Personal Health Care +

Personal Hospitalization & Surgical

Expense Policy

Jubilee General Insurance Company Limited

(formerly New Jubilee Insurance Company Limited)
2nd Floor, Jubilee Insurance House, I.I. Chundrigar Road
P.O Box 4795, Karachi-74000, Pakistan PREAMBLE AND OPERATIVE CLAUSE
UAN: 111 654 111. Tel: (021) 32416022-26
Fax: (021) 32438738, 32416728
This Policy is granted by Jubilee General Insurance Company
Email: [email protected]
Ltd. (hereinafter called “the Company”) to the person(s) de-
Website: www.jubileegeneral.com.pk
scribed in the Policy Schedule as the Policy Owner(s) on the
life of the person mentioned therein as the Life Assured.

The proposal, declaration(s), and any statement(s) made by

the Policy Owner(s) and Life Assured in connection with this
Policy shall be the basis of this contract, which provides that
in consideration of receipt and realisation by the Company
of the Premium mentioned in the Policy Schedule, the Com-
pany will pay to the Life Assured, Nominee(s), successor(s)
or assignee(s) of the Policy Owner(s), the specified Benefit
Assured on the happening of the event described in the Policy
Schedule as the Event Assured Against.

The liability of the Company is at all times subject to the Policy

Schedule, Standard Policy Conditions and any special condi-
tions or endorsements issued by the Company and attached
to this Policy, all of which are part of the contract evidenced
by this Policy.

This is a digitally signed copy of the policy which may be

verified for authenticity by logging on to our
website: https://online.jubileegeneral.com.pk/manage

(*) Jubilee General Insurance Company is registered and

supervised by the Securities and Exchange Commission of
Pakistan
 SCHEDULE OF BENEFITS

SECTION I dence of the age of any Insured Member or of any person

GENERAL POLICY TERMS who has applied to join this Policy.
ENTIRE CONTRACT MISSTATEMENT OF FACTS
This policy, the application of the Policyholder, endorsements If relevant facts pertaining to any Insured concerned with in-
and riders, if any, and the list of Insured attached hereto, surance under this policy shall be found to have been mis-
constitute the entire contract between the Company and the stated fraudulently, by the Policyholder, then insurance on the
Policyholder. Insured shall be void able at the option of the Company. The
ALTERATIONS TO THIS POLICY Company reserves the right to make adjustments in premium
The terms, conditions and benefits provided by this policy and/or amounts of insurance as the Company may consider
may be altered at any time by Company. All such altera- appropriate, had the facts been declared correctly.
tions shall be communicated to the Policyholder in writing and ELIGIBILITY
deemed to be an endorsement of the policy and shall be The Policyholder when applying for coverage apply to cover
binding on all Insured covered under the policy. himself/herself only.
REQUIRED INFORMATION / CLERICAL ERRORS Insurance for an eligible Policyholder shall commence under
The Policyholder shall furnish to the Company all information the provisions of this policy only if the Company approves his
that may be required by the Company with regard to any evidence of insurability. Such evidence shall be furnished, at
matter pertaining to the policy. All documents and records no cost to the Company, through the Policyholder, in a form
that may have a bearing on the benefits or premium rates satisfactory to the Company. The eligible Insured should be
provided by this policy shall be open for inspection by the Actively At Work and below the Maximum Eligibility Age.
Company at all times during the continuance of this policy. AMOUNTS OF INSURANCE
Neither clerical error, by the Policyholder or by the Company, The amounts of insurance for the benefits provided by this pol-
in maintaining any records concerning the insurance here- icy to each Insured person shall be determined in accordance
under, nor delays in compiling such records shall invalidate with the plan of benefit stated in the Schedule of Benefits.
insurance otherwise validly in force or continue insurance oth- EFFECTIVE DATES OF INSURANCE
erwise validly terminated, or establish any insurance not oth- The effective date of a Policyholder’s insurance will be the
erwise in existence, but upon discovery of such error or delay date on which the Company approves the Policyholders‟
an equitable adjustment of remium shall be made. evidence of insurability.
REFUSAL OR ACCEPTANCE OF APPLICATION Notwithstanding the foregoing, neither initial insurance, nor
The Company reserves the right to refuse any application any increase in insurance shall become effective on a date
without giving any reason or to accept the application on when a Policyholder is not Actively At Work because of a
any special terms which the Company may require. disability resulting from Sickness or Injury. In such case, the
EVIDENCE OF AGE Company shall require the Policyholder to furnish evidence of
The Company reserves the right at any time to request evi- insurability for himself in the manner aforementioned, after he
returns back to Actively At Work status.
Up to 3 months 40%
The effective date of initial insurance or the increase in in-
surance shall be determined by the Company on the basis Up to 6 months 20%
of such evidence of insurability and, communicated to the
Policyholder in writing. 06 months above Nil
TERMINATION OF AN INSURED’S INSURANCE
All insurance of any Insured under this policy shall cease at The Company reserves the right to terminate the policy, by
the earliest of the following times: giving a 15 days written notice to the Policyholder, or add or
(1) Upon termination of this policy alter or repeal the terms and conditions hereof for whatever
(2) Upon the Insured ttaining the Maximum Eligibility Age. reasons. In the event of the termination of this contract by the
(3) Upon any other date on which the Insured ceases to be Company the premium shall be refunded for the unutilized pe-
eligible for insurance. riod of the policy. There will be no refund if any claims have
The Company also reserves the right at any time to terminate been made under the policy.
the insurance of any Insured after giving notice in writing to LATE SETTLEMENT OF CLAIMS:
the Policyholder if he/she covered by this contract has at any When payment of a claim by the Company becomes due
time fraudulently: and the Policyholder has complied with all the requirements,
(1) Misled the Company by miss-statement or concealment. including filing of complete papers, for claiming the payment
(2) Agreed to any attempt by a third party to obtain an un- and the Company fails to make a payment in 90 days from
reasonable pecuniary advantage to the Company’s detri- the date at which the payment becomes due or the date on
ment. which the Policyholder complies with the requirernent, which-
(3) Failed to act with the utmost good faith. ever is later, pay as liquidated damages a sum calculated in
PREMIUMS /RENEWALS a manner specified below, as the payment so payable unless
All Premiums are payable yearly in advance at the head of- the Company proves that such failure wad due to circum-
fice or the relevant branch of the Company. Failure to pay stances beyond its control.
any premium on or before its due date shall constitute CALCULATION OF LIQUIDATED DAMAGES:
default hereunder. The liquidated damages payable for the late settlement of
The Policyholder shall also be responsible for the payment of claim shall be payable for the period for which the failure
the premium, The first premium is policy on the Policy Effective continues and shall be calculated as monthly rests at the rate
Date and will continue the policy for a term of twelve months. of 5% higher than the prevailing base rate.
Thereafter, at the consent of the Company, this policy may POLICYHOLDER’S OBLIGATIONS:
be renewed from year to year, on such terms and conditions 1. The Policyholder undertakes to reimburse the Company
and on payment of such renewal premiums as the Company within 30 days for any expenses or loses incurred by the
may determine. The Company reserves the right to decline to Company in respect of Treatments by covered Persons
renew the policy. which were not covered by the terms and conditions of
For renewals, the company is under no obligation to notify this Policy, including but not limited to payments in excess
you of the renewal date of the policy, however a Grace Pe- of the applicable benefit limits; payments in cases where
riod of 30 days is permissible and the policy will be consid- a policy exclusion applies and payments incurred after
ered as continues for the purpose of 04 year waiting period termination of coverage of a Covered Person or termina-
for Pre existing condition. tion of this Policy.
For renewals received after the completion of 30 days Grace 2. The Policyholder undertakes to reimburse the Company
Period, a new application should be submitted the compa- for any expenses or losses incurred by the Company due
ny and it would be processed as a NEW Business Proposal. to the failure by the Policyholder to discharge its respon-
RENEWAL INCENTIVE sibilities under the Policy, including any unauthorized use
If no claim has been made under the policy and the policy is of the Companys Health Card.
renewed without any break for 02 policy years. The company 3. The Policyholder will reimburse the Company for any
will increase the amount of coverage by 15 % for the next benefit paid or expenses or losses incurred by the Com-
renewal. pany on account of any Pre-existing Condition which is
i. The maximum cumulative increase in the Limit of Indem- not revealed to the Company at the time of commence-
nity will be limited to 45% of Sum Insured. ment of coverage.
ii. If a claim is made in any year where a cumulative increase FRAUD
has been applied, then the increased Limit of Indemnity shall If any claim shall be false or fraudulent in any respect, then
be reduced by 15%. the Company will be entitled to undertake any or all of
Free Look Period the following actions:
Policy Holder has a period of 5 days from the date of receipt 1) Refuse to pay any benefits in relation to the Claim.
of the policy document to review the terms and conditions of 2) Cancel the Policy immediately, without returning the pre-
this Policy. If Policy Holder has any objections to any of the mium payments made.
terms and conditions, Policy Holder has the option of cancel- 3) Recover any monetary amounts already paid.
ling the Policy stating the reasons for cancellation. If Policy WAIVER OF CONTRACT PROVISIONS
Holder has not made any claim during the Free look period, The waiver by the Company of any provisions of this Policy
Policy Holder shall be entitled to refund of premium subject or the introduction of any change in interpretation or practice
to, deduction of the Administrative charges and Government of any terms or conditions of this Policy shall not prevent the
taxes expenses incurred by Company. subsequent enforcement of those provisions, terms or condi-
TERMINATION OF POLICY tions and shall not be deemed to be a waiver of any similar
The Policyholder may terminate this policy by giving to the provisions of this Policy or change in interpretation or practice
Company written notice stating when, not less than 15 days of any similar terms or conditions of this Policy.
after the date of such notice, such termination shall become TERRITORIAL LIMITS
effective. Refund of premium in this case shall only be in case This policy is meant to cover treatment within Pakistan for the
if no claims have been made under the policy and will be as residents of Karachi, Lahore, Islamabad and Rawalpindi.
per the following table: ARBITRATION
Any difference which may arise between the Company
Length Of Policy Percentage Of Premium and the Policyholder and can not be settled amicably shall be
In force Refund settled by arbitration in accordance with the statutory provi-
sions for the time being in force applicable thereto and the
Up to 01 month 70% obtaining of an award shall be a condition precedent to any
liability of the Company or any right of action against the
Company.
APPLICABLE LAW Treatment related to pregnancy are excluded from the
This Policy, and all rights, obligations and liabilities arising scope of this benefit
hereunder, shall be governed and interpreted in accordance (7) Ambulance Service Expenses: Expenses incurred for the
with the Laws of the Islamic Republic of Pakistan. use of a roadambulance for the transportation of the
CUSTOMER SERVICE & GRIEVANCES REDDRESSAL: Insured to or between Hospitals within the same city
(i). In case of any query or complaint/grievance, Policy in the course of an Emergency. The maximum amount
Holder may approach office at the following address: payable for such expenses shall be as per the sub limit,
Health Insurance Administration Office 36-A/2 Lalazar, M. T. specified in the Schedule Of Benefits.
Khan Road, Karachi- 74000, Pakistan (8) Medical Second Opinion (MSO) Benefit:International
Phone: 021-35644312-4 and 021- 35611709 Medical Second opinion from Mediguide International
Facsimile: 021-35611349 for more than 100 top hospitals across the world
E-mail: [email protected] PROCEDURE OF OBTAINING BENEFIT
(ii). In case Policy Holder is not satisfied with the decision of For inpatient benefits only, the Company will arrange the
the above office, or have not Received any response within Treatment on credit/Cashless basis and has made credit ar-
10 days, then Policy Holder may contact the following official rangements with a number of Approved Hospitals, a list of
for Resolution: which is attached to the policy.
Jubilee General Insurance Company Limited This credit arrangement is subject to a prior approval from
(Formerly New Jubilee Insurance Company Limited) the Company as per the following procedure:
2nd Floor, Jubilee Insurance House, I.I. Chundrigar Road, In case Hospital Confinement is advised by a Physician, the
P.O.BOX 4795, Karachi. - 74000, Pakistan Policyholder must first seek approval, from the
UAN: (021)111-654-111, Tel: 021- 32416022-26 Fax: Company at least 03 days in advance, by submitting a duly
021-32416728, 32438738 filled prior approval form with details of the Treatment / pro-
Email - [email protected] cedures to be carried out. Once the Treatment is approved,
Website: www.jubileegeneral.com.pk. the Company would then coordinate with the Panel Hospital
SECTION II to arrange credit for the approved Eligible Expenses.
BENEFITS-TERMS, PROVISIONS & EXCLUSIONS Each Policyholder will be issued with a health card, outlining
HOSPITAL EXPENSE BENEFITS briefly the services covered under the policy along with the
Subject to the expense limits under Hospitalization Expense details of the Policyholder.
Benefits as stated in the Schedule Of Benefits, and other At the time of commencement of Hospital Confinement at a
terms and conditions of the policy, the Company shall pay for Panel Hospital, the Policyholder should present his health card
Reasonable and Customary charges for all Medically Neces- to the Panel Hospital and show proof of identification of him
sary Treatment, provided on the advice of a Physician to the in form of national identity card. All eligible expenses (as de-
Insured during Hospital Confinement OR if the Insured under- fined in this Policy) will be settled directly by the Company to
goes a Surgical Operation without being registered as a bed the Panel Hospital, in line with the approval. The Policyholder
patient. The following benefits are payable: shall pay all expenses other than the eligible expenses directly
(1) Daily Room Benefits: The room charges per day, as to the Hospital before discharge of the Covered Insured
per the sub limit specified in the Schedule Of Benefits. HOSPITAL CONFINEMENT IN A NON PANEL HOSPITAL
(2) Intensive Care Unit Charges: The charges per day The Policyholder is allowed to seek Treatment from a Non-Pan-
for ICU or another unit for similar purpose, as per the el Hospital, only in case of an Emergency. If the Policyholder
sub limit specified in the Schedule Of Benefits. gets Treatment from a Non-Panel Hospital in a non-Emergency
(3) Hospital Miscellaneous Expenses: Expenses, which situation, the Company reserves the right to decline the claim.
are made for the following: NOTIFICATION IN CASE OF AN EMERGENCY HOSPI-
a. Prescribed medical supplies and services (except TAL CONFINEMENT
room charges andcharges arising from special In all Emergency Hospital Confinement(s), whether in a Panel
nursing services), or Non-Panel Hospital, the Company should be intimated
b. Physicians‟ and surgeons’ visits, within 24 hours of such Hospital Confinement. Intimation
c. Laboratory tests and X-ray examinations, to the Company shall mean intimation given by or on behalf
d. Operation theatre charges, of the Insured to the Company at its Head Office, with infor-
e. Anesthesia and administration thereof, mation sufficient to identify the Insured, the Hospital and the
f. Blood transfusions, including cost of blood, pro- Physician.
vided, however, that if the Insured is confined as a In case any of the above procedures are not followed, the
registered bed-patient, benefits shall be paid here- Company reserves the right to either negate or reduce the
under only for charges incurred during the period benefit amount for such Hospital Confinement(s).
for which benefits are payable under (1) above, Medical Second Opinion (MSO):
g. Physiotherapy. Utilization Procedure Patient
h. Ventilator and allied services. (Policy Holder or his/her spouse or his/her Children) is di-
(4) Surgical Expenses: Fee for any Surgical Operation, agnosed with a condition which is Covered under Medical
performed by a licensed Physician/ Surgeon. Second Opinion, Mediguide Covers any Medical Condition
(5) Day Care Surgery Expenses: Charges incurred for The member calls MediGuide’s local service center (111-11-
surgical operations on a pre-planned basis without an 2273) to establish eligibility and initiates the Medical Second
overnight stay in a Hospital. Opinion service.
(6) Pre and Post Hospitalization Expenses: Reasonable Patient must sign a form consenting to the release of their
and Customary charges for all Medically Necessary medical records and details. The doctor will then prepare the
Out-Patient Treatment, which are directly related to the relevant patient medical records for MediGuide.
cause of hospitalization, provided on the advice of MediGuide will identify 3 medical centers available to pro-
a Physician to the Insured, occurring while the Insured vide the review and gives the names to the patient and doctor.
is covered under the policy. The benefit is restricted to Patient and doctor choose the medical center they wish to use
the number of days before and after the hospitalization for the Medical Second Opinion from the list of 3 provided.
and the sub limit for such expenses, as specified in the Within 10 business days of receipt of medical records, both
Schedule of Benefits. the patient and/or doctor will receive a written review from
The following benefits are payable: the selected medical center of the original diagnosis and a
• Physicians fee. proposed treatment plan, subject to data protection
• Cost of prescribed medicines. CLAIMS
• Cost of Laboratory Tests. Where the indemnity is on a reimbursement basis, a fully
• Dressing Charges, stitch removal. completed Claim Form together with required supporting in-
Expenses for any Pre / Post hospitalization Outpatient formation/documents such as discharge summary, prescrip-
tions, payment receipts, itemized hospital bill,any other rel- 7. Any In-Patient dental Treatment, X- ays, extractions or
evant supporting document where applicable etc. must be fillings unless necessitated due to accidental injury oc-
submitted to the Company, in original, within 30 days of the curring while the insured was covered.
date of commencement of the event which gave rise to the 8. Cost of limbs any other organ (prostheses).
claim. Photo copies are not acceptable. 9. Treatment of any refractive errors of the eyes including
Failure to furnish such proof within the time required shall cost of procedures such as ‘Radial Keratotomy ‘ and ‘
not invalidate nor reduceany claim if it was not reasonably Excimer Laser„.
possible to give proof within such time, provided such proof 10. Weight reduction/enhancement programs.
is furnished as soon as reasonably possible andin no event 11. Any cosmetic Treatment or plastic surgery, unless neces-
later than 90 days from dateofsuch loss. No action in law or sitated due to accidental injuries occurring while the In-
equity shall be brought to recover under the Policy until after sured was covered under the scheme.
theexpiration of 90 days from the date Proof of loss has been 12. Injury or illness, due to war or due to active participation
furnished in accordance with Policy conditions. No such ac- in riots or civil war or civil commotion.
tion shall be broughtafter the expiration of one year from the 13. Self-inflicted injuries while sane or insane, including at-
time written proof of loss is required to be furnished. tempted suicide.
EXAMINATIONS 14. Engaging in air travel, except when travelling in a li-
The Company shall have the right and opportunity through its censed aircraft being operated by a licensed airline
medical representative to examine the person of the Insured according to published schedules.
when and as often as it may reasonably require duringthe 15. Any kind of inpatient treatment which could generally
pendency of a claim hereunder. The expenses of be done on an Outpatient basis or any Hospital Con-
such examinations shall be borne by the Company. finement primarily for diagnostic purposes, unless specifi-
BENEFITS & THEIR PAYMENT cally authorized by the Company in writing.
The benefits payable by the Company in respect of the ex- 16. Treatment or surgical operation for congenital defects or
penses incurred for the treatment provided to an Insured dur- deformities, including physical and mental defects pres-
ing the policy period shall be limited to: ent from birth.
i) Reasonable and Customary charges for the treatment & 17. Pregnancy and complications thereof, childbirth (includ-
ii) The Insureds benefit limit stated on the Schedule Of ing surgical delivery),miscarriage, abortion and/or any
Benefits. related prenatal or postnatal care, circumcision.
The benefits, payable under the terms of this policy, which 18. Treatment of infertility, impotency, sterilization & contra-
have not been paid directly by the Company to the Panel ception including any complication relating hereto.
Hospital, shall be paid to the Policyholder. 19. Treatment for injuries sustained as a result of participation
CURRENCY OF PAYMENT by the Insured in any dangerous sport, pastime or com-
All payments under this policy shall be made in the legal cur- petition, including but not restricted to riding, driving in
rency of Pakistan. any race or competition and engaging in professional
NON-DUPLICATION OF BENEFITS sport.
If the Insured is entitled to indemnity from any other source in 20. Any increase in the expenses incurred for the treatment
respect of the same Disability, including but not restricted to on account of the Insured being admitted to a more ex-
indemnity from another group or individual health insurance pensive room than allowed by his daily room rent limit.
policy, then the Company will only pay reimbursement on a 21. Treatment for injuries sustained as a result of participation
proportionate basis. The Company has full rights of subroga- by the Insured in an act which is illegal according to the
tion and may undertake legal proceedings in the Covered laws of Pakistan.
Persons name, but at the Companys expense, to recover for 22. Any Outpatient Treatment, except the one covered un-
the Company„s benefit from the other insurance company, der the sub limit for Accidental Outpatient Expense Ben-
any payment made by the Company. efit.
EXCLUSIONS: See section titled ‘Exclusions’. 23. Any charge in respect of the donor for any organ trans-
EXCLUSIONS plant claim.
The exclusions in this section are in addition to any other 24. Any experimental and or unproven Treatment.
exclusion that may be contained in a specific benefit section. ExclusionforMedical Second Opinion( MSO):
This policy does not insure and no benefits shall be paid for Mediguide is able to review any medical Diagnosis with a
expenses resulting from: MSO with the exception of the following circumstances:
1. Benefits will not be available for Any Pre-existing con- 1. No diagnosis
dition, ailment or injury, until 48 months of continuous 2. No evaluation by a treating physician For > 1 years
coverage have elapsed, after the date of inception of 3. Condition is acute or life threatening (requires immediate
the first Personal. HealthCare policy with the Company. medical intervention)
The above exclusion shall cease to apply if a Personal 4. An in person evaluation is required (e.g. mental illness)
health care Policy has been maintained for a continuous
period of 4 years without break.
In case of enhancement of Sum Insured this Exclusion shall SECION III
apply afresh only to the extent of the amount by which DEFINITIONS
the limit of indemnity has been increased (i.e. enhanced For the purpose of this policy the following words shall
sum insured) if the policy is a renewal of Personal Health- have the meaning as under, wherever they appear in
Care Policy without break in cover.. the policy document:
2. Any Treatment incurred within 30 days of the commence- ‘Actively At Work’ means that a Policyholder will be consid-
ment of the Policy Period except those incurred as a ered to be Actively at work on any day if he is then perform-
result of Accidental Bodily Injury. This does not apply to ing or is capable of performing in the customary manner all
any subsequent and continuous renewal of the policy. of the regular duties of his employment on the last scheduled
3. Any Treatment not recommended by a legally licensed working day. A person will be considered to have satisfied
Physician or which is not medically necessary. the Actively at work provisions on any day if he is then able
4. Mental illnesses, psychiatric disorders and any sickness to perform all the normal activities of a typical person of the
or condition arising from, and including drug abuse, al- same age and sex, and is confined neither at home nor in a
coholism or an Insureds criminal act. Hospital or any other medical facility.
5. Routine physical check-ups, rest cures, services including „Company’ means Jubilee General Insurance Company Ltd.
immunization. ‘Covered Individual’ subject to the payment of the required
6. Supply or fitting of eye glasses, contact lenses, hearing premium, includes the Policyholder, as defined herein, pro-
aids, wheelchairs andmedical appliances not required vided such coverage has been applied for and has been ap-
surgically. proved by the Company and is in force under the provisions
of this policy. ‘Physician’ means an individual who is legally licensed in
‘Disability’ means a Sickness or Injury necessitating medical Pakistan, under a degree recognized by the Government of
treatment by a licensed physician. Pakistan, and who:
‘Eligible Expenses’ means expenses incurred on treatment a) is someone other than the Covered Person;
by a covered person that are payable by the company and b) is not related by blood or marriage to the Covered Person;
which are: c) is qualified to treat the Disability for which the claim is
a) Reasonable and Customary being made.
b) Medically Necessary ‘Policy’ means this agreement, its schedule (and any en-
c) Within policy coverage and limits; and dorsements attaching to or forming part thereof) and the poli-
d) Not excluded under any of the terms and conditions of cy document. Claims procedures, along with the application
this policy. and any claim form.
‘Emergency’ means a sudden illness or injury which raises a ‘Policy Effective Date’ means the date and time from which
professional concern that there may be a significant medical this policy takes effect, and as shown on the Schedule Of
problem jeopardizing the Insureds life and which necessi- Benefits
tates Treatment which must not be delayed and which requires ‘Policy Expiry Date’ means the date and time when cover
confinement to the emergency facility of a Hospital. ceases.
‘Health Card’ means the identification card issued to the ‘Policy Year’ means a twelve-month period starting from
Policyholder. the Policy Effective Date, or a Renewal Date, shown on the
‘Hospital’ means an institution that: Schedule Of Benefits.
a) is properly licensed to provide medical care in accor- ‘Policyholder’ means a person so named in the Schedule
dance with the laws of Pakistan; of Benefits.
b) is primarily engaged in providing diagnostic, medical ‘Pre-existing Conditions’ means any illness or injury or
and surgical facilities; related condition for which treatment, or medication, or ad-
c) has 24 hours-a-day nursing service by registered gradu- vice, or diagnosis was sought or received within 48 months
ate nurses under the permanent supervision of the Physi- prior to the commencement of this Policy for the Insured con-
cian in charge; cerned OR which was known or reasonably should have
d) maintains in-patient facilities; and been known to exist prior to the commencement of this Policy
e) maintains a daily medical record for each of its patients, for the Insured or in respect of which the need for treatment
which is accessible to the Company.” was foreseeable at inception of this Policy whether or not
‘Hospital Confinement’ means that a covered person is treatment or medication or advice or diagnosis had been
registered as a bed-patient in a hospital and incurs a daily sought or received.
room charge. ‘Reasonable and Customary Charges’ means charges
‘Insured’ or ‘Covered Person’, means the Policyholder, as for Medically Necessary Treatment of a standard customarily
defined herein, provided such coverage has been applied for provided for the medical condition concerned. Such charges
and has been approved by the Company and is in force should not exceed the general level of charges being made
under the provisions of this policy. by other Hospitals or Physicians when giving like or compara-
‘Injury’ means any bodily injury caused in an accident by ble treatment, services or supplies to individuals of the same
violent, external and visible means, and which shall have oc- sex and of comparable age for a similar disease or injury.
curred solely by and independently of any other cause. Regardless of whether medical treatment is obtained within
‘Limit Per Person’ means the maximum amount payable to or outside Pakistan Reasonable and Customary charges shall
a Person during the Policy Year ‘Maximum Eligibility Age’ mean, what is Reasonable and Customary in the area of resi-
means the maximum age to which an Insured can be cov- dence within Pakistan where the insured normally lives.
ered as under: ‘Renewal Date’ means any subsequent anniversary of the
Policy Effective Date.
Policyholder 18-49 years, Once enrolled cover ‘Sickness’ means a disease or pathological condition
can continue till the 60th birthday. leading to the impairment of normal physiological function
„Medically Necessary means any treatment, tests, medica- which manifests itself during the Policy Period and requires
tion, or stay in hospital or part of a stay in hospital which medical
- is required for the medical management of the illness or Treatment.
injury suffered by the insured; ‘Surgical Operation’ means only the following:
- must not exceed the level of care necessary to provide (1) A cutting operation
safe, adequate and appropriate medical care in scope, (2) Suturing a wound
duration, or intensity; and not just for the convenience of (3) Treatment of a fracture
the Insured. (4) Reduction of a dislocation
- must have been prescribed by a medical practitioner, (5) Radiotherapy (excluding radioactive isotope therapy) if
- must conform to the professional standards widely ac- used in lieu of a cutting operation for the removal of
cepted in international medical practice or by the medical tumors
community in Pakistan (6) Electrocautherization
‘Medical 2nd Opinion(MSO)’ means International Medical (7) Therapeutic endoscopic procedures.
2nd Opinion from Mediguide International, a world leading ‘Treatment’ means a surgical procedure or medical inter-
Medical Assistance provider from more than 100 top class vention to cure a Disability.
medical centers and hospitals across the world including the feminine and the singular as plural if the context so re-
USA, Canada, Europe and Asia. quires.
‘Non Panel Hospital’ means any hospital, day care centre Credit Card/Online Payment
or other provider that is not part of the network. Coverage purchased by credit card is subject to validation
‘Outpatient’ means treatment is one in which the Insured and acceptance by the credit card company and the Card
visits a clinic / hospital or associated facility like a consulta- issuing bank.
tion room for diagnosis and treatment based on the advice of Confidential Information
a Medical Practitioner. The Insured is not admitted as a day All information provided shall be kept for Companys use and
care or in-patient. will not be shared with third parties, vendors &/or con-
‘Panel Hospital’ means a Hospital approved and identified tractors. Please note that Credit card information is also not
by the Company to provide Treatment to covered Persons, stored by the Company and that Company shall not be liable
and which is included in the List of Panel Hospitals attached for any fraudulent usage of your Card. Company maintains
to this policy. The list may be amended from time to time by secured technology processes to safeguard the information
mutual agreement between the Policyholder and the Com- provided.
pany.