stay in hospital for a longer period

than we have approved in advance, or decides that the

treatment which the beneficiary needs is different to that

which we have approved in advance, then that medical

practitioner must provide us with a report, explaining:

how long the beneficiary will need to stay in hospital; the

diagnosis (if this has changed); and the treatment which

the beneficiary has received, and needs to receive.

Annual benefit - maximum per beneficiary per

period of cover.This includes claims paid across all sections of

International Medical Insurance.


USD1,000,000 USD2,000,000 USD3,000,000

INTERNATIONAL MEDICAL INSURANCE

Our plans comprise of 3 distinct levels of cover: Silver, Gold and Platinum.

Your chosen level of cover is detailed in the table below. All amounts apply per beneficiary and per period of

cover (except where otherwise noted).

International Medical Insurance is your essential cover for inpatient, daypatient and accommodation costs,

as well as cover for cancer, mental health care and much more. Our Gold and Platinum plans also give you

cover for inpatient and daypatient maternity care.

YOUR STANDARD MEDICAL BENEFITS

YOUR OVERALL LIMIT

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Hospital charges for:

• operating theatre.

• prescribed medicines, drugs and dressings

for inpatient or daypatient treatment.

• treatment room fees for outpatient surgery.


Paid in full Paid in full Paid in full

Operating theatre costs

• We will pay any costs and charges relating to the use

of an operating theatre, if the treatment being given is

covered under this policy.

Medicines, drugs and dressings

• We will pay for medicines, drugs and dressings which are

prescribed for the beneficiary whilst he or she is receiving

inpatient or daypatient treatment.

• We will only pay for medicines, drugs and dressings

which are prescribed for use at home if the beneficiary

has cover under the International Outpatient option

(unless they are prescribed as part of cancer treatment).

Intensive care:

• intensive therapy.

• coronary care.

• high dependency unit.



• We will pay for a beneficiary to be treated in an intensive care, intensive therapy, coronary care or high dependency facility if:

• that facility is the most appropriate place for them to be treated;

• the care provided by that facility is an essential part of their treatment; and

• the care provided by that facility is routinely required by patients suffering from the same type of illness or injury, or

receiving the same type of treatment.

Surgeons’ and anaesthetists’ fees



• We will pay for inpatient, daypatient or outpatient costs for:

• surgeons’ and anaesthetists’ surgery fees; and

• surgeons’ and anaesthetists’ fees in respect of treatment which is needed immediately before or after surgery (i.e. on the

same day as the surgery).

• We will only pay for outpatient treatments received before or after surgery if the beneficiary has cover under the International

Outpatient option (unless the treatment is given as part of cancer treatment).

Specialists’ consultation fees



• We will pay for regular visits by a specialist during stays in hospital including intensive care by a specialist for as long as is

required by medical necessity.

• We will pay for consultations with a specialist during stays in a hospital where the beneficiary:

• is being treated on an inpatient or daypatient basis;

• is having surgery; or

• where the consultation is a medical necessity.

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Hospital accommodation for a parent or guardianUp to the maximum amount shown per period of cover.


USD1,000 USD1,000 Paid in full

• If a beneficiary who is under the age of 18 years old needs inpatient treatment and has to stay in hospital overnight, we will

also pay for hospital accommodation for a parent or legal guardian, if:

• accommodation is available in the same hospital; and

• the cost is reasonable.

• We will only pay for hospital accommodation for a parent or legal guardian if the treatment which the beneficiary is receiving

during their stay in hospital is covered under this policy.

Transplant services for organ, bone marrow and

stem cell transplants



• We will pay for inpatient treatment directly associated with an organ transplant, for the beneficiary if:

• the transplant is medically necessary, and the organ to be transplanted has been donated by a member of the

beneficiary’s family or comes from a verified and legitimate source.

• We will pay for anti-rejection medicines following a transplant, when they are given on an inpatient basis.

• We will pay for inpatient treatment directly associated with a bone marrow or peripheral stem cell transplant if:

• the transplant is medically necessary; and

• the material to be transplanted is the beneficiary’s own bone marrow or stem cells, or bone marrow taken from a verified

and legitimate source.

• We will not pay for bone marrow or peripheral stem cell transplants under this part of this policy if the transplants form part

of cancer treatment. The cover which we provide in respect of cancer treatment is explained in other parts of this policy.

• If a person donates bone marrow or an organ to a beneficiary, we will pay for:

• the harvesting of the organ or bone marrow;

• any medically necessary tissue matching tests or procedures;

• the donor’s hospital costs; and

• any costs which are incurred if the donor experiences complications, for a period of 30 days after their procedure;

whether or not the donor is covered by this policy.

• The amount which we will pay towards a donor’s medical costs will be reduced by the amount which is payable to them in

relation to those costs under any other insurance policy or from any other source.

• We will not pay for outpatient treatment for either the beneficiary or donor, unless the beneficiary has cover under the

International Outpatient option for the specific outpatient treatment required.

• If a beneficiary donates an organ for a medically necessary transplant, we will cover the medical costs incurred by the

beneficiary associated with this donation up to any policy limits. However, we will only pay for the harvesting of the donated

organ if the intended recipient is also a beneficiary under this plan.

• We will consider all medically necessary transplants. Other transplants (such as transplants which are considered to be

experimental procedures) are not covered under this policy. This is because of conditions or limitations to coverage which

are explained elsewhere in this policy.

Important note

• A beneficiary must contact us and get approval in advance before they incur any costs relating to organ, bone marrow or

stem cell donation or transplant.

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Kidney dialysis



• Treatment for kidney dialysis will be covered if such treatment is available in the beneficiary’s country of residence. We will

pay for this on an inpatient, daypatient, or outpatient basis.

• We will pay for kidney dialysis treatment outside the beneficiary’s country of habitual residence if the country where that

treatment is provided is within the beneficiary’s selected area of coverage. We will pay for this on a daypatient basis. Travel

and accommodation expenses incurred in connection with such treatment will not be covered.

Pathology, radiology and diagnostic tests (excluding Advanced Medical Imaging)



• Where investigations are provided on an inpatient or daypatient basis.

• We will pay for:

• blood and urine tests;

• X-rays;

• ultrasound scans;

• electrocardiograms (ECG); and

• other diagnostic tests (excluding advanced medical imaging);

where they are medically necessary and are recommended by a specialist as part of a beneficiary’s hospital stay for inpatient

or daypatient treatment.

Advanced Medical Imaging (MRI, CT and PET

scans)Up to the maximum amount shown per period of cover.



• We will pay for the following scans if they are recommended by a specialist as a part of a beneficiary’s inpatient, daypatient

or outpatient treatment:

• magnetic resonance imaging (MRI);

• computed tomography (CT); and / or

• positron emission tomography (PET);

• We may require a medical report in advance of a magnetic resonance imaging (MRI) scan.

Physiotherapy and complementary therapies Up to the maximum amount shown per period of cover.



• Where treatment is provided on an inpatient or daypatient basis.

• We will pay for treatment provided by physiotherapist and complementary therapists; (acupuncturists, homeopaths, and

practitioners of Chinese medicine) if these therapies are recommended by a specialist as part of the beneficiary’s hospital

stay for inpatient or daypatient treatment (but are not the primary treatment which they are in hospital to receive).

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Home nursingUp to 30 days and the maximum amount shown per

period of cover.



• We will pay for a beneficiary to have up to 30 days of home nursing care per period of cover if:

• it is recommended by a specialist following inpatient or daypatient treatment which is covered by this policy;

• it starts immediately after the beneficiary leaves hospital; and

• it reduces the length of time for which the beneficiary needs to stay in hospital.

Important note

• We will only pay for home nursing if it is provided in the beneficiary’s home by a qualified nurse and it comprises medically

necessary care that would normally be provided in a hospital. We will not pay for home nursing which only provides non-

medical care or personal assistance.

RehabilitationUp to 30 days and the maximum amount shown per

period of cover.



• We will pay for rehabilitation treatments (physical, occupational and speech therapies), which are recommended by a

specialist and are medically necessary after a traumatic event such as a stroke or spinal injury.

• If the rehabilitation treatment is required in a residential rehabilitation centre we will pay for accommodation and board for up

to 30 days for each separate condition that requires rehabilitation treatment.

In determining when the 30 day limit has been reached:

• we count each overnight stay during which a beneficiary receives inpatient treatment as one day

• we count each day on which a beneficiary receives outpatient and daypatient treatment as one day.

• Subject to prior approval being obtained, prior to the commencement of any treatment, we will pay for rehabilitation

treatment for more than 30 days, if further treatment is medically necessary and is recommended by the treating specialist.

Important note

• We will only pay for rehabilitation treatment if it is needed after, or as a result of, treatment which is covered by this policy

and it begins within 30 days of the end of that original treatment.

• All rehabilitation treatment must be approved by us in advance. We will only approve rehabilitation treatment if the treating

specialist provides us with a report, explaining:

i) how long the beneficiary will need to stay in hospital;

ii) the diagnosis; and

iii) the treatment which the beneficiary has received, or needs to receive.

Hospice and palliative careUp to the maximum amount shown per lifetime.



• If a beneficiary is given a terminal diagnosis, and there is no available treatment which will be effective in aiding recovery,

we will pay for hospital or hospice care and accommodation, nursing care, prescribed medicines, and physical and

psychological care.

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Internal prosthetic devices / surgical and medical appliances Up to the maximum amount shown per period of cover.



• We will pay for internal prosthetic implants, devices or appliances which are put in place during surgery as part of a

beneficiary’s treatment.

• A surgical appliance or a medical appliance can mean:

• an artificial limb, prosthesis or device which is required for the purpose of or in connection with surgery; or

• an artificial device or prosthesis which is a necessary part of the treatment immediately following surgery for as long as

required by medical necessity; or

• a prosthesis or appliance which is medically necessary and is part of the recuperation process on a short-term basis.

External prosthetic devices/surgical and medical appliancesUp to the maximum amount shown per period of cover.


For each prosthetic device

USD3,100


USD3,100


USD3,100

• We will pay for external prosthetics, devices or appliances which are necessary as part of a beneficiary’s treatment (subject

to the limitations explained below).


• a prosthetic device or appliance which is a necessary part of the treatment immediately following surgery for as long as is

required by medical necessity;

• a prosthetic device or appliance which is medically necessary and is part of the recuperation process on a short-term

basis.

• We will pay for an initial external prosthetic device for beneficiaries aged 18 or over per period of cover. We do not pay for

any replacement prosthetic devices for beneficiaries who are aged 18 and over.

• We will pay for an initial external prosthetic device and up to two replacements for beneficiaries aged 17 or younger per

period of cover.

• By an external ‘prosthetic device’, we mean an external artificial body part, such as a prosthetic limb or prosthetic

hand which is medically necessary as part of treatment immediately following the beneficiary’s surgery or as part of the

recuperation process on a short-term basis.

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Inpatient cash benefitPer night up to 30 nights per period of cover.


USD100 USD100 USD200

• We will make a cash payment directly to a beneficiary when they:

• receive treatment in hospital which is covered under this plan;

• stay in a hospital overnight; and

• have not been charged for their room, board and treatment costs.

Emergency inpatient dental treatment



• We will cover dental treatment in hospital after a serious accident, subject to the conditions set out below.

• We will pay for emergency dental treatment which is required by a beneficiary while they are in hospital as an inpatient, if that

emergency inpatient dental treatment is recommended by the treating medical practitioner because of a dental emergency

(but is not the primary treatment which the beneficiary is in hospital to receive).

• This benefit is paid instead of any other dental benefits the beneficiary may be entitled to in these circumstances.

Local ambulance and air ambulance services



• Where it is medically necessary, we will pay for a local ambulance to transport a beneficiary:

• from the scene of an accident or injury to a hospital;

• from one hospital to another; or

• from their home to a hospital.

• We will only pay for a local road ambulance where its use relates to treatment which a beneficiary needs to receive in

hospital. Where it is medically necessary, we will pay for an air ambulance to transport the beneficiary from the scene of an

accident or injury to a hospital or from one hospital to another.

Important notes

• Air ambulance cover is subject to the following conditions and limitations:

• In some situations it will be impossible, impractical or unreasonably dangerous for an air ambulance to operate. In these

situations, we will not arrange or pay for an air ambulance. This policy does not guarantee that an air ambulance will

always be available when requested, even if it is medically appropriate.

• We will only pay for a local air ambulance, such as a helicopter, to transport a beneficiary for distances up to 100 miles

(160 kilometres) and we will only pay for an air ambulance where its use relates to treatment which a beneficiary needs to

receive in hospital.

• This policy does not provide cover for mountain rescue services.

• Cover for medical evacuation or repatriation is only available if you have cover under the International Medical Evacuation

option. Please refer to the relevant section of this brochure for details of that option.

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Treatment for mental health conditions and disorders and addiction treatmentUp to the maximum amount shown per period of cover.



• Subject to the limits explained below we will pay for:

• the treatment of mental health conditions and disorders; and

• the diagnosis of addictions (including alcoholism);

Addiction treatment

• We will pay for one course or programme of addiction treatment at a specialist centre providing evidence-based treatment,

if that treatment is medically necessary and recommended by a medical practitioner.

• We pay for up to three attempts at detoxification, following which we will only pay for further detoxification treatment if the

beneficiary completes a formal outpatient course or programme of addiction treatment.

• We will not pay for any other treatment related to alcoholism or addiction; or treatment of any related condition (such as

depression, dementia or liver failure); where we reasonably believe that the condition which requires treatment was the direct

result of alcoholism or addiction.

Important notes

• For treatment of mental health conditions and disorders and addiction treatment, we will only pay for evidence-based,

medically necessary treatment and recommended by a medical practitioner.

• We will pay for up to a combined maximum total of 90 days of treatment for mental health conditions and disorders and

addiction treatment in any one period of cover, including up to 30 days of inpatient treatment.

• We will pay for up to a combined maximum total of 180 days of treatment for mental health conditions and disorders;

and addiction treatment in any five year period. For example, if a beneficiary uses 90 days of mental health or addiction

treatment in one period of cover, and 90 days of mental health or addiction treatment in the following period of cover, we will

not pay for any further mental health or addiction treatment for the next three consecutive years of cover.

• In determining when these 30, 90 and 180 day limits have been reached:

• we count each overnight stay during which a beneficiary received inpatient treatment as one day; and

• we count each day on which a beneficiary receives outpatient and daypatient treatment as one day.

• We will not pay for prescription drugs or medication prescribed on an outpatient basis for any of these conditions, unless

you have purchased the International Outpatient option.

• Subject to prior approval and provided the medical practitioner is within your selected area of coverage, we may pay for

consultations that take place by use of electronic means or telephone.

Cancer care



• Following a diagnosis of cancer, we will pay for costs for the treatment of cancer if the treatment is considered by us to be

active treatment and evidence-based treatment. This includes chemotherapy, radiotherapy, oncology, diagnostic tests and

drugs, whether the beneficiary is staying in a hospital overnight or receiving treatment as a daypatient or outpatient.

• We do not pay for genetic cancer screening.

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Routine maternity benefit care (Gold and Platinum plans only)Up to the maximum amount shown per period of cover.

Available once the mother has been covered by the

policy for twelve (12) months or more.


Not covered USD7,000 USD14,000

• We will pay for the following parent and baby care and treatment, on an inpatient or daypatient basis as appropriate, if the

mother has been a beneficiary under this policy for a continuous period of at least twelve (12) months or more:

• hospital, obstetricians’ and midwives’ fees for routine childbirth; and

• any fees as a result of post-natal care required by the mother immediately following routine childbirth.

• We will not pay for surrogacy or any related treatment. We will not pay for maternity benefit care or treatment for a

beneficiary acting as a surrogate or anyone acting as a surrogate for a beneficiary.

PARENT AND BABY CARE

Complications from maternity (Gold and Platinum plans only)Up to the maximum amount shown per period of cover.





• We will pay for inpatient or outpatient treatment relating to complications resulting from pregnancy or childbirth if the mother

has been a beneficiary under this policy for a continuous period of at least twelve (12) months or more. This is limited to

conditions which can only arise as a direct result of pregnancy or childbirth, including miscarriage and ectopic pregnancy.

• This part of the policy does not provide cover for home births.

• We will only pay for a Caesarean section, where it is medically necessary. If we cannot confirm that it was medically

necessary, we will only pay up to the limit of the mother’s routine maternity benefit care cover.

• We will not pay for surrogacy or any related treatment. We will not pay for maternity benefit care or treatment for a

beneficiary acting as a surrogate or anyone acting as a surrogate for a beneficiary.

Homebirths (Gold and Platinum plans only)Up to the maximum amount shown per period of cover.




Not covered USD500 USD1,100

• We will pay midwives’ and specialists’ fees relating to routine home births if the mother has been a beneficiary under this

policy for a continuous period of twelve (12) months or more.

• Please note that the Complications from maternity cover explained above does not include cover for home childbirth. This

means that any costs relating to complications which arise in relation to home childbirth will only be paid in accordance with

the home childbirth limits, as explained in the list of benefits.

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Newborn care Up to the maximum amount shown for treatment within the first 90 days following birth. Available once at least one parent has been covered by the policy for twelve (12) months or more.


USD25,000 USD75,000 USD156,000

• Provided the newborn is added to the policy, we will pay for:

• up to 10 days routine care for the baby following birth; and

• all treatment required for the baby during the first 90 days after birth instead of any other benefit; if at least one parent

has been covered by the policy for a continuous period of twelve (12) months or more prior to the newborn’s birth.

We will not require information about the newborn’s health or a medical examination if an application is received by us to

add the newborn to the policy within 30 days of the newborn’s date of birth. If an application is received after 30 days of

the newborn’s date of birth, the newborn will be subject to medical underwriting and we will require the completion of a

medical health questionnaire whereby we may apply special restrictions or exclusions.



• all treatment required for the baby during the first 90 days after birth instead of any other benefit; if neither parent has

been covered by the policy for a continuous period of twelve (12) months or more prior to the newborn’s birth and an

application is received by us to add the newborn to the policy as a beneficiary. The newborn will be subject to medical

underwriting and we will require the completion of a medical health questionnaire. Cover for the newborn will be subject

to medical underwriting whereby we may apply special restrictions or exclusions.

• The newborn care benefits explained above are not available for children who are born following fertility treatment (such

as IVF), are born to a surrogate, or have been adopted. In these circumstances children can only be covered by the policy

when they are 90 days old. Cover for the baby will be subject to completion of a medical health questionnaire whereby we

may apply special restrictions or exclusions.

Congenital conditions Up to the maximum amount shown per period of cover.


USD5,000 USD20,000 USD39,000

• We will pay for treatment of congenital conditions on an inpatient or daypatient basis which manifest themselves before the

beneficiary’s 18th birthday if:

• at least one parent has been covered by the policy for a continuous period of twelve (12) months or more prior to the

newborn’s birth and the newborn is added to the policy within 30 days of the birth.

• they were not evident at policy inception.

Deductible (various)A deductible is the amount which you must pay before any claims are covered by your plan.

USD0 / USD375 / USD750 / USD1,500 / USD3,000 / USD7,500 / USD10,000

Cost share after deductible and out of pocket maximum Cost share is the percentage of each claim not covered by your plan.

The out of pocket maximum is the maximum amount of cost share you would have to pay in a period of cover.

The cost share amount is calculated after the deductible is taken into account. Only amounts you pay related to cost share contribute to the out of pocket maximum.

First, choose your cost share percentage:

0% / 10% / 20% / 30%

Next, choose your out of pocket maximum:

USD2,000 or USD5,000

YOUR DEDUCTIBLE AND COST SHARE OPTIONS

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THE FOLLOWING PAGES DETAIL THE OPTIONAL BENEFITS

YOU MAY HAVE CHOSEN TO ADD TO YOUR CORE COVER –

INTERNATIONAL MEDICAL INSURANCE.

YOU CAN ADD AS MANY OPTIONAL BENEFITS AS YOU

WISH TO BUILD A PLAN THAT SUITS YOUR NEEDS.

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Consultation with medical practitioners and

SpecialistsUp to the maximum amount shown per period of cover.


USD125 limit per visit. Up to 15 visits per year.


Paid in full

• We will pay for consultations or meetings with a medical practitioner which are necessary to diagnose an illness, or to

arrange or receive treatment up to the maximum number of visits shown in the benefit table.

• We will pay for non-surgical treatment on an outpatient basis, which is recommended by a specialist as being medically

necessary.

• Subject to prior approval and provided the medical practitioner is within your selected area of coverage, we may pay for

consultations that take place by use of electronic means or telephone.


period of coverThis includes claims paid across all sections of

International Outpatient.


USD10,000 USD25,000 USD78,000

INTERNATIONAL OUTPATIENTInternational Outpatient covers you more comprehensively for outpatient care and medical emergencies that

may arise where a hospital admission as a daypatient or inpatient is not required. As well as this,

consultations with specialists and medical practitioners, prescribed outpatient drugs and dressings, pre-

natal and post-natal outpatient care, physiotherapy, osteopathy, chiropractic and much more.

YOUR OVERALL LIMIT


Pre-natal and post-natal care

(Gold and Platinum plans only)Up to the maximum amount shown per period of cover.

Available once the mother has been covered on this

option for twelve (12) months or more.



• We will pay for medically necessary pre-natal and post-natal care on an outpatient basis, if the mother has been a

beneficiary under the International Outpatient optional benefit for a continuous period of at least twelve (12) months or more.

Examples of such treatment and tests include:

• Routine obstetricians’ and midwives’ fees;

• All scheduled ultrasounds and examinations;

• Prescribed medicines, drugs and dressings;

• Routine pre-natal blood tests, if required;

• Amniocentesis procedure (also referred to as amniotic fluid test or AFT) or chorionic villous sampling (also referred to as

CVS);

• Non-invasive pre-natal testing (NIPT) for high risk individuals; and

• Any fees as a result of post-natal care required by the mother immediately following routine childbirth.

21

Pathology, radiology and diagnostic tests

(excluding Advanced Medical Imaging)Up to the maximum amount shown per period of cover.



• We will pay for the following tests where they are medically necessary and are recommended by a specialist as part of a

beneficiary’s outpatient treatment:


• X-rays;



• other diagnostic tests (excluding advanced medical imaging).

Physiotherapy treatmentUp to the maximum amount shown per period of cover.



• We will pay for physiotherapy treatment on an outpatient basis that is medically necessary and restorative in nature to help

you to carry out your normal activities of daily living. The treatment must be carried out by a properly qualified practitioner

who holds the appropriate license to practice in the country where the treatment is received. This excludes any sports

medicine treatment.

• We will require a medical report and treatment plan prior to approval.

Osteopathy and chiropractic treatmentUp to the maximum amount shown per period of cover.


Paid in full up to 15 visits



• We will pay up to a combined maximum total of visits in any one period of cover for osteopathy and chiropractic treatment

which is evidence-based treatment, medically necessary and recommended by a treating specialist, if a medical practitioner

recommends the treatment and provides a referral. The treatment must be carried out by a properly qualified practitioner

who holds the appropriate license to practice in the country where the treatment is received. We will require a medical report

and treatment plan prior to approval. This excludes any sports medicine treatment.

Acupuncture, Homeopathy, and

Chinese medicineUp to a combined maximum of 15 visits per period of

cover.



• We will pay for a combined maximum total of 15 consultations with acupuncturists, homeopaths and practitioners of

Chinese medicine for each beneficiary in any one period of cover, if those treatments are recommended by a medical

practitioner. The treatment must be carried out by a properly qualified practitioner who holds the appropriate license to

practice in the country where the treatment is received.

22

Restorative speech therapyUp to the maximum amount shown per period of cover.



• We will pay for restorative speech therapy if:

• it is required immediately following treatment which is covered under this policy (for example, as part of a beneficiary’s

follow-up care after they have suffered a stroke);

• it is confirmed by a specialist to be medically necessary on a short-term basis.

Important notes

• We will only pay for speech therapy if the aim of that therapy is to restore impaired speech function.

• We will not pay for speech therapy which:

• aims to improve speech skills which are not fully developed;

• is educational in nature;

• is intended to maintain speech communication;

• aims to improve speech or language disorders (such as stammering); or

• is as a result of learning difficulties, developmental problems (such as dyslexia), attention-deficit hyperactivity disorder or

autism.

Prescribed drugs and dressingsUp to the maximum amount shown per period of cover.


USD500 USD2,000 Paid in full

• We will pay for prescription drugs and dressings which are prescribed by a medical practitioner on an outpatient basis.

Rental of durable equipmentUp to a maximum of 45 days in the period of cover.



• We will pay for the rental of durable medical equipment for up to 45 days per period of cover, if the use of that equipment is

recommended by a specialist in order to support the beneficiary’s treatment.

• We will only pay for the rental of durable medical equipment which:

• is not disposable, and is capable of being used more than once;

• serves a medical purpose;

• is fit for use in the home; and

• is of a type only normally used by a person who is suffering from the effect of a disease, illness or injury.

Adult vaccinationsUp to the maximum amount shown per period of cover.


USD250 Paid in full Paid in full

• We will pay for certain vaccinations and immunisations that are clinically appropriate namely:

• Influenza (flu);

• Tetanus (once every 10 years);

• Hepatitis A;

• Hepatitis B;

• Meningitis;

• Rabies;

• Cholera;

• Yellow Fever;

• Japanese Encephalitis;

• Polio booster;

• Typhoid; and

• Malaria (in tablet form, either daily or weekly).

23

Dental accidentsUp to the maximum amount shown per period of cover.


USD1,000 Paid in full Paid in full

• If a beneficiary needs dental treatment as a result of injuries which they have suffered in an accident, we will pay for

outpatient dental treatment for any sound natural tooth/teeth damaged or affected by the accident, provided the treatment

commences immediately after the accident and is completed within 30 days of the date of the accident.

• In order to approve this treatment, we will require confirmation from the beneficiary’s treating dentist of:

• the date of the accident; and

• the fact that the tooth/teeth which are the subject of the proposed treatment are sound natural tooth/teeth.

• We will pay for this treatment instead of any other dental treatment the beneficiary may be entitled to under this policy, when

they need treatment following accidental damage to a tooth or teeth.

• We will not pay for the repair or provision of dental implants, crowns or dentures under this part of this policy.

Well child tests



• Payable for children at appropriate age intervals up to the age of 6.

• We will pay for well child routine tests at any of the appropriate age intervals (birth, 2 months, 4 months, 6 months, 9

months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, 5 years and 6 years) and for a medical practitioner to

provide preventative care consisting of:

• evaluating medical history;

• physical examinations;

• development assessment;

• anticipatory guidance; and

• appropriate immunisations and laboratory tests; for children aged 6 or younger.

We will pay for one visit to a medical practitioner at each of the appropriate age intervals (up to a total of 13 visits for each

child) for the purposes of receiving preventative care services.

• In addition, we will pay for:

• one school entry health check, to assess growth, hearing and vision, for each child aged 6 or younger.

• diabetic retinopathy screening for children over the age of 12 who have diabetes.

Child immunisations



• We will pay for the following immunisations for children aged 17 or younger:

• DPT (Diphtheria, Pertussis and Tetanus);

• MMR (Measles, Mumps and Rubella);

• HiB (Haemophilus influenza type b);

• Polio;

• Influenza;

• Hepatitis B;

• Meningitis; and

• Human Papilloma Virus (HPV).

24

Annual routine tests



• We will pay for the following routine tests for children aged 15 or younger:

• one eye test; and

• one hearing test.


USD0 / USD150 / USD500 / USD1,000 / USD1,500





0% / 10% / 20% / 30%

Your out of pocket maximum is:

USD3,000


25

Medical Evacuation



• Transfer to the nearest centre of medical excellence if the treatment the beneficiary needs is not available locally in an

emergency.

• If a beneficiary requires emergency treatment, we will pay for medical evacuation for them:

• to be taken to the nearest hospital where the necessary treatment is available (even if this is in another part of the

country, or in another country); and

• to return to the place they were taken from, provided the return journey takes place not more than 14 days after the

treatment is completed.

• As regards the return journey, we will pay:

• the price of an economy class air ticket; or

• the reasonable cost of travel by land or sea; whichever is lesser.

• We will only pay for taxi fares if:

• it is medically preferable for the beneficiary to travel to the airport by taxi, rather than by ambulance; and

• approval is obtained in advance from the medical assistance service.

• We will pay for evacuation (but not repatriation) if the beneficiary needs diagnostic tests or cancer treatment (such as

chemotherapy) if, in the opinion of our medical assistance service, evacuation is appropriate and medically necessary in the

circumstances.

• We will not pay any other costs related to an evacuation (such as accommodation costs).

Important note

• If you require to return to the hospital where you were evacuated for follow up treatment, we will not pay for travel costs or

living allowance costs.


period of cover


USD1,000,000 USD1,000,000 USD1,000,000

INTERNATIONAL MEDICAL EVACUATION

International Medical Evacuation provides coverage for reasonable transportation costs to the nearest centre

of medical excellence in the event that the treatment is not available locally in an emergency. This option

also includes repatriation coverage, allowing the beneficiary to return to their country of habitual residence

or country of nationality to be treated in a familiar location. It also includes compassionate visits for a parent,

spouse, partner, sibling or child to visit a beneficiary after an accident or sudden illness and the beneficiary

has not been evacuated or repatriated.


YOUR OVERALL LIMIT

26

Medical repatriation



• If a beneficiary requires a medical repatriation, we will pay:

• for them to be returned to their country of habitual residence or country of nationality; and

• to return them to the place they were taken from, provided the return journey takes place not more than 14 days after

the treatment is completed.

• The above journey must be approved in advance by our medical assistance service and to avoid doubt all transportation

costs are required to be reasonable and customary.





• it is medically preferable for the beneficiary to travel to the airport by taxi, rather than by ambulance; and


• We will not pay any other costs related to a repatriation (such as accommodation costs).

Important notes

• If you require to return to the hospital where you were repatriated for follow up treatment, we will not pay for travel costs or

living allowance costs.

• If a beneficiary contacts the medical assistance service to ask for prior approval for repatriation, but the medical assistance

service does not consider repatriation to be medically appropriate, we may instead arrange for the beneficiary to be

evacuated to the nearest hospital where the necessary treatment is available. We will then repatriate the beneficiary to his

or her specified country of nationality or country of habitual residence when his or her condition is stable, and it is medically

appropriate to do so.

Repatriation of mortal remains



• If a beneficiary dies outside their country of habitual residence during the period of cover, the medical assistance service

will arrange for their mortal remains to be returned to their country of habitual residence or country of nationality as soon as

reasonably practicable, subject to airlines requirements and restrictions.

• We will not pay any costs associated with burial or cremation or the transport costs for someone to collect or accompany

the beneficiary’s mortal remains.

27

Compassionate visits - travel costsUp to a maximum of 5 trips per lifetime.

Up to the maximum amount shown per period of cover.


USD1,200 USD1,200 USD1,200

Compassionate visits - living allowance costsUp to the maximum amount shown per day for each visit with a maximum of 10 days per visit. Up to the maximum amount shown per period of cover.


• For each beneficiary we will pay for up to 5 compassionate visits over the lifetime of the cover. Compassionate visits must

be approved in advance by our medical assistance service.

• We will pay the cost of economy class return travel for a parent, spouse, partner, sibling or child to visit a beneficiary after

an accident or sudden illness, if the beneficiary is in a different country and is anticipated to be hospitalised for five days or

more, or has been given a short-term terminal prognosis.

• We will also pay for living expenses incurred by a family member during a compassionate visit, for up to 10 days per visit

while they are away from their country of habitual residence up to the limits shown in the list of benefits (subject to being

provided with receipts in respect of the costs incurred).

Important note

• We will not pay for a compassionate visit when the beneficiary has been evacuated or repatriated. If an evacuation or

repatriation takes place during a compassionate visit, we will not pay any further third party transportation costs.

Travel costs for an accompanying person



• If a beneficiary needs a parent, sibling, child, spouse or partner, to travel with them on their journey in conjunction with a

medical evacuation or repatriation, because they:

• need help getting on or off an aeroplane or other vehicle;

• are travelling 1000 miles (or 1600km) or further;

• are severely anxious or distressed, and are not being accompanied by a nurse, paramedic or other medical escort and;

or

• are very seriously ill or injured;

we will pay for a relative or partner to accompany them. The journeys (for the avoidance of doubt shall mean one outbound

and one return) must be approved in advance by the medical assistance service and the return journey must take place not

more than 14 days after the treatment is completed.

• We will pay:


• the reasonable cost of travel by land or sea; whichever is the lesser.

If it is appropriate, considering the beneficiary’s medical requirements, the family member or partner who is accompanying

them may travel in a different class.

If it is medically necessary for a beneficiary to be evacuated or repatriated, and they are going to be accompanied by their

spouse or partner, we will also pay the reasonable travel costs of any children aged 17 or under, if those children would

otherwise be left without a parent or guardian.

Important notes

• We will not pay for a third party to accompany a beneficiary if the original purpose of the evacuation was to enable the

beneficiary to receive outpatient treatment.

• We will not pay for any other costs relating to third party travel costs, such as accommodation or local transportation.

If you have purchased this option, we will also make available the provision below for compassionate

visits to you by immediate family members.

28

Routine adult physical examinationsUp to the maximum amount shown per period of cover.



• We will pay for routine adult physical examinations (including but not limited to: height, weight, bloods, urinalysis, blood

pressure, lung function etc), for persons aged 18 or older.

INTERNATIONAL HEALTH AND WELLBEING

International Health and Wellbeing covers the beneficiary for screenings, tests, examinations and counselling

support for a range of life crises and tailored advice and support through our online health education and

health risk assessment, helping the beneficiary to take control and manage their health the way they want.

During each period of cover we will pay for the following tests to be carried out by a medical practitioner.

Pap smearUp to the maximum amount shown per period of cover.


USD225 USD450 Paid in full

• We will pay for one papanicolaou test (pap smear) for female beneficiaries.

Prostate cancer screeningUp to the maximum amount shown per period of cover.



• We will pay for one prostate examination (prostate specific antigen (PSA) test) for male beneficiaries aged 50 or over.

Mammograms for breast cancer screening Up to the maximum amount shown per period of cover.




• Aged 35-39: one baseline mammogram for asymptomatic women.

• Aged 40-49: one mammogram for asymptomatic women every two years.

• Aged 50 or older: one mammogram each year.

29

Bowel cancer screeningUp to the maximum amount shown per period of cover.



• We will pay for one bowel cancer screening for beneficiaries aged 55 or older.

Bone densitometryUp to the maximum amount shown per period of cover.



• We will pay for one scan to determine the density of the beneficiary’s bones.

Dietetic consultations


Not covered Not covered Paid in full

• We will pay for up to 4 consultations with a dietician per period of cover, if the beneficiary requires dietary advice relating to a

diagnosed disease or illness such as diabetes (Platinum plan only).

Life management assistance programme



• Our Life Management service is available 24 hours a day, 7 days a week, 365 days a year. Professionals are ready to assist

you with any issue that matters to you.

• We will pay for up to 5 counselling sessions per issue per period of cover. This could be telephonic or face to face

counselling support.

• Unlimited in the moment telephonic support for live assistance.

• Provides information, resources and counselling on any work, life, personal, or family issue that matters to you.

• Information services provide support including assistance for day to day demands or the logistics of relocating. The

information specialists can offer assistance over the phone and perform research and provide pre-qualified referrals to local

resources.

Please contact us for approval. The service is provided by our chosen counselling provider.

Online health education, health assessments

and web-based coaching programmes



30

Eye examinationMaximum per beneficiary per period of cover.



• We will pay for one routine eye examination per period of cover, to be carried out by either an ophthalmologist or

optometrist.

• We will not pay for more than one eye examination in any one period of cover.

INTERNATIONAL VISION AND DENTAL

International Vision and Dental pays for the beneficiary’s routine eye examination and pays costs for

spectacles and lenses. It also covers a wide range of preventative, routine and major dental treatments.

VISION CARE

Expenses for:

• Spectacle lenses;

• Contact lenses;

• Spectacle frames;

• Prescription sunglasses; when all are prescribed by an optometrist or ophthalmologist.




• We will not pay for:

• sunglasses, unless medically prescribed, by an ophthalmologist or optometrist;

• glasses or lenses which are not medically necessary or not prescribed by an ophthalmologist or optometrist; or

• treatment or surgery, including treatment or surgery which aims to correct eyesight, such as laser eye surgery, refractive

keratotomy (RK) or photorefractive keratectomy (PRK).

• A copy of a prescription or invoice for corrective lenses will need to be provided to us in support of any claim for frames.


period of cover


USD1,250 USD2,500 USD5,500

DENTAL TREATMENT

YOUR OVERALL LIMIT

31

Preventative dental treatment After the beneficiary has been covered on this option for 3 months.



• We will pay for the following preventative dental treatment recommended by a dentist after a beneficiary has had

International Vision and Dental cover for at least 3 months:

• two dental check-ups per period of cover;

• X-rays, including bitewing, single view, and orthopantomogram (OPG);

• scaling and polishing including topical fluoride application when necessary (two per period of cover);

• one mouth guard per period of cover;

• one night guard per period of cover; and

• Fissure sealant.

Routine dental treatmentAfter the beneficiary has been covered on this option for 3 months.


80% refund per period of cover


Paid in full

• We will pay treatment costs for the following routine dental treatment after the beneficiary has had International Vision and

Dental cover for at least 3 months (if that treatment is necessary for continued oral health and is recommended by a dentist):

• root canal treatment;

• extractions;

• surgical procedures;

• occasional treatment;

• anaesthetics; and

• periodontal treatment.

Major restorative dental treatmentAfter the beneficiary has been covered on this option for 12 months.




Paid in full

• We will pay treatment costs for the following major restorative dental treatments after the beneficiary has had International

Vision and Dental cover for at least 12 months:

• dentures (acrylic/synthetic, metal and metal/acrylic);

• crowns;

• inlays; and

• placement of dental implants.

• If a beneficiary needs major restorative dental treatment before they have had International Vision and Dental cover for 12

months, we will pay 50% of the treatment costs.

Orthodontic treatmentAfter the beneficiary has been covered on this options

for 2 consecutive years.





• We will pay for orthodontic treatment for beneficiaries aged 18 years old or younger, if they have had International Vision and

Dental cover for at least 24 months.

• We will only pay for orthodontic treatment if:

• the dentist or orthodontist who is going to provide the treatment provides us, in advance, with a detailed description of

the proposed treatment (including X-rays and models), and an estimate of the cost of treatment; and

• we have approved the treatment in advance.

32

WE HAVE YOU COVEREDPre-existing conditions

There may be some medical conditions that we agree

to include at an additional premium. Our Underwriters

will determine whether we are able to include a

medical condition that would normally have been

excluded. Where applicable, we will present you with a

quote with the option to include the condition.

Out of area emergency cover

For additional peace of mind, all of our plans include

emergency short-term medical coverage when you

are visiting a location outside of your selected area of

coverage (you can select from Worldwide including

USA or Worldwide excluding USA cover). So if you

purchase the Worldwide excluding USA option, you

will still be covered for emergency treatment on an

Inpatient or Daypatient basis, or Outpatient basis (if the

International Outpatient additional coverage option has

been purchased under your policy) during temporary

business or holiday trips to the USA. Coverage is

limited to a maximum period of 3 weeks per trip and

a maximum of 60 days per period of cover for all trips

combined. Please read our policy documentation for

the full terms and conditions relating to this benefit.

32

3333

WHAT YOU CAN EXPECT FROM US

In addition to your Prestige Global Health Options plan, there are a few more things you might like to know

about us and the service you can expect as a customer of OAC.

Comprehensive welcome pack

Please read through all your policy documents

when you receive them and make sure you check

the details of your policy on the certificate of

insurance. You will need to show your ID card

when you require treatment so your doctor knows

who you are (it’s not used for payment). It also has

all the contact numbers you’ll need.

Getting treatment

Prior approval should be obtained from us for all

treatment. This will help ensure your claims are

covered under the policy. The Customer Care

Team will help you find a high quality hospital or

doctor near you. Wherever possible, we will pay

them directly, saving you the inconvenience of

paying for your treatment yourself and claiming a

refund later.

On the rare occasion you do pay for treatment

yourself, we’ll aim to process your claim within

five (5) working days after receiving all necessary

documentation. The Customer Guide in your

welcome pack will tell you everything you need to

know about getting treatment and making a claim.

Your policy documents include the following:

Customer Guide

How your plan works and

your guide to the benefits.

Policy Rules

The terms and conditions,

general exclusions and

definitions of your policy

in one handy booklet.

Certificate of

Insurance

A record of the plan you

chose, the premium and

what and who it covers.

ID Card

Proof of your identity and

cover for when you need

treatment.

Getting in touch

If you have any questions about your policy, need to get approval for treatment, or for any other reason, please

contact the Customer Care Team 24 hours a day, 7 days a week, 365 days a year.

Call: +65 6291 1242

Email: [email protected]

33

34

NOTES

PGH Sales Brochure December 2015

This brochure is for general information only. It is not a contract of Insurance. Please refer to the Policy documents for the precise terms and conditions of the insurance plan. It is usually

detrimental to replace an existing accident and health plan with a new one. A new plan may cost more or have less benefits at the same cost. Please refer to clause 14 of the Policy

Rules for more information on early plan termination (and the consequences). This plan is protected under the Policy Owners’ Protection Scheme which is administered by the Singapore

Deposit Insurance Corporation (SDIC). Coverage for your Policy is automatic and no further action is required from you. For more information on the types of benefits that are covered

under the scheme as well as the limits of coverage, where applicable, please contact us or visit the General Insurance Association (GIA) or SDIC websites (www.gia.org.sg or www.sdic.

org.sg). Information correct as of 30 November 2015.

The Overseas Assurance Corporation Limited (Reg No. 192000003W) 1 Pickering Street, #13-01 Great Eastern Centre, Singapore 048659.

Cigna Europe Insurance Company S.A.-N.V. - Singapore Branch (Reg No. T10FC0145E) 152 Beach Road, #26-05 The Gateway East, Singapore 189721

“Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries.

Call: +65 6291 1242

Email: [email protected]

PRESTIGE GLOBAL HEALTH OPTIONSProposal form

Lifestyle

Section A

Application details

.

Your plan

Which plan are you applying for? you applying for? Silver Gold Platinum

Policyholder

You must notify us of any change of contact details so we can ensure that correspondence reaches you.

Title First Name Other Initials Surname

Gender (please tick) Male Female Date of birth (DD/MM/YYYY)

Occupation

Correspondence address

Daytime telephone number (Country code – Area code – Number)

Mobile telephone number (Country code – Area code – Number)

Fax (Country code – Area code – Number)

Email address

Nationality (What is the nationality of the primary passport that you hold?)

Location (The country in which you live/will live for the majority of your time for the period of cover)

NRIC / Passport No / FIN No

Height: Centimetres Weight: Kilogrammes

Have you smoked, or used tobacco or nicotine replacement products in the last 12 months? Yes No

If Yes, how many per day? Less than 20 per day 20 or more per day


Relationship to policyholder Gender (please tick) Male Female

Date of birth (DD/MM/YYYY) Occupation







Please complete this application form and return it to us, either by electronic mail or post. See our contact information at the end of this form.

Please complete this form in BLOCK CAPITALS.

Important Notes:

1. Statement Pursuant to Section 25(5) of the Insurance Act (Cap 142) (or any subsequent amendment thereof), you are to disclose in this

proposal form, fully and faithfully, all the facts you know, or ought to know, which may affect the insurance cover you are applying for.

Otherwise, you may receive nothing from the policy.

2. This policy will be entered into the register of Singapore Policies.

3. Please answer all the questions or indicate “Nil” or “NA” where applicable.

4. This policy is protected under the Policy Owners’ Protection Scheme which is administered by the Singapore Deposit Insurance

Corporation (SDIC). Coverage for your policy is automatic and no further action is required from you. For more information on the types

Insurance Association (GIA) or SDIC websites (www.gia.org.sg or www.sdic.org.sg)

5. This policy is administered by Cigna Europe Insurance Company S.A.-N.V. - Singapore Branch.

Section B

Applicant details

Where do you want your cover? Worldwide Worldwide excluding USA

International Medical Insurance Plan/

Choose your deductible USD0 USD375 USD750 USD1,500 USD3,000 USD7,500 USD10,000

Then, select your cost share percentage No cost share 10% 20% 30%

Choose your out of pocket maximum (This is the maximum amount of cost share under International Medical Insurance plan you must pay in the event of a claim or claims per period of cover)

USD2,000 USD5,000

Do you wish to upgrade your plan with any of the following options

International Outpatient Yes No Deductible USD0 USD150 USD500

USD1,000 USD1,500

Cost share after deductible (a USD3,000 out of pocket maximum is applied to cost shares on International Outpatient)

No cost share 10% 20% 30%

International Medical Evacuation Yes No

International Health and Wellbeing Yes No

International Vision and Dental Yes No

Please note that International Outpatient, International Medical Evacuation, International Health and Wellbeing and International Vision and Dental plans can only be purchased in

conjunction with the International Medical Insurance plan.

Your plan selection can only be amended at policy renewal. Should you wish to increase your level of cover at renewal, full medical underwriting and waiting periods may apply

and an additional premium amount will be payable.




























Section D

please provide full details in Section E.

Please read the following questions very carefully. Please take reasonable care to answer all questions honestly and fully. Careless misrepresentation could

result in reduction of the amount of any claims proportionately; whereas deliberate or reckless misrepresentation could result in rejection of claims, and/or

cancellation of cover. If you need help completing your application, please contact us.

If you are unsure about the answer to any question you should make the enquiries necessary to allow you to provide an accurate answer.

Your plan

Have you, or any person named in Section A been treated for:

(Please tick if Yes)

PO

LIC

YH

OL

DE

R

1Diabetes and other endocrine (glandular) disorders e.g. any thyroid disorder, weight problems, gout, pituitary or adrenal gland conditions?

2Heart or circulatory disorders e.g. chest pain, heart attack, high blood pressure, vascular disease, coronary artery disease, angina, irregular heartbeat, aneurysm or heart murmur.

3 including polyps, cysts or breast lumps.

4Muscle or skeletal problems e.g. back pain, whiplash, arthritis, joint pain or problems, gout, fractures, cartilage, tendon or ligament problems.

Section C

Payment details

Payment currency US Dollar

Payment method Bank Transfer / Payment at OCBC branch

The following is the bank details for electronic bank transfer or making payment at OCBC branches. Please make sure to

provide your full name and quotation number as the reference for your bank transfer or over-the-counter deposit.

OAC Bank Details – USD A/C

Name: The Overseas Assurance Corporation Limited

Address: No 1 Pickering Street #13-01, Great Eastern Centre, Singapore 048659

Name of Bank: Oversea-Chinese Banking Corporation Limited

Address of the Bank: 65 Chulia Street, OCBC Centre, Singapore, 049513

Bank Code / Swift Code: 7339 / OCBCSGSG

Name of the Branch: OCBC Centre Branch

Account Number: 503-124844-301

date, subject to the underwriting decision.

Cash

You can make your

premium payment in cash

at the cashier at Great

Eastern Centre Customer

Service Centre.

For cash payment, your

(5) business days from

application submission

date, subject to the

underwriting decision.

(local bank

issued)

Cheques must be payable

to ‘The Overseas Assurance

Corporation Limited’. Please

make sure that your full name

and quotation number are

clearly shown on the back of the

cheque in case your payment

becomes separated from this

application.

For local bank issued USD

cheque, your cover start date

from application submission

date, subject to the underwriting

decision.

(foreign bank issued)

Cheques must be payable to ‘The Overseas

Assurance Corporation Limited’. Please

make sure that your full name and quotation

number are clearly shown on the back of

the cheque in case your payment becomes

separated from this application.For local

bank issued USD cheque, your cover start

application submission date, subject to the

underwriting decision.

For foreign bank issued USD cheque, your

cover start date will be twenty (20) business

days from application submission date,

subject to the underwriting decision.

Payment frequency Annually

Section E

Additional Health Information

Please tell us more if you have answered ‘Yes’ to any questions in Section D. If you are unsure if any details are relevant, please include them anyway. If you run out of space, please use a separate sheet.

Section D Question Number

The name of the illness or medical problem. Where applicable state the area of the body affected (e.g. left arm, right foot).

When did the symptoms occur and when did you last have symptoms?

What treatment was provided? (Include details of medication and dates of when treatment started and ended.)

What is the current status of the illness or medical problem? (E.g. ongoing, complete, recovery, recurrent or likely to recur.)

PO

LIC

YH

OL

DE

R

5 e.g. chest infections, pneumonia,

bronchitis, shortness of breath, rhinitis, TB, emphysema or chronic obstructive pulmonary disease.

6e.g. irritable bowel disease,

hernia, haemorrhoids or hepatitis.

7Brain or neurological disorders e.g. multiple sclerosis, epilepsy or seizures, stroke, migraines, recurring or severe headaches, meningitis, shingles or nerve pain.

8Skin problems e.g. eczema, acne, moles, rashes, allergic reactions, cysts, dermatitis or psoriasis.

9 e.g. high cholesterol, anaemia, malaria, HIV or

systemic lupus erythematosus.

10Urinary or reproductive disorderspainful, irregular or heavy periods, fertility problems, polycystic ovarian syndrome, endometriosis, testicular or prostate problems.

11 including eating disorders,

post-traumatic stress disorder, alcohol or drug issues.

12 e.g. ear infections, sinus problems, tonsils and

adenoids, cataracts, glaucoma, wisdom teeth problems.

13Does anyone have any illness, condition or symptom not already mentioned? Please include details of any known or suspected issues whether or not medical advice has been sought or a diagnosis reached.

14Does anyone take any medication, receive any treatment of any kind or expect to have a review or follow up for any current or past medical problem not already mentioned?

Personal Data Protection

By providing the information set out in this application form, I/we agree and consent to OAC, its related corporations (collectively, the ‘Companies’), their

respective representatives and agents (‘Representatives’), as well as the Companies’ authorised service providers (including, without limitation, Cigna)

collecting, using, disclosing and sharing amongst themselves my/our personal data, and disclosing such personal data to the Companies’ authorised

service providers (including, without limitation, Cigna) and relevant third parties for purposes reasonably required by the Companies to evaluate my/our

proposal and to provide the products or services which I am/we are applying for (including, without limitation, any policy renewals and policy upgrades,

substitutions or replacements).

These purposes are set out in Great Eastern’s Privacy Statement, which is accessible at https://www.greateasternlife.com/sg/en/privacy-and- security-policy.

I/we consent to the Companies, their Representatives, business partners and authorised service providers (including, without limitation, Cigna) collecting,

using and disclosing my/our personal data in their records for marketing and promotional purposes and providing me/us such information via:

Voice calls, text and fax

Mail and email

Signature of Policyholder

Date

Name of distribution representative

Distribution representative’s agent code

Section F

Important declaration for all customers

I/We hereby declare that I/we have taken reasonable care to answer all questions accurately, honestly and completely. I/we acknowledge that if I/we

do not answer all questions accurately and completely as a result of my/our carelessness that could result in the reduction of the amount of any claims

proportionately. I/We also acknowledge that if I/we deliberately or recklessly provide inaccurate or incomplete information in answering the questions, that

could result in rejection of claims, and/or cancellation of cover.

The duty to answer the questions accurately in this application form, honestly and completely applies in respect of each person who is covered by this

personal information (e.g. medical information) contained in this application form to The Overseas Assurance Corporation (‘OAC’) and/or Cigna Europe

questions accurately, honestly, completely and to the best of their knowledge.

I/We agree that the policy is issued as a Singapore policy expressed in US dollars and all payments under the policy, whether to or by OAC and/or Cigna will

be payable in US dollars in Singapore.

your covered family members’ actual declarations and consents.)

and refuse all claims and need not return any premiums paid in, except for where it would be unfair for the premiums to be retained. I have carefully read,

understood and agree to abide by the Policy Rules and Customer Guide as they form part of my contract of insurance.

Signature of Policyholder

Date (DD/MM/YYYY)

Fraud notice

Any person who, dishonestly and with intent to make a gain for himself or cause loss to another, or to expose another to a risk of loss: (1) makes an

application for insurance or makes a claim under a policy containing any information he knows to be untrue or misleading ; or who (2) in making an

application for insurance or a claim under a policy dishonestly and with intent to make a gain for himself or cause loss to another, or to expose another to a

risk of loss fails to disclose information which has been asked for, commits fraud. We will investigate any claims or applications for insurance which we have

grounds to believe may be fraudulent. Committing fraud may result in your policy being terminated and any claims you make under not being paid. We

may, for the purposes of the detection and prevention of fraud, share information relating to suspected fraud with other insurance companies and/or with law

enforcement authorities.

PRODUCT SUMMARYThis Product Summary is for general information only. It is not a contract of insurance. The

precise terms and conditions of this insurance plan are shown in the Policy Rules. I hereby

a satisfactory manner.

(a) Your Guide to Health Insurance (receive a hard copy or directed to view or download from

www.greateasternlife.com or www.gia.org.sg) and;

(b) Product Summary

Signature of Customer:

Signature of Distribution Representative:

Date:

PRODUCT INFORMATION

INTERNATIONAL MEDICAL INSURANCE

Our plans comprise of 3 distinct levels of cover: Silver, Gold and Platinum.

period of cover (except where otherwise noted).

International Medical Insurance is your essential cover for inpatient, daypatient and accommodation

costs, as well as cover for cancer, mental health care and much more. Our Gold and Platinum plans

also give you cover for inpatient and daypatient maternity care.

Hospital charges for:Nursing and accommodation for inpatient and

daypatient treatment and recovery room.


Paid in full for a

semi-private

room

Paid in full for a

private room

Paid in full for a

private room

• We will pay for nursing care and accommodation

treatment; or the cost of a treatment room while a

required.

• We will only pay these costs if:

treated on an inpatient or daypatient basis;

• they stay in hospital for a medically appropriate

period of time;

• the treatment which they receive is provided or

managed by a specialist; and

• they stay in a standard single room with a private

bathroom or equivalent (applicable on the Gold and

Platinum plans only).

• they stay in a semi-private room with shared

bathroom (applicable on the Silver plan only).

• If a hospital’s fees vary depending on the type of room

amount which we will pay is the amount which would

a standard single room with a private bathroom or

equivalent (applicable on the Gold and Platinum plans

only), or a semi-private room with shared bathroom or

equivalent (applicable on the Silver plan only).

• If the treating medical practitioner decides that the

period than we have approved in advance, or decides

different to that which we have approved in advance,

then that medical practitioner must provide us with a

to stay in hospital; the diagnosis (if this has changed);

and needs to receive.

period of cover.This includes claims paid across all sections of

International Medical Insurance.


USD1,000,000 USD2,000,000 USD3,000,000


YOUR OVERALL LIMIT

Hospital charges for:

• operating theatre.

• prescribed medicines, drugs and

dressings for inpatient or daypatient

treatment.

• treatment room fees for outpatient surgery.



Operating theatre costs

• We will pay any costs and charges relating to the use

of an operating theatre, if the treatment being given is

covered under this policy.

Medicines, drugs and dressings

• We will pay for medicines, drugs and dressings which

receiving inpatient or daypatient treatment.

• We will only pay for medicines, drugs and dressings

has cover under the International Outpatient option

(unless they are prescribed as part of cancer

Intensive care:

• intensive therapy.

• coronary care.

• high dependency unit.



•

facility if:

• that facility is the most appropriate place for them to be treated;

• the care provided by that facility is an essential part of their treatment; and

• the care provided by that facility is routinely required by patients suffering from the same type of illness or injury, or

receiving the same type of treatment.

Surgeons’ and anaesthetists’ fees



• We will pay for inpatient, daypatient or outpatient costs for:

• surgeons’ and anaesthetists’ surgery fees; and

• surgeons’ and anaesthetists’ fees in respect of treatment which is needed immediately before or after surgery (i.e.

on the same day as the surgery).

•

International Outpatient option (unless the treatment is given as part of cancer treatment).

Specialists’ consultation fees



• We will pay for regular visits by a specialist during stays in hospital including intensive care by a specialist for as long

as is required by medical necessity.

•

• is being treated on an inpatient or daypatient basis;

• is having surgery; or

• where the consultation is a medical necessity.

Hospital accommodation for a parent or guardianUp to the maximum amount shown per period of cover.



•

will also pay for hospital accommodation for a parent or legal guardian, if:

• accommodation is available in the same hospital; and

• the cost is reasonable.

•

receiving during their stay in hospital is covered under this policy.

Transplant services for organ, bone marrow

and stem cell transplants



•

• the transplant is medically necessary, and the organ to be transplanted has been donated by a member of the

• We will pay for anti-rejection medicines following a transplant, when they are given on an inpatient basis.

• We will pay for inpatient treatment directly associated with a bone marrow or peripheral stem cell transplant if:

• the transplant is medically necessary; and

• We will not pay for bone marrow or peripheral stem cell transplants under this part of this policy if the transplants form

part of cancer treatment. The cover which we provide in respect of cancer treatment is explained in other parts of this

policy.

•

• the harvesting of the organ or bone marrow;

• any medically necessary tissue matching tests or procedures;

• the donor’s hospital costs; and

• any costs which are incurred if the donor experiences complications, for a period of 30 days after their procedure;

whether or not the donor is covered by this policy.

• The amount which we will pay towards a donor’s medical costs will be reduced by the amount which is payable to

them in relation to those costs under any other insurance policy or from any other source.

•

•

• We will consider all medically necessary transplants. Other transplants (such as transplants which are considered to

be experimental procedures) are not covered under this policy. This is because of conditions or limitations to coverage

which are explained elsewhere in this policy.

Important note

•

or stem cell donation or transplant.

Kidney dialysis



•

will pay for this on an inpatient, daypatient, or outpatient basis.

•

Travel and accommodation expenses incurred in connection with such treatment will not be covered.

Pathology, radiology and diagnostic tests (excluding Advanced Medical Imaging)



• Where investigations are provided on an inpatient or daypatient basis.



• X-rays;



• other diagnostic tests (excluding advanced medical imaging);

inpatient or daypatient treatment.

Advanced Medical Imaging (MRI, CT and

PET scans)Up to the maximum amount shown per period of cover.



•

daypatient or outpatient treatment:

• magnetic resonance imaging (MRI);

• computed tomography (CT); and / or

• positron emission tomography (PET);

• We may require a medical report in advance of a magnetic resonance imaging (MRI) scan.

Physiotherapy and complementary therapies Up to the maximum amount shown per period of cover.



• Where treatment is provided on an inpatient or daypatient basis.

• We will pay for treatment provided by physiotherapist and complementary therapists; (acupuncturists, homeopaths,

hospital stay for inpatient or daypatient treatment (but are not the primary treatment which they are in hospital to

receive).

Home nursingUp to 30 days and the maximum amount shown per

period of cover.



•

• it is recommended by a specialist following inpatient or daypatient treatment which is covered by this policy;

Important note

•

medically necessary care that would normally be provided in a hospital. We will not pay for home nursing which only

provides non-medical care or personal assistance.

RehabilitationUp to 30 days and the maximum amount shown per

period of cover.



• We will pay for rehabilitation treatments (physical, occupational and speech therapies), which are recommended by a

specialist and are medically necessary after a traumatic event such as a stroke or spinal injury.

• If the rehabilitation treatment is required in a residential rehabilitation centre we will pay for accommodation and board

for up to 30 days for each separate condition that requires rehabilitation treatment.

In determining when the 30 day limit has been reached:

• Subject to prior approval being obtained, prior to the commencement of any treatment, we will pay for rehabilitation

treatment for more than 30 days, if further treatment is medically necessary and is recommended by the treating

specialist.

Important note

• We will only pay for rehabilitation treatment if it is needed after, or as a result of, treatment which is covered by this

policy and it begins within 30 days of the end of that original treatment.

• All rehabilitation treatment must be approved by us in advance. We will only approve rehabilitation treatment if the

treating specialist provides us with a report, explaining:

ii) the diagnosis; and

Hospice and palliative careUp to the maximum amount shown per lifetime.



•

recovery, we will pay for hospital or hospice care and accommodation, nursing care, prescribed medicines, and

physical and psychological care.

Internal prosthetic devices / surgical and medical appliances Up to the maximum amount shown per period of cover.



• We will pay for internal prosthetic implants, devices or appliances which are put in place during surgery as part of a

• A surgical appliance or a medical appliance can mean:

as required by medical necessity; or

• a prosthesis or appliance which is medically necessary and is part of the recuperation process on a short-term

basis.

External prosthetic devices/surgical and medical appliancesUp to the maximum amount shown per period of cover.



USD3,100


USD3,100


USD3,100

•

(subject to the limitations explained below).


• a prosthetic device or appliance which is a necessary part of the treatment immediately following surgery for as

long as is required by medical necessity;

• a prosthetic device or appliance which is medically necessary and is part of the recuperation process on a short-

term basis.

•

•

per period of cover.

•

recuperation process on a short-term basis.

Per night up to 30 nights per period of cover.



•

• receive treatment in hospital which is covered under this plan;

• stay in a hospital overnight; and

• have not been charged for their room, board and treatment costs.

Emergency inpatient dental treatment



• We will cover dental treatment in hospital after a serious accident, subject to the conditions set out below.

•

if that emergency inpatient dental treatment is recommended by the treating medical practitioner because of a dental

•

Local ambulance and air ambulance services



•

• from the scene of an accident or injury to a hospital;

• from one hospital to another; or

• from their home to a hospital.

•

of an accident or injury to a hospital or from one hospital to another.

Important notes

• Air ambulance cover is subject to the following conditions and limitations:

• In some situations it will be impossible, impractical or unreasonably dangerous for an air ambulance to operate.

In these situations, we will not arrange or pay for an air ambulance. This policy does not guarantee that an air

ambulance will always be available when requested, even if it is medically appropriate.

100 miles (160 kilometres) and we will only pay for an air ambulance where its use relates to treatment which a

• This policy does not provide cover for mountain rescue services.

• Cover for medical evacuation or repatriation is only available if you have cover under the International Medical

Evacuation option. Please refer to the relevant section of this brochure for details of that option.

Treatment for mental health conditions and disorders and addiction treatmentUp to the maximum amount shown per period of cover.



• Subject to the limits explained below we will pay for:

• the treatment of mental health conditions and disorders; and

• the diagnosis of addictions (including alcoholism);

Addiction treatment

• We will pay for one course or programme of addiction treatment at a specialist centre providing evidence-based

treatment, if that treatment is medically necessary and recommended by a medical practitioner.

•

• We will not pay for any other treatment related to alcoholism or addiction; or treatment of any related condition (such as

depression, dementia or liver failure); where we reasonably believe that the condition which requires treatment was the

direct result of alcoholism or addiction.

Important notes

• For treatment of mental health conditions and disorders and addiction treatment, we will only pay for evidence-based,

medically necessary treatment and recommended by a medical practitioner.

• We will pay for up to a combined maximum total of 90 days of treatment for mental health conditions and disorders and

addiction treatment in any one period of cover, including up to 30 days of inpatient treatment.

• We will pay for up to a combined maximum total of 180 days of treatment for mental health conditions and disorders;

addiction treatment in one period of cover, and 90 days of mental health or addiction treatment in the following period

of cover, we will not pay for any further mental health or addiction treatment for the next three consecutive years of

cover.

• In determining when these 30, 90 and 180 day limits have been reached:

• We will not pay for prescription drugs or medication prescribed on an outpatient basis for any of these conditions,

unless you have purchased the International Outpatient option.

• Subject to prior approval and provided the medical practitioner is within your selected area of coverage, we may pay

for consultations that take place by use of electronic means or telephone.

Cancer care



• Following a diagnosis of cancer, we will pay for costs for the treatment of cancer if the treatment is considered by us to

be active treatment and evidence-based treatment. This includes chemotherapy, radiotherapy, oncology, diagnostic

outpatient.

• We do not pay for genetic cancer screening.

(Gold and Platinum plans only)Up to the maximum amount shown per period of

cover. Available once the mother has been covered

by the policy for twelve (12) months or more.



• We will pay for the following parent and baby care and treatment, on an inpatient or daypatient basis as appropriate, if

• hospital, obstetricians’ and midwives’ fees for routine childbirth; and

• any fees as a result of post-natal care required by the mother immediately following routine childbirth.

•

PARENT AND BABY CARE

Complications from maternity (Gold and Platinum plans only)Up to the maximum amount shown per period of





• We will pay for inpatient or outpatient treatment relating to complications resulting from pregnancy or childbirth if the

is limited to conditions which can only arise as a direct result of pregnancy or childbirth, including miscarriage and

ectopic pregnancy.

• This part of the policy does not provide cover for home births.

•

•

Homebirths (Gold and Platinum plans only)Up to the maximum amount shown per period of




Not covered USD500 USD1,100

•

this policy for a continuous period of twelve (12) months or more.

• Please note that the Complications from maternity cover explained above does not include cover for home childbirth.

This means that any costs relating to complications which arise in relation to home childbirth will only be paid in

Newborn care Up to the maximum amount shown for treatment within

one parent has been covered by the policy for twelve (12) months or more.


USD25,000 USD75,000 USD156,000

• Provided the newborn is added to the policy, we will pay for:


parent has been covered by the policy for a continuous period of twelve (12) months or more prior to the newborn’s

birth.

We will not require information about the newborn’s health or a medical examination if an application is received by

us to add the newborn to the policy within 30 days of the newborn’s date of birth. If an application is received after

30 days of the newborn’s date of birth, the newborn will be subject to medical underwriting and we will require the

completion of a medical health questionnaire whereby we may apply special restrictions or exclusions.



has been covered by the policy for a continuous period of twelve (12) months or more prior to the newborn’s birth

to medical underwriting and we will require the completion of a medical health questionnaire. Cover for the newborn

will be subject to medical underwriting whereby we may apply special restrictions or exclusions.

•

(such as IVF), are born to a surrogate, or have been adopted. In these circumstances children can only be covered

by the policy when they are 90 days old. Cover for the baby will be subject to completion of a medical health

questionnaire whereby we may apply special restrictions or exclusions.

Congenital conditions Up to the maximum amount shown per period of

cover.


USD5,000 USD20,000 USD39,000

• We will pay for treatment of congenital conditions on an inpatient or daypatient basis which manifest themselves before

• at least one parent has been covered by the policy for a continuous period of twelve (12) months or more prior to

the newborn’s birth and the newborn is added to the policy within 30 days of the birth.

• they were not evident at policy inception.


USD0 / USD375 / USD750 / USD1,500 / USD3,000 / USD7,500 / USD10,000





0% / 10% / 20% / 30%

Next, choose your out of pocket maximum:

USD2,000 or USD5,000


THE FOLLOWING PAGES DETAIL THE OPTIONAL

BENEFITS AVAILABLE TO ADD TO YOUR CORE COVER –

INTERNATIONAL MEDICAL INSURANCE.

YOU CAN ADD AS MANY OPTIONAL BENEFITS AS YOU

WISH TO BUILD A PLAN THAT SUITS YOUR NEEDS.

Consultation with medical practitioners and

SpecialistsUp to the maximum amount shown per period of

cover.




Paid in full

• We will pay for consultations or meetings with a medical practitioner which are necessary to diagnose an illness, or to

• We will pay for non-surgical treatment on an outpatient basis, which is recommended by a specialist as being

medically necessary.

• Subject to prior approval and provided the medical practitioner is within your selected area of coverage, we may pay

for consultations that take place by use of electronic means or telephone.

period of coverThis includes claims paid across all sections of

International Outpatient.


USD10,000 USD25,000 USD78,000

INTERNATIONAL OUTPATIENTInternational Outpatient covers you more comprehensively for outpatient care and medical

emergencies that may arise where a hospital admission as a daypatient or inpatient is not required. As

well as this, consultations with specialists and medical practitioners, prescribed outpatient drugs and

dressings, pre-natal and post-natal outpatient care, physiotherapy, osteopathy, chiropractic and much

more.

YOUR OVERALL LIMIT


Pre-natal and post-natal care

(Gold and Platinum plans only)Up to the maximum amount shown per period of


on this option for twelve (12) months or more.



• We will pay for medically necessary pre-natal and post-natal care on an outpatient basis, if the mother has been a

more.

Examples of such treatment and tests include:

• Routine obstetricians’ and midwives’ fees;

• All scheduled ultrasounds and examinations;

• Prescribed medicines, drugs and dressings;

• Routine pre-natal blood tests, if required;

to as CVS);

• Non-invasive pre-natal testing (NIPT) for high risk individuals; and

• Any fees as a result of post-natal care required by the mother immediately following routine childbirth.

Pathology, radiology and diagnostic tests

(excluding Advanced Medical Imaging)Up to the maximum amount shown per period of

cover.



• We will pay for the following tests where they are medically necessary and are recommended by a specialist as part of


• X-rays;



• other diagnostic tests (excluding advanced medical imaging).

Physiotherapy treatmentUp to the maximum amount shown per period of

cover.



• We will pay for physiotherapy treatment on an outpatient basis that is medically necessary and restorative in nature

practitioner who holds the appropriate license to practice in the country where the treatment is received. This excludes

any sports medicine treatment.

• We will require a medical report and treatment plan prior to approval.

Osteopathy and chiropractic treatmentUp to the maximum amount shown per period of

cover.





• We will pay up to a combined maximum total of visits in any one period of cover for osteopathy and chiropractic

treatment which is evidence-based treatment, medically necessary and recommended by a treating specialist, if

a medical practitioner recommends the treatment and provides a referral. The treatment must be carried out by a

received. We will require a medical report and treatment plan prior to approval. This excludes any sports medicine

treatment.

Acupuncture, Homeopathy, and

Chinese medicineUp to a combined maximum of 15 visits per period of

cover.



• We will pay for a combined maximum total of 15 consultations with acupuncturists, homeopaths and practitioners of

practitioner. practice in the country where the treatment is received.

Restorative speech therapyUp to the maximum amount shown per period of

cover.



• We will pay for restorative speech therapy if:

• it is required immediately following treatment which is covered under this policy (for example, as part of a

Important notes

• We will only pay for speech therapy if the aim of that therapy is to restore impaired speech function.

• We will not pay for speech therapy which:

• aims to improve speech skills which are not fully developed;

• is educational in nature;

• is intended to maintain speech communication;

• aims to improve speech or language disorders (such as stammering); or

disorder or autism.

Prescribed drugs and dressingsUp to the maximum amount shown per period of

cover.


USD500 USD2,000 Paid in full

• We will pay for prescription drugs and dressings which are prescribed by a medical practitioner on an outpatient basis.

Rental of durable equipmentUp to a maximum of 45 days in the period of cover.



• We will pay for the rental of durable medical equipment for up to 45 days per period of cover, if the use of that

• We will only pay for the rental of durable medical equipment which:

• is not disposable, and is capable of being used more than once;

• serves a medical purpose;

• is of a type only normally used by a person who is suffering from the effect of a disease, illness or injury.

Adult vaccinationsUp to the maximum amount shown per period of

cover.


USD250 Paid in full Paid in full

• We will pay for certain vaccinations and immunisations that are clinically appropriate namely:

• Tetanus (once every 10 years);

• Hepatitis A;

• Hepatitis B;

• Meningitis;

• Rabies;

• Cholera;

• Yellow Fever;

• Japanese Encephalitis;

• Polio booster;

• Typhoid; and

• Malaria (in tablet form, either daily or weekly).

Dental accidentsUp to the maximum amount shown per period of

cover.


USD1,000 Paid in full Paid in full

•

for outpatient dental treatment for any sound natural tooth/teeth damaged or affected by the accident, provided the

treatment commences immediately after the accident and is completed within 30 days of the date of the accident.

•

• the date of the accident; and

• the fact that the tooth/teeth which are the subject of the proposed treatment are sound natural tooth/teeth.

•

when they need treatment following accidental damage to a tooth or teeth.

• We will not pay for the repair or provision of dental implants, crowns or dentures under this part of this policy.

Well child tests



• Payable for children at appropriate age intervals up to the age of 6.

• We will pay for well child routine tests at any of the appropriate age intervals (birth, 2 months, 4 months, 6 months,

9 months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, 5 years and 6 years) and for a medical

practitioner to provide preventative care consisting of:

• evaluating medical history;

• physical examinations;

• development assessment;

• anticipatory guidance; and

• appropriate immunisations and laboratory tests; for children aged 6 or younger.

We will pay for one visit to a medical practitioner at each of the appropriate age intervals (up to a total of 13 visits for

each child) for the purposes of receiving preventative care services.

• In addition, we will pay for:

• one school entry health check, to assess growth, hearing and vision, for each child aged 6 or younger.

• diabetic retinopathy screening for children over the age of 12 who have diabetes.

Child immunisations



• We will pay for the following immunisations for children aged 17 or younger:

• DPT (Diphtheria, Pertussis and Tetanus);

• MMR (Measles, Mumps and Rubella);

• Polio;

• Hepatitis B;

• Meningitis; and

• Human Papilloma Virus (HPV).

Annual routine tests



• We will pay for the following routine tests for children aged 15 or younger:

• one eye test; and

• one hearing test.


USD0 / USD150 / USD500 / USD1,000 / USD1,500





0% / 10% / 20% / 30%

Your out of pocket maximum is:

USD3,000


Medical Evacuation



•

emergency.

•

• to be taken to the nearest hospital where the necessary treatment is available (even if this is in another part of the

country, or in another country); and

• to return to the place they were taken from, provided the return journey takes place not more than 14 days after the

treatment is completed.






•

chemotherapy) if, in the opinion of our medical assistance service, evacuation is appropriate and medically necessary

in the circumstances.

• We will not pay any other costs related to an evacuation (such as accommodation costs).

Important note

• If you require to return to the hospital where you were evacuated for follow up treatment, we will not pay for travel costs

or living allowance costs.

period of cover


USD1,000,000 USD1,000,000 USD1,000,000

INTERNATIONAL MEDICAL EVACUATION

International Medical Evacuation provides coverage for reasonable transportation costs to the nearest

centre of medical excellence in the event that the treatment is not available locally in an emergency.

of habitual residence or country of nationality to be treated in a familiar location. It also includes


YOUR OVERALL LIMIT

Medical repatriation



•

• for them to be returned to their country of habitual residence or country of nationality; and

• to return them to the place they were taken from, provided the return journey takes place not more than 14 days

after the treatment is completed.

• The above journey must be approved in advance by our medical assistance service and to avoid doubt all

transportation costs are required to be reasonable and customary.






• We will not pay any other costs related to a repatriation (such as accommodation costs).

Important notes

• If you require to return to the hospital where you were repatriated for follow up treatment, we will not pay for travel

costs or living allowance costs.

•

assistance service does not consider repatriation to be medically appropriate, we may instead arrange for the

stable, and it is medically appropriate to do so.

Repatriation of mortal remains



•

service will arrange for their mortal remains to be returned to their country of habitual residence or country of nationality

as soon as reasonably practicable, subject to airlines requirements and restrictions.

• We will not pay any costs associated with burial or cremation or the transport costs for someone to collect or

Compassionate visits - travel costsUp to a maximum of 5 trips per lifetime.

Up to the maximum amount shown per period of

cover.


USD1,200 USD1,200 USD1,200

Compassionate visits - living allowance costsUp to the maximum amount shown per day for each visit with a maximum of 10 days per visit. Up to the maximum amount shown per period of cover.


•

must be approved in advance by our medical assistance service.

•

• We will also pay for living expenses incurred by a family member during a compassionate visit, for up to 10 days per

being provided with receipts in respect of the costs incurred).

Important note

•

repatriation takes place during a compassionate visit, we will not pay any further third party transportation costs.

Travel costs for an accompanying person



•

a medical evacuation or repatriation, because they:

• need help getting on or off an aeroplane or other vehicle;

• are travelling 1000 miles (or 1600km) or further;

• are severely anxious or distressed, and are not being accompanied by a nurse, paramedic or other medical escort

and; or

• are very seriously ill or injured;

we will pay for a relative or partner to accompany them. The journeys (for the avoidance of doubt shall mean one

outbound and one return) must be approved in advance by the medical assistance service and the return journey

must take place not more than 14 days after the treatment is completed.

• We will pay:


• the reasonable cost of travel by land or sea; whichever is the lesser.

accompanying them may travel in a different class.

their spouse or partner, we will also pay the reasonable travel costs of any children aged 17 or under, if those children

would otherwise be left without a parent or guardian.

Important notes

•

• We will not pay for any other costs relating to third party travel costs, such as accommodation or local transportation.

visits to you by immediate family members.

The following important notes and general conditions apply to all of the cover which is provided under the International Medical Evacuation option.

Important notes

The services described in this section are provided or arranged by the medical assistance service under this policy.

The following conditions apply to both emergency medical evacuations and repatriations:

• all evacuations and repatriations must be approved in advance by the medical assistance service, which is contactable through the Customer Care Team;

• nurse or medical practitioner;

• treated) on an inpatient or daypatient basis;

• the treatment because of which the evacuation or repatriation service is required must:

evacuation or repatriation service;

Worldwide including USA cover).

• We will only pay for evacuation or repatriation services if all arrangements are approved in advance by our medical assistance service. Before that approval will be given, we must be provided with any information or proof that we may reasonably request;

• We will not approve or pay for an evacuation or repatriation if, in our reasonable opinion, it is not appropriate, or if it is against medical advice. In coming to a decision as to whether an evacuation or repatriation is appropriate, we will refer to established clinical and medical practice;

• From time to time we may carry out a review of this cover and reserve the right to contact you to obtain further information when it is reasonable for us to do so.

General conditions

• Where local conditions make it impossible, impractical, or unreasonably dangerous to enter an area, for example because of political instability or war, we may not be able to arrange evacuation or repatriation services. This policy does not guarantee that evacuation or repatriation services will always be available when requested, even if they are medically appropriate.

•

• International Medical Insurance plan (or under another coverage option if appropriate) provided that the treatment is covered under this policy and you have purchased the relevant cover.

• We cannot be held liable for any delays or lack of availability of evacuation or repatriation services which result from adverse weather conditions, technical or mechanical problems, conditions or restrictions imposed by public authorities, or any other factor which is beyond our reasonable control.

• We will only pay for evacuation, repatriation and third party transportation if the treatment for which, or because of which, the evacuation or repatriation is necessary is covered under this policy.

• All decisions as to:• the medical necessity of evacuation or repatriation;• the means and timing of any evacuation or repatriation;• the medical equipment and medical personnel to be used; and

into account all of the relevant medical factors and considerations.

Routine adult physical examinationsUp to the maximum amount shown per period of

cover.



• We will pay for routine adult physical examinations (including but not limited to: height, weight, bloods, urinalysis, blood

pressure, lung function etc), for persons aged 18 or older.

INTERNATIONAL HEALTH AND WELLBEING

counselling support for a range of life crises and tailored advice and support through our online health

the way they want.

During each period of cover we will pay for the following tests to be carried out by a medical

practitioner.

Pap smearUp to the maximum amount shown per period of

cover.



•

Prostate cancer screeningUp to the maximum amount shown per period of

cover.



•

Mammograms for breast cancer screening Up to the maximum amount shown per period of

cover.




• Aged 35-39: one baseline mammogram for asymptomatic women.

• Aged 40-49: one mammogram for asymptomatic women every two years.

• Aged 50 or older: one mammogram each year.

Bowel cancer screeningUp to the maximum amount shown per period of

cover.



•

Bone densitometryUp to the maximum amount shown per period of

cover.



•

Dietetic consultations


Not covered Not covered Paid in full

•

relating to a diagnosed disease or illness such as diabetes (Platinum plan only).

Life management assistance programme



• Our Life Management service is available 24 hours a day, 7 days a week, 365 days a year. Professionals are ready to

assist you with any issue that matters to you.

• We will pay for up to 5 counselling sessions per issue per period of cover. This could be telephonic or face to face

counselling support.

• Unlimited in the moment telephonic support for live assistance.

• Provides information, resources and counselling on any work, life, personal, or family issue that matters to you.

• Information services provide support including assistance for day to day demands or the logistics of relocating. The

local resources.

Please contact us for approval. The service is provided by our chosen counselling provider.

Online health education, health assessments

and web-based coaching programmes



Eye examination



• We will pay for one routine eye examination per period of cover, to be carried out by either an ophthalmologist or

optometrist.

• We will not pay for more than one eye examination in any one period of cover.

INTERNATIONAL VISION AND DENTAL

spectacles and lenses. It also covers a wide range of preventative, routine and major dental treatments.

VISION CARE

Expenses for:

• Spectacle lenses;

• Contact lenses;

• Spectacle frames;

• Prescription sunglasses; when all are prescribed by an optometrist or ophthalmologist.





• sunglasses, unless medically prescribed, by an ophthalmologist or optometrist;

• glasses or lenses which are not medically necessary or not prescribed by an ophthalmologist or optometrist; or

• treatment or surgery, including treatment or surgery which aims to correct eyesight, such as laser eye surgery,

refractive keratotomy (RK) or photorefractive keratectomy (PRK).

• A copy of a prescription or invoice for corrective lenses will need to be provided to us in support of any claim for

frames.

period of cover


USD1,250 USD2,500 USD5,500

DENTAL TREATMENT

YOUR OVERALL LIMIT

Preventative dental treatment

for 3 months.



•


• two dental check-ups per period of cover;

• X-rays, including bitewing, single view, and orthopantomogram (OPG);

• one mouth guard per period of cover;

• one night guard per period of cover; and

• Fissure sealant.

Routine dental treatment

for 3 months.




Paid in full

•

and Dental cover for at least 3 months (if that treatment is necessary for continued oral health and is recommended by

a dentist):

• root canal treatment;

• extractions;

• surgical procedures;

• occasional treatment;

• anaesthetics; and

• periodontal treatment.

Major restorative dental treatment

for 12 months.




Paid in full

•


• dentures (acrylic/synthetic, metal and metal/acrylic);

• crowns;

• inlays; and

• placement of dental implants.

•

12 months, we will pay 50% of the treatment costs.

Orthodontic treatment

for 2 consecutive years.





•

Vision and Dental cover for at least 24 months.

• We will only pay for orthodontic treatment if:

• the dentist or orthodontist who is going to provide the treatment provides us, in advance, with a detailed description

of the proposed treatment (including X-rays and models), and an estimate of the cost of treatment; and

• we have approved the treatment in advance.

Other dental treatment

If a requires a form of which is not provided for in this , they may contact us (before

the is received) to enquire whether we will provide cover for that . We will consider the request, and will

decide, at our discretion:

• whether we will pay for the ;

• if so, whether we will pay all or part of the cost; and

• which of the areas of cover it will come within (for the purposes of calculating when limits of cover are reached).

• prior approval should be obtained before any is received.

Dental exclusions

The following exclusions apply to , in addition to those set out elsewhere in this and in


• Purely , or other which are not necessary for continued or improved .

• The replacement of any dental appliance which is lost or stolen, or associated .

• The replacement of a bridge, crown or denture which (in the reasonable opinion of a of ordinary competence and

skill in the ) is capable of being repaired and made usable.

• it has been damaged beyond repair, whilst in use, as a result of a suffered by the whilst they are

covered under this ; or

• the replacement is necessary because the requires the extraction of a ; or

• the replacement is necessary because of the placement of an original opposing full denture.

• Acrylic or porcelain veneers.

• they are constructed of either porcelain; bonded-to-metal or metal alone (for example, a gold alloy crown); or

• a temporary crown or pontic is necessary as part of routine or emergency .

• , procedures and materials which are experimental or do not meet generally accepted dental standards.

• for dental implants directly or indirectly related to:

• failure of the implant to integrate;

• breakdown of osseointegration;

• peri-implantitis;

• replacement of crowns, bridges or dentures; or

• any accident or including for any prosthetic device.

• Advice relating to plaque control, oral hygiene and diet.

• Services and supplies, including but not limited to mouthwash, toothbrush and toothpaste.

• Medical carried out in by an oral may be covered under International Medical Insurance plan

and/or International Outpatient, if this option has been bought, except when is the reason for being in

.

• Orthodontic for anyone after their 19th birthday.

• Bite registration, precision or semi-precision attachments.

• Any , procedure, appliance or restoration (except full dentures) if its main purpose is to:

• change vertical dimensions; or

• diagnose or treat conditions or dysfunction of the temporomandibular joint; or

• stabilise periodontally involved teeth; or

• restore occlusion.

KEY PRODUCT PROVISIONS

The following are key product provisions found in our Policy documents. This is only a brief summary,

intended for guidance and information. You are advised to also refer to the Policy Rules, which will prevail

Please consult us should you require further explanation.

terminate this policy if:

1.1 Any premium or other charges (including any relevant tax) is not paid in full within thirty (30) days of

the date on which it is due. We will give you written notice if we are going to terminate the policy for

this reason; or

1.2 It becomes unlawful for us to provide any of the cover available under this policy; or

maintained by the European Union, the United Kingdom, the USA, Singapore or any other applicable

jurisdiction. Furthermore, we will not pay claims for services received in sanctioned countries if

doing so would violate the requirements of the United Nations Security Council, the European Union,

Singapore or any other jurisdiction applicable to us; or

1.4 We determine, you have knowingly or recklessly provided information which you know or believe to

be untrue or inaccurate or failed to provide information which we have asked for. This could affect

payment of claims under your policy and may result in us terminating your cover; or

1.5 We are no longer in the market to sell the policy or a suitable alternative in your geographical area.

If this policy ends before the normal end date, any premium which has been paid in relation to the period

after cover has ended will be refunded on a pro rata basis, so long as no claims have been made and no

guarantees of payment or prior approvals have been put in place during the period of cover. If your policy

is terminated in accordance with clause 14.1.4 of the Policy Rules, we may not refund any premiums you

have paid nor pay any claims you have made under your policy.

If the policy ends before the normal end date and you have made claims under it, you will be liable for the

remainder of any premiums in respect of the policy which are unpaid.

If treatment has been authorised, we will not be held responsible for any treatment costs if the policy ends

We will wherever possible, write to you at least one (1) month before the end date to give you written

notice that the policy will not be renewed with effect from the end date.

- This policy is an annual contract. This means that, unless it is terminated

earlier or renewed, the cover will end one (1) year after the start date.

We will write to you at least one (1) calendar month before the end date and ask you whether you want to

month’s notice of such changes.

If you choose to renew, you do not need to do anything, and your cover will be renewed automatically for

Policy Rules in force at the time of renewal. If you do not want to renew your cover, you must inform us in

writing at least seven (7) days before your policy end date.

their own cover. We will consider their applications individually, and inform them whether, and on what

terms, we are willing to offer them such cover.

- We will write to you at least one (1) calendar month before the

end date and ask you whether you want to renew the cover you currently have. Premiums may change if

you request to change coverage options at the annual renewal date. We will inform you of any changes

to the premiums or terms and conditions which would apply on your renewal. The premium and/or other

charges may vary from year to year.

exclusions.

• Treatment for a pre-existing condition or any conditions or symptoms which result from, or are related

to, a pre-existing condition. We will not pay for treatment for a pre-existing condition of which the

policyholder was (or should reasonably have been) aware at the date cover commenced, and in

respect of which we have not expressly agreed to provide cover.

• Congenital anomalies or defects, except new-borns who are eligible to join the plan without medical

birthday, or were not evident at policy inception.

5. WAITING PERIOD

•

parent and baby care and treatment.

• The mother has been covered by the policy for a continuous period of at least twelve (12) months

or more.

•

plans) on an outpatient basis if the mother has been covered under the optional International

• Complications from Maternity

• A twelve (12) month waiting period applies for complications resulting from pregnancy or

childbirth

• The mother has been covered by the policy for a continuous period of at least twelve (12) months

or more.

• Homebirths

• A twelve (12) month waiting period applies for Homebirths.

• Available once the mother has been covered by the policy for a continuous period of twelve (12)

months or more.

• Newborn care

• A twelve (12) month waiting period applies.

• At least one (1) parent has been covered by the policy for a continuous period of twelve (12)

months or more prior to the newborn’s birth.

International Vision and Dental Care optional module

Dental Treatment:

• Preventative & Routine treatment

• International Vision and Dental cover for at least three (3) months

• Major Restorative treatment

restorative dental treatment before they have had International Vision and Dental cover for twelve

(12) months, will pay 50% of the treatment costs.

• Orthodontic treatment

• International Vision and Dental cover for at least twenty-four (24) months.

6. REASONABLE AND CUSTOMARY CHARGES - We will pay reasonable and customary

for such treatment costs in line with the appropriate fees in the location of treatment and according to

established clinical and medical practice.

7. AREA OF COVER - You may choose between two (2) options, which determine where in the world

8. FREE LOOK PERIOD - If the policy does not meet your needs, or has not been issued in

accordance with your intention, you may ask us to cancel it within fourteen (14) days from the date of

receipt of the policy. If no claims have been made, and no guarantees of payment or prior approvals have

been put in place, we will refund any premium that has been paid.

9. CHANGE OF OCCUPATION - No requirement for you to inform us of a change of occupation.

- Not applicable to our products.

– Details of any distribution costs, charges and expenses will be made

available upon your request.

Post: The Overseas Assurance Corporation Limited

The Overseas Assurance Corporation Limited (Reg No. 192000003W) 1 Pickering Street, #13-01 Great Eastern Centre, Singapore 048659

Cigna Europe Insurance Company S.A.-N.V. - Singapore Branch (Reg No. T10FC0145E) 152 Beach Road, #26-05 The Gateway East, Singapore 189721

PGH Proposal Form December 2015

PRESTIGE GLOBAL HEALTH OPTIONS - Great Eastern … · OAC is a general insurance company regulated...

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