Exclusive Provider Organization (EPO) - Health Insurance Definition

An Exclusive Provider Organization - often called an EPO - has some similarities to a PPO, but there are also some major drawbacks to the EPO. As a rule, the EPO is a network of health care professionals who have signed agreements saying that they will provide specific services at huge discounts. The idea is to make medical costs more affordable rather than having the health care professionals make big bucks from the insurance companies. Things to consider before you select an EPO: There could be a maximum lifetime cap. For example, you may be limited to $100,000 in benefits. If you reach that point, your insurance will no longer pay - ever. The amount will vary but a young person who faces a catastrophic illness that stretches over many years may very reach that cap amount. That person may then have difficulty finding another insurance provider because the illness is then considered a pre-existing illness. Your insurance will probably pay nothing if you go outside the list of approved health care providers, and that could very well include specialists. Compare the costs for some specific services with the EPO, with no insurance, and with another insurance plan. For example, compare the cost of a normal office visit to your local doctor, the cost with the EPO and the cost if you had some other insurance plan. This will help you decide if an EPO is right for you and your family.

Health Insurance Definition: A policy that will pay specified sums for medical expenses or treatments. Health policies can offer many options and vary in their approaches to coverage. Two questions small-business owners face when considering health insurance are "What kind of benefits should I buy?" and "How much should I pay?" Regarding the first, buy the benefits that will protect you, your employees and your families in case of emergency. Regarding the second, it depends on your age (and your employees' ages), gender, and whether families will be considered. Choosing the most suitable and cost-effective selection of medical benefits can be time consuming. A workforce that's married with children will have considerably different needs, such as maternity and dental coverage, than groups of single workers. People who work outdoors or workers who spend their days at a computer may prefer an optical program for eye care, safety glasses and sunglasses.Take a look at your workforce to determine: How many workers fall into each age group How many heads of households there are Where your workers live How big their families are Any other pertinent information that could affect your decision, such as the type of work they do Your medical insurance costs may be determined solely on the basis of your company's experience, such as the aggregate number and dollar value of claims submitted by your employees. In other cases, you'll be a part of a larger statistical group that the insurance company or health-care provider uses in calculating your premiums. Be sure to explore the wide range of options available in health-care coverage today, including these: Fee-for-service coverage provides eligible employees with the services of a doctor or hospital with partial or total reimbursement depending on the insurance company. Most insurance companies offer 80/20 plans; the insurance company pays 80 percent of the bill, and the employee pays 20 percent. The employee can go to any doctor he or she chooses, and the plan covers any service that is defined as medically necessary and specified in the plan. Health maintenance organizations (HMOs) provide a range of benefits to employees at a fixed price with a minimal contribution (or sometimes no contribution) from the employee, as long as employees use doctors or hospitals specified in the plan. Usually, HMOs are set up so patients go to the managed-care-plan facilities. If a patient goes to a doctor or hospital outside the plan--except in case of an emergency or if the individual was traveling outside the plan's service area--no benefits are paid at all. Make sure the HMO has facilities near where your employees live and get feedback on the HMO's reputation in the community before you sign up. Preferred provider organizations (PPOs) are considered managed fee-for-service plans because some restrictions are put in place to control the frequency and cost of health care. Under a PPO, arrangements are made among the providers, hospitals, and doctors to offer service at an alternative price--usually a lower price. Many times there's a co-pay amount, which means that employees pay $5 or $10 for each visit to doctors specified in the plan, and the insurance company pays the rest. PPOs differ from an HMO in that if an employee goes to a doctor not specified by the insurance company, the plan still partially covers it. There's usually a higher copay amount or a deductible with varying percentages. A "flexible-benefit" plan allows employees to choose from different fringe benefits. If your workforce is largely white-collar, for example, they may appreciate a health program that encompasses an executive fitness program. Other health programs include vision care plans and rehabilitation for alcohol and substance abuse. Aside from being concerned about the cost of your health-insurance plan, you should also look into the creditworthiness of the insurance provider. Make sure it's rated A or better by A.M. Best, an insurance industry rating service whose rankings are available online and at your library. When choosing between two providers, go with the higher rated, established company, even if its cost is a little higher. That way, you can protect yourself from "insurer flight," which when an insurance carrier packs up its bags and leaves rather than meeting new mandates in your state. If you've narrowed your choices down to two HMOs, ask each to name a private firm you can speak to that's already using their services. Given equal price and medical services, maybe one HMO has a simpler billing method or a superior consumer service division than the other does. Growing enterprises need to know that government legislation requires businesses to offer continued coverage in health insurance benefits even after an employee has left. The Consolidated Omnibus Budget Reconciliation Act (COBRA) calls for this privilege to be extended to any worker in a firm with 20 or more full-time employees. Signed into law in 1986, COBRA demands compliance in both union and nonunion plans. Only two groups are exempt from complying with COBRA: churches or church-operated, tax-exempt organizations and federal or District of Columbia employers. You, the employer, need only offer continued coverage--you don't have to pay for their coverage. Any ex-employee who elects to continue coverage must pay the full cost of that coverage. This includes both the employer and employee's share. Employees may elect to remain covered under the firm's plan for up to 19 months, and dependents can maintain coverage for up to 36 months. COBRA has imposed additional administrative burdens and potentially higher plan costs on virtually all group insurance plans. Managing and monitoring COBRA compliance procedures is necessary to avoid costly financial penalties involved with noncompliance. One penalty is loss of the corporation's tax deduction for its group insurance plan. The plan administrator, in a small firm, is subject to a personal fine for failing to notify an employee of his or her COBRA rights at each step of the termination or hiring process. COBRA provisions include advising all new and terminated employees, and all spouses, of their COBRA continuation rights in writing. Be sure that those electing continued coverage are removed from the plan as soon as they become covered under a new plan.

Complementary Therapies

Complementary cancer therapies are another coverage consideration. A cancer patient undergoing this type of therapy should check with his or her insurance policy regarding coverage.

Cancer Screening Coverage

Cancer screening coverage is an important consideration. Forty-four states mandate insurance coverage of screenings for at least one of these cancers: breast, cervical, prostate, and colorectal. Breast cancer screening coverage is most commonly mandated. Most mandates refer to screenings that follow the American Cancer Society guidelines. A Women's Health Initiative Observational Study investigated the use of cancer screenings by more than 55,000 women between September 1994 and February 1997. The study found that the type of insurance a woman had was linked with the number of cancer screenings she reported. Women age 65 years and older who had Medicare plus prepaid insurance were more likely to report that they had screenings than those who had Medicare alone.

Health Care Regulations

The Health Insurance Portability and Accountability Act (HIPAA), passed by the U.S. Congress in 1996, offers people rights and protections regarding their health care plans. Because of HIPAA, there are limits on preexisting condition exclusions, people cannot be discriminated because of health factors, there are special enrollment requirements for people who lose other group plans or have new dependents, small employers are guaranteed group health plan availability, and all group plans have guaranteed renewal if the employer wishes to renew. In summary these rights and protections include:

• Portability. This is the ability for a person to get new health insurance if a change is desired or needed.
• Availability. This refers to whether or not health insurance must be offered to a person and his or her dependents.
• Renewability. This refers to whether or not a person is able to renew his or her health plan.

Preexisting Condition

A preexisting condition, such as cancer, is a concern when choosing insurance. If a person received medical advice or treatment for a medical problem within six months of enrolling in new insurance, this condition is called preexisting, and it can be excluded from the new coverage. The six-month time lapse before a person enrolls in a new health insurance policy is called the look-back period. If a person received medical advice, recommendations, prescription drugs, diagnosis, or treatment for a health problem during the look-back period, he or she is considered to have a preexisting condition. People should check with their state insurance boards to determine preexisting condition rules.

Coverage Renewal

Some people with diseases such as cancer worry about group health plans renewing their coverage. As long as the person meets the plan's eligibility requirements and the plan covers similar cases, the coverage must be offered. Coverage cannot be cancelled for health reasons.

Experimental/Investigational Treatments

Experimental/investigational treatments are often a concern for people with cancer. These treatments may or may not be covered by a person's health insurance. Some states mandate coverage for investigational treatments. People should check with their insurance plans and state insurance boards to determine if coverage is available.

A clinical trial is a type of investigational treatment. Costs involved include patient care costs and research costs. Usual patient care costs that may be covered by insurance are visits to the doctor, stays in the hospital, tests, and other procedures that occur whether a person is part of an experiment or is receiving traditional care. Extra patient care costs that may or may not be covered by insurance are the special tests required as part of the research study.

Health insurance plans have policies regarding coverage for clinical trials. People should determine their level of health insurance coverage for clinical trials, and they should learn about the costs associated with a particular study.

In 2000, Medicare began covering certain clinical trials. The trials must meet specific criteria in order to be covered. In eligible trials treatments and services such as tests, procedures, and doctor visits that are normally covered by Medicare are covered. Some items may not be covered including investigational items like the experimental drug itself or items that are used only for data collection in the clinical trial. Patients should check to see if the clinical trial sponsor is providing the investigational drug at no charge.

Medicaid

Medicaid, created in 1965 under Title 19 of the Social Security Act, is designed for people receiving federal government aid such as Aid to Families with Dependent Children. This program covers hospitalization, doctors' visits, lab tests, and x rays. Some other services may be partially covered.

Tricare

Eligible military families may enroll in TRICARE Prime, which is an HMO; TRICARE Extra, which offers an expanded choice of providers; or TRICARE Standard, which is the new name for CHAMPUS.

Supplemental Insurance

Supplemental insurance covers expenses that are not paid for by a person's health insurance. Cancer insurance is a specific form of supplemental insurance that covers expenses that are not normally covered by health insurance but are specifically related to cancer treatments.

Workers' Compensation

Workers' compensation covers health care costs for an injury or illness related to a person's job. Medical conditions that are unrelated to work are not covered under this plan. In some cases an evaluation is done to determine whether or not the medical condition is truly related to a person's employment.

Special Concerns

There are a variety of special concerns that people with cancer have regarding health insurance.

Waiting Period

Insurance may not take effect immediately upon signing up for a policy. Sometimes a waiting period exists, during which time premiums are not paid and benefits are not available. Health care services received during this period are not covered.

Preferred Provider Organization (PPO)

A PPO combines the benefits of fee-for-service with the features of an HMO. If patients use health care providers (doctors, hospitals, etc.) who are part of the PPO network, they will receive coverage for most of their bills after a deductible and, perhaps a copayment, is met. Some PPOs require people to choose a primary care physician who will coordinate care and arrange referrals to specialists when needed. Other PPOs allow patients to choose specialists on their own. A PPO may offer lower levels of coverage for care given by doctors and other professionals not affiliated with the PPO. In these cases the patient may have to fill out claim forms to receive coverage.

Government Health Plans

Medicare and Medicaid are two health plans offered by the U.S. government. They are available to individuals who meet certain age, income, or disability criteria. TRICARE Standard, formerly called CHAMPUS, is the health plan for U.S. military personnel.

Medicare

Medicare, created in 1965 under Title 18 of the Social Security Act, is available to people who meet certain age and disability criteria. Eligible people include:

• those who are age 65 years and older
• some younger individuals who have disabilities
• those who have end-stage renal disease (permanent kidney failure)

Medicare has two parts: Part A and Part B. Part A is hospital insurance and helps cover the costs of inpatient hospital stays, skilled nursing centers, home health services, and hospice care. Part B helps cover medical services such as doctors' bills, ambulances, outpatient therapy, and a host of other services, supplies, and equipment that Part A does not cover.

Health Maintenance Organization (HMO)

An HMO is a type of managed care called a prepaid plan. This type of coverage was designed initially to help keep people healthy by covering the cost of preventive care, such as medical checkups. The patient selects a primary care doctor, such as a family physician, from an HMO list. This doctor coordinates the patient's care and determines if referrals to specialist doctors are needed. People pay a premium, usually every month, and receive their health care services (doctor visits, hospital care, lab work, emergency services, etc.) when they pay a small fee called a copayment. The HMO has arrangements with caregivers and hospitals and the copayment only applies to those caregivers and facilities affiliated with the HMO. This type of coverage offers less freedom than fee-for-service, but out-of-pocket health care costs are generally lower and more predictable. A person's out-of-pocket costs will be much higher if he or she receives care outside of the HMO unless prior approval from the HMO is received.

Managed Care

Managed care plans are also sold to both groups and individuals. In these plans a person's health care is managed by the insurance company. Approvals are needed for some services, including visits to specialist doctors, medical tests, or surgical procedures. In order for people to receive the highest level of coverage they must obtain services from the doctors, hospitals, labs, imaging centers, and other providers affiliated with their managed care plan.

People with cancer who are considering a managed care plan should check with the plan regarding coverage for services outside of the plan's list of participating providers. For example, if a person wants to travel to a cancer center for treatment, he or she should find out what coverage will be available. In these plans coverage is usually much less if a person receives treatment from doctors and hospitals not affiliated with the plan.

Fee-For-Service

Fee-for-service is traditional health insurance in which the insurance company reimburses the doctor, hospital, or other health care provider for all or part of the fees charged. Fee-for-service plans may be offered to groups or individuals. This type of plan gives people the highest level of freedom to choose a doctor, hospital, or other health care provider. A person may be able to receive medical care anywhere in the United States and, often, in the world.

Under this type of insurance a premium is paid and there is usually a yearly deductible, which means benefits do not begin until this deductible is met. After the person has paid the deductible (an amount specified by the terms of the insurance policy) the insurance company pays a portion of covered medical services. For example, the deductible may be $250 so the patient pays the first $250 of yearly covered medical expenses. After that he or she may pay 20% of covered services while the insurance company pays 80%. The exact percentages and deductibles will vary with each policy. The person may have to fill out forms (claims) and send them to the insurance company to have their claims paid.

People who have cancer may be attracted to the freedom of choice that traditional fee-for-service plans offer. However, they will most likely have higher out-of-pocket costs than they would in a managed care plan.

health insurance

Definition

Health insurance is insurance that pays for all or part of a person's health care bills. The types of health insurance are group health plans, individual plans, workers' compensation, and government health plans such as Medicare and Medicaid.

Health insurance can be further classified into feefor-service (traditional insurance) and managed care. Both group and individual insurance plans can be either fee-for-service or managed care plans.

The following are types of managed care plans:

• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)

Purpose

The purpose of health insurance is to help people cover their health care costs. Health care costs include doctor visits, hospital stays, surgery, procedures, tests, home care, and other treatments and services.

Description

Health insurance is available to groups as well as individuals. Government plans, such as Medicare, are offered to people who meet certain criteria.

Group and individual plans can be further classified as either fee-for-service or managed care. Cancer patients may have specific concerns, such as the freedom to select specialists, that play a factor in choosing a health care plan. Fee-for-service plans traditionally offer greater freedom when choosing a health care professional. Managed care often limits a patient to health care professionals listed by the managed care insurance company.

Group Health Plans

A group health plan offers health care coverage for employers, student organizations, professional associations, religious organizations, and other groups. Many employers offer group health plans to employees and their dependents as a benefit of working with that particular employer (medical benefits). The employer may pay for part or all of the insurance cost (premium).

When an employee leaves a job he or she may be eligible for continued health insurance as a result of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). This federal law protects employees and their families in certain situations by allowing them to keep his or her health insurance for a specified amount of time. The individual must, however, pay a premium to keep their insurance plan in effect It is important to note that COBRA only applies under certain conditions, such as job loss, death, divorce, or other life events. The COBRA law usually applies to group health plans offered by companies with more than 20 employees. Some states have laws that require employers to offer continued health care coverage for people who do not qualify for COBRA. Each state's insurance board can provide additional information.

Individual Plans

These type of health care plans are sold directly to individuals.

I currently am on worker's compensation. Can my employer make me pay for my own health insurance while I'm off?

The employer generally has no obligation to maintain health coverage at its expense, although you probably have a right to COBRA it. Also, check the firm's long term and short term disability policies. Depending on what state you work in, your rights may be also different under some states' workers comp laws.

Are there dangers in cancelling health insurance?

There can be potential serious adverse consequences associated with canceling health. If you cancel health insurance before replacement health insurance coverage is confirmed and already available, there may be a gap in your health insurance coverage.

First, there is no assurance that you will be able to obtain new health insurance. You might be denied coverage due to health conditions that developed prior to applying for the new insurance or plan, or go completely uncovered during the underwriting process. Second, even if you are accepted for subsequent health insurance coverage you could face a situation in which certain medical conditions that developed during the prior health insurance coverage are excluded from coverage under the new insurance as "preexisting conditions."

These problems may not exist if you are moving from one group insurance plan to another, as many group policies ignore pre-existing conditions if you move from a similar group health coverage within 30 days of prior coverage. A second exception will probably result in the same continuation of coverage mandated by HIPAA on and after January 1, 1998.

If I cancel do I get my unused premium back?

That may depend on the state involved and the policy you have. You generally do not get back any premiums that have been paid and applied to the period of time for which coverage was available.

Can I cancel my health insurance, and will there be a penalty or adverse consequence?

Generally, there is no prohibition against insured or plan members canceling their health insurance coverage or their participation in a health service plan.

One major exception to this generality is in the case of Medicare assignments. If a Medicare recipient has chosen to obtain private insurance or HMO coverage involving an assignment of the Medicare benefits to the insurer or plan, the Medicare recipient must apply to the Health Care Financing Administration (HCFA) before changing insurers or plans. Otherwise, there is no financial penalty per se to canceling health insurance coverage.

Can a health insurance company or health service plan cancel my policy for membership for any reason?

As a general proposition, insurers and plans cannot cancel an individual's coverage under a policy or plan arbitrarily. In addition, federal and state laws prohibit discrimination based upon race, national origin, gender or age. Some states have been proactive, as well, in the area of discrimination involving particular medical conditions or traits. For instance, some states prohibit insurers and plans from denying health care coverage to, or canceling health care coverage of, persons with mental dementia (such as Alzheimer's disease) or human immunosuppressive virus (HIV) or mental illness.

Health care insurance policies or plans can be canceled (rescinded) if there is a material omissions or misrepresentations made by the insured or member in the application for coverage. Recession, in general, works as follows: when you apply for insurance and sign an application, you answer questions and provide information about the medical history of anyone who will be covered under the policy or plan. In doing so, you must reveal any serious medical condition or treatment that might reasonably affect the decision by the insurer or plan to undertake the risk associated with providing the coverage.

Even if the policy or plan is issued and premiums are paid, the insurer or plan can cancel or rescind the policy later if they discover that the policyholder or insured did not disclose in the application significant medical history. The result is that the insurer or plan does not pay for the care that was rendered, the policy is canceled and the premiums that were paid on the policy are returned to the policyholder less a reasonable cost of insurance associated with the period of time during which the policy was in force.

A limited form of cancellation can occur involving reduction or elimination of benefits. Other than a requirement of reasonable notice, insurers and plans may reduce or eliminate benefits, unless the contract or plan prohibits it or limits it. In some states there is a major exception known as "vesting," which means that if the insured or member already has a claim or has received benefits for a particular injury or illness, they may continue to receive the benefit even if it is otherwise canceled.

General Health Insurance Questions

FAQs

How do I obtain health insurance?

Are there government sponsored programs?

Can a health insurance company or health service plan cancel my policy for membership for any reason?

What is a health insurance policy?

Can the insurer or plan cancel or rescind at any time?

What if the insured lied about a heart attack?

Can I cancel my health insurance, and will there be a penalty or adverse consequence?

If I think certain words in my policy mean something different from what my insurance company says they mean, how do we resolve it?

If I cancel do I get my unused premium back?

How does an insurance policy ‘protect’ me?

Are there dangers in cancelling health insurance?

What will happen to our health insurance for my dependent children and I after the divorce from their father?

What are typical problems that arise in getting health care benefits provided or paid?

My father who has conjestive heart failure and type 2 diabetes recently underwent a quintuple heart bypass. His medical bills are staggering and he has no health insurance. Short of filing bankruptcy, what are his options in getting these amounts reduced?

What can, or must, I do when a health insurance company or plan refuses to pay a claim or provide a benefit or service?

How long will my medical insurance allow my new baby and myself remain in the hospital following childbirth?

Are there any limitations on what an insurance company can charge for insurance?

What is the appeals and grievance process like?

What to Ask Insurance Salespeople When Buying a Medical Insurance Policy

What is a health insurance plan?

I currently am on worker's compensation. Can my employer make me pay for my own health insurance while I'm off?

How does a health insurance policy or health plan protect me?

What are my legal remedies if a health insurance company or plan refuses to pay a claim for a benefit or service?

How do I determine what my health care coverage or benefits are?

Would I need a lawyer to handle my case?

Suppose the contract or booklet is ambiguous or unclear?

What is health insurance?

What are ‘definitions,’ ‘benefits,’ ‘limitations,’ and ‘exclusions?’

What is private indemnity insurance?

Are there any government agencies that regulate how health insurance companies or plans operate?

What are health care maintenance organizations?

Will one of these many agencies be able to help me?

What about employer sponsored plans?

Compare our Core Plans for Individuals

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Core Plans

Treatment Guarantee is required for all in-patient benefits () and may be required for other benefits () as indicated in the table below - please refer to note 2 for more information. These plans are valid from 1st November 2008. To change currency, please use the dropdown menu above.

		Premier Individual	Club Individual	Classic Individual	Essential Individual
	Maximum plan benefit	€2,250,000	€1,500,000	€1,125,000	€500,000
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()">	In-patient benefits - please refer to note 2 for Treatment Guarantee
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()"> Hospital accommodation refers to standard private or semi-private accommodation as indicated on the Table of Benefits. Deluxe, executive rooms and suites are not covered.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Hospital accommodation	Private room	Private room	Private room	Semi-private room
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()"> Prescription drugs refers to products, including insulin, hypodermic needles or syringes, prescribed by a medical practitioner for the treatment of a confirmed diagnosis or medical condition or to compensate vital bodily substances. The prescribed drugs must be clinically proven to be effective, and recognised by the pharmaceutical regulator in a given country.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Prescription drugs and materials	Full refund	Full refund	Full refund	Full refund
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()">	Surgical fees, including anaesthesia & theatre charges	Full refund	Full refund	Full refund	Full refund
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()">	Physician and therapist fees	Full refund	Full refund	Full refund	Full refund
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()"> Surgical appliances and prostheses refers to artificial body parts or devices, which are an integral part of a surgical procedure or part of any medically necessary treatment following surgery.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Surgical appliances and prostheses	Full refund	Full refund	Full refund	Full refund
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()">	Diagnostic tests	Full refund	Full refund	Full refund	Full refund
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()"> Organ transplant is the surgical procedure in performing the following organ and/or tissue transplants: heart, heart/valve, heart/lung, liver, pancreas, pancreas/kidney, kidney, bone marrow, parathyroid, muscular/skeletal and cornea transplants. Expenses incurred in the acquisition of organs are not reimbursable.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Organ transplant	Full refund	Full refund	Full refund	€10,000
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()"> Psychiatry and psychotherapy refers to treatment of a mental, nervous or eating disorder carried out by a clinical psychiatrist or clinical psychologist. The disorder must be associated with present distress, or substantial impairment of the individual’s ability to function in a major life activity (e.g. employment). The aforementioned condition must be clinically significant and not merely an expected response to a particular event such as bereavement, relationship or academic problems and acculturation. The disorder must meet the criteria for classification under an international classification system such as the Diagnostic and Statistical Manual (DSM-IV) or the International Classification of Diseases (ICD-10).","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Psychiatry and psychotherapy (10 month waiting period applies)	Full refund	€6,000	€5,000	€5,000
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()"> Accommodation costs for one parent staying in hospital with an insured child under 18 refers to the hospital accommodation costs of one parent for the duration of the insured child’s admission to hospital for eligible treatment. If a suitable bed is not available in the hospital, we will contribute the equivalent of a 3 star daily room rate towards any hotel costs incurred. We will not, however, cover sundry expenses such as meals, telephone calls, newspapers etc.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Accommodation costs for one parent staying in hospital with an insured child under 18	Full refund	Full refund	Full refund	Full refund
Emergency in-patient dental treatment refers to acute emergency dental treatment due to a serious accident requiring hospitalisation. The treatment must be received within 24 hours of the emergency event. Please note that cover under this benefit does not extend to follow-up dental treatment, dental surgery, dental prostheses, orthodontics or periodontics. If cover is provided for these benefits, it will be listed separately in the Table of Benefits.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Emergency in-patient dental treatment	Full refund	Full refund	Full refund	Full refund
‘1’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 80% of the eligible benefits.","", 300, "one")' ;="" onmouseout="hideddrivetip()">	Other benefits - please refer to note 2 for Treatment Guarantee
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Day-care treatment is treatment received in a hospital or day-care facility during the day, including a hospital room and nursing that does not medically require the patient to stay overnight and where a discharge note is issued.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Day-care treatment	Full refund	Full refund	Full refund	Full refund
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Out-patient surgery is a surgical procedure performed in a surgery, hospital, day-care facility or out-patient department that does not require the patient to stay overnight out of medical necessity.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Out-patient surgery	Full refund	Full refund	Full refund	Full refund
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Nursing at home or in a convalescent home refers to nursing received immediately after or instead of eligible in-patient or day-care treatment. We will only pay the benefit listed in the Table of Benefits where the treating doctor decides (and our Medical Director agrees) that it is medically necessary for the member to stay in a convalescent home or have a nurse in attendance at home. Cover is not provided for spas, cure centres and health resorts or in relation to palliative care or long term care (as defined).","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Nursing at home or in a convalescent home (immediately after or instead of hospitalisation)	€4,250	€2,830	€2,500	€2,500
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Rehabilitation is treatment aimed at the restoration of a normal form and/or function after an acute illness or injury. The rehabilitation benefit is payable only for treatment that starts immediately after the acute medical treatment ceases.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Rehabilitation treatment (immediately after acute medical treatment ceases)	€4,420	N/A	N/A	N/A
Local ambulance is ambulance transport, required for an emergency or out of medical necessity, to the nearest available and appropriate hospital or licensed medical facility.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Local ambulance	Full refund	Full refund	Full refund	€500
Emergency treatment outside area of cover. Where applicable, you and your dependants will be covered for emergencies only, which occur during business and holiday trips, outside of your chosen area of cover (where relevant). Cover is provided up to a maximum period of 6 weeks per trip within the maximum benefit amount. You will not be covered for any curative or follow-up non-emergency treatment, even if deemed unable to travel to a country within your geographical area of cover. Not only are you covered in the event of an accident but you are also covered for the sudden beginning or worsening of a severe illness, resulting in a medical condition that presents an immediate threat to your health. To be considered emergency treatment, and thus covered under this benefit, please remember that the medical treatment (through a physician, general practitioner or specialist) should commence within 24 hours of the emergency event.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Emergency treatment outside area of cover (for trips of a maximum period of 6 weeks)	Full Refund Max. 42 days	Full Refund Max. 42 days	Full Refund Max. 42 days	Up to €10,000 Max. 42 days
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Medical evacuation applies where the necessary treatment for which the insured person is covered is not available locally or if adequately screened blood is unavailable in the event of an emergency. We will evacuate the insured person to the nearest appropriate medical centre. Please note that the nearest appropriate medical centre may not be located in your home country. Following completion of treatment, we will also cover the cost of the return trip, at economy rates, for the evacuated member to return to his/her principle country of residence. If medical necessity prevents the insured member from undertaking the evacuation or transportation following discharge from an in-patient episode of care, we will cover the reasonable costs of hotel accommodation up to a maximum of 7 days, comprising of a private room with en suite facilities. Where an insured member has been evacuated to the nearest centre of excellence for ongoing treatment, we will agree to cover the reasonable cost of hotel accommodation comprising of a private room with en suite facilities.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Medical evacuation	Full refund	Full refund	Full refund	Full refund
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Expenses for one person accompanying an evacuated/repatriated person refers to the cost of one person travelling with the evacuated/repatriated person. If this cannot take place in the same transportation vehicle, transport at economy rates will be paid for. Following completion of treatment, we will also cover the cost of the return trip, at economy rates, for the accompanying person to return to the country from where the evacuation/repatriation originated. Cover does not extend to hotel accommodation and other related expenses.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Expenses for one person accompanying an evacuated or repatriated person	€3,000	€3,000	€3,000	€3,000
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Repatriation of mortal remains is the transportation of the insured person’s mortal remains from the principal country of residence to the country of burial. Covered expenses include, but are not limited to, expenses for embalming, a container legally appropriate for transportation, shipping costs and the necessary government authorisations. Cremation costs will only be covered in the event that this is required for legal purposes. Costs incurred by any accompanying persons are not covered.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Repatriation of mortal remains	€10,000	€10,000	€10,000	€10,000
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> CT, MRI and PET scans, as well as CT/PET scans, carried out on an in-patient or out-patient basis. Submission of a Treatment Guarantee Form is required for MRI, PET and CT/PET scans.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	CT, MRI & PET scans (in-patient and out-patient treatment)	Full refund	Full refund	Full refund	Full refund
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Oncology refers to specialist fees, diagnostic tests, radiotherapy, chemotherapy, and hospital charges incurred in relation to the planning and carrying out treatment for cancer, from the point of diagnosis.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Oncology (in-patient and out-patient treatment)	Full refund	Full refund	Full refund	Full refund
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Complications of pregnancy relates to the health of the mother. Only the following complications that arise during the pre-natal stages of pregnancy are covered: ectopic pregnancy, miscarriage, stillbirth and hydatidiform mole.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Complications of pregnancy (in-patient and out-patient treatment) (10 month waiting period applies)	Full refund	Full refund	Full refund	N/A
Laser eye treatment refers to the surgical improvement of the refractive quality of the cornea using laser technology, including necessary pre-operative investigations.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Laser eye treatment (limited to one treatment per lifetime)	€1,000 per lifetime	€500 per lifetime	N/A	N/A
In-patient cash benefit is payable when treatment and accommodation for a medical condition, that would otherwise be covered under the insured’s plan, is provided in a hospital where no charges are billed. Cover is limited to the amount specified in the Table of Benefits and is payable upon discharge from hospital.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	In-patient cash benefit (per night) (where treatment has been received free of charge)	€150 Max. 25 nights	€150 Max. 25 nights	€150 Max. 25 nights	€150 Max. 25 nights
Emergency out-patient treatment is treatment received in a casualty ward/emergency room following an accident or sudden illness, where the insured does not, out of medical necessity, occupy a hospital bed. The treatment must be received within 24 hours of the emergency event.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Emergency out-patient treatment (where these benefit amounts are reached, any additional costs may be reimbursed within the terms of any separate out-patient plan)	€750	€750	€750	N/A
Emergency out-patient dental treatment is treatment received in a dental surgery/hospital emergency room for the immediate relief of dental pain, including temporary fillings limited to three fillings per Insurance Year, and/or the repair of damage caused in an accident. The treatment must be received within 24 hours of the emergency event. This does not include any form of dental prosthesis and root canal treatment.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	Emergency out-patient dental treatment (where these benefit amounts are reached, any additional costs may be reimbursed within the terms of any separate dental plan)	€750	€500	N/A	N/A
‘2’, we reserve the right to decline a claim. If in the aftermath the respective treatment is proven medically necessary, we will pay only 50% of the eligible benefits.","", 300, "two")' ;="" onmouseout="hideddrivetip()"> Palliative care refers to in-patient, day-care or out-patient treatment following the diagnosis that your condition is terminal and treatment can no longer be expected to cure your condition. Included within your benefit we will pay for your physical care, pyschological care as well as hospital or hospice accommodation, nursing care and prescription drugs. Long term care refers to care over an extended period of time after the acute treatment has been completed, usually for a chronic condition or disability requiring periodic, intermittent or continuous care. Long term care can be provided at home, in the community, in a hospital or in a nursing home.","", 500, "def")' ;="" onmouseout="hideddrivetip()">	NEW Palliative care and long term care	Full refund, Max. 30 days per lifetime	Full refund, Max. 30 days per lifetime	Full refund, Max. 30 days per lifetime	Full refund, Max. 30 days per lifetime