Long Term Insurance – Executive Medical Assurance Policy
1. Policy Terms and conditions
This policy the schedule and any memorandum thereon shall be considered one document and any word or expression to which a specific meaning has been attached in any of them shall bear such meaning throughout.
The insured and the Corporation agree as follows:
i. The proposal shall be incorporated in and be the basis of the contract
ii. The insured shall pay the premium
iii. The Corporation will provide the insurance subject to the terms of this policy
Conditions precedent to any liability of the Corporation:-
a) Observance of the terms of this policy relating to anything to be done or complied with by the Insured or the insured person.
b) The truth of the proposal
The Corporation will indemnify the insured subject to the overall limit applicable to an insured person in respect of all medical expenses within twelve months of and as the direct result of an insured person falling ill or sustaining accidental bodily injury during the period of insurance. The maximum amount payable by the corporation for medical expenses in respect of:
a) One claim or all claims of series (whether arising in one period of insurance or not) consequent upon or attributable to one original cause shall not exceed the overall limit of indemnity applicable to the insured person concerned.
b) Any one period of insurance for all claims where the disease and/or illness or bodily injury becomes apparent during such period of insurance shall not exceed the overall limit of indemnity applicable to the insured person concerned.
2. Optional Covers (only covered if indicated in the policy)
A) Group emergency expenses
In consideration of the payment of an additional premium, the Corporation will reimburse expenses incurred in respect of treatment immediately necessary to stabilize medical condition without which treatment a major deterioration would develop in the insured person’s state of health which would result in a significant reduction in life expectancy. Provided that reimbursement under this heading shall apply only which limits under the primary standard benefits selected have been exhausted and the treatment is necessitated by the following causes.
1. a condition that warrants treatment in an intensive care unit
2. a condition that warrants travel and treatment overseas because the treatment is not available in Ethiopia
3. if as a consequence of (1) and (2) above an extended course of hospitalization is necessary
Provided that payment under clause 2 above will be made only if adequate medical facilities are not available in Ethiopia and the Corporation reserves the right to seek the advice of its own medical consultant whose opinion will be binding upon all parties to the contract.
The Corporation’s maximum liability shall not exceed the limit stated in the schedule. The limit of liability under the optional cover where a group has been obtained is for the entire group (not per individual) and is the maximum amount that the corporation may be liable to pay during any one insurance period in respect of the group. The amount of cover reduces as payments are made.
B) Dental Expenses
In consideration of the payment of an additional premium, the cost of dental consultation resulting in treatment and treatment expenses, Inclusive of anaesthetics fee, Hospital and Operating Theatre costs, covering extractions, fillings crowns and caps or damage to dentures caused solely by accidental external and visible means.
The Corporation shall not be liable for payment in respect of:
a) The cost of replacement or repairs of old denture bridges and plates unless damage to the said dentures bridges and plates becomes necessary as the result of bodily injury sustained by the insured person caused solely and directly by accidental external and visible means,
b) The cost of orthodontic treatment or any treatment of a cosmetic nature unless such treatment becomes necessary as the result of bodily injury sustained by the insured person caused solely and directly by accidental, external and visible means or as a result of disease other than normal decay.
The maximum amount recoverable in any one period of insurance shall be subject to the limit of indemnity specified in the schedule.
C) Optical expenses
In consideration of the payment of an additional premium the Corporation will reimburse the insured person for the cost of eyeglasses and treatment arising from injury to the eyes caused solely and directly by accidental external and visible means or arising from all diseases affecting the eye or optic nerve. Provided that the total reimbursement under this section in any one period of insurance shall not exceed the limit stated against optical expenses in the schedule.
The corporation shall not be liable for payments in respect of:
a) the replacement or repair of eye glasses unless necessitated in the course of further treatment in connection with contingency insured hereby;
b) eye testing or the provision of eyeglasses or contract lenses resulting from the deterioration of sight.
The Corporation shall not be liable in respect of
1. bodily injury or disease and/or illness
a. sustained as a result of the insured person engaging in (or practicing for or taking part in training peculiar to) any of the excluded activities
b. occurring to an insured person after expiry of the period of insurance during which such insured persons attains the age of 60 years
c. occurring to an insured person who has retired from full time employment. This exception shall not apply to the spouse or child of an insured person who is engaged in full time employment.
d. Consequent upon an insured person committing or attempting to commit sucide or intentionally self inflicting wounds or ailments on himself or willfully exposing himself to needless peril except in an attempt to save human life.
e. consequent upon ionizing, radiations or contamination by radioactivity from any nuclear waste from the combustion of nuclear fuel. For the purpose of this exception combustion shall include any self sustaining process of nuclear fission.
f. Consequent upon war invasion, act of foreign enemy hostilities (whether war be declared or not) civil war, rebellion, revolution, insurrection or military or usurped power.
g. Occurring to any member who is below six months.
2. Bodily injury illness and/or disease or medical expenses consequent upon or contributed to by the insured person
a) having taken a drug unless the insured proves that the drug was taken in accordance with proper medical prescription and directions from a medical practitioner and not for treatment of drug addiction
b) suffering from alcoholism or venereal disease
c) suffering from physical or mental defect or infirmity which existed before the commencement of the period of insurance which has not been declared to and accepted in writing by the corporation
d) suffering from chronic illness unless the ailment has been declared and accepted in writing by the corporation
3. medical expenses consequent upon
a) dental treatment unless as direct result of bodily injury
b) the cost of optical care unless the treatment involves other than corrective lenses
c) psychiatric treatment unless such medical expenses are charged by a hospital or lawfully operated institution for the confinement or treatment of mentally sick persons whilst the insured person is confined therein as in -patient.
d) Cosmetic or plastic surgery unless necessary to correct traumatic bodily injury
e) Maintenance or treatment received in health hydros nature cure clinic or similar establishments or private beds registered within a nursing home attached to such establishments
f) Any residential stay in a hospital or nursing home which is arranged
i. Wholly or partly for domestic reasons
ii. In circumstances where the treatment could reasonably be provided whilst living in a normal place of residence
i. Unless provided by a qualified registered nurse.
ii. In circumstances where the attention could reasonably be given by a person other than a qualified registered nurse.
h) Treatment within 28 days of one becoming a member unless necessitated by accidental injury
i) Drugs dispensed by a doctor or clinic.
4. any expenses for which the insured person has been or can be reimbursed from any other insurance or source including benefits received under any Workmen’s Compensation Act or Government Schemes or compensation except in respect of any excess or expenditure beyond the amount recovered from such other than insurance or source.
- as soon as practicable and in any case within thirty days after the happening of any event which may give rise to a claim written notice shall be given to the corporation.
- all certificates, information and evidence required by the corporation shall be furnished free of expenses to and in the form prescribed by the corporation. The insured person shall often as often required to submit medical examination on behalf of and at the expense of the Corporation in connection with any claim,
- the insured’s or the insured’s personal representatives’ receipt shall discharge the corporation. The insured person or the insured’s personal representatives shall have no rights to claim from or sue the corporation. If the insured comprises more than one party having an interest in the insured person, the Overall Limit of Indemnity applicable shall represent the total amount payable in respect of that insured person for all interest covered by this policy.
- the corporation shall be entitled at any time in the corporation’s or the insured’s name to take proceedings at its own expense and for its own benefit to secure reimbursement from any third party in respect of anything covered by this policy. The insured shall give all such assistance as the corporation may require.
- no sum payable under this policy shall carry interest.
- the corporation shall not be bound to accept or be affected by any notice of any trust charge lien assignment of dealing with or related to this policy
- the insured shall give notice to the corporation within a reasonable time of any material change in the business or the insured person’s occupation or activities and shall pay any additional premium required by the Corporation in consequence thereof.
- if any part of the premium or renewal premium is calculated on estimates furnished by the insured, the insured shall keep an accurate record containing all relative particulars and shall allow the corporation to inspect such record. The insured shall within one month after the expiry of each period of insurance furnish such information as the corporation may require. The premium or renewal premium shall thereupon be adjusted.
- the Corporation or the insured may cancel the policy by giving fourteen days’ notice in writing to the other party at its last known address. If the corporation gives such notice the insured shall thereupon become entitled to a proportionate return of premium otherwise the insured shall only be entitled to a return of premium in accordance with the corporation’s usual short period scale provided that no claim has been made in the then current period of insurance.