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NICG T01. Health Insurance Terms and Conditions - Annex 2 PDF
NICG T01. Health Insurance Terms and Conditions - Annex 2 PDF
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Insurer Initial(s)
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Insurer Initial(s)
The Policy consists of the Terms and Conditions appearing herein and the Schedule. These
documents shall be read together and any word or expression to which a specific meaning has been
attached therein shall bear such meaning wherever it may appear.
INTRODUCTION
NIC General Insurance Co. Ltd hereinafter referred to as “the Company” will pay benefits, as defined
in this Insurance Contract (hereinafter referred to as “the Policy”), to the Insured Persons or their
Dependants, requiring medical and/or surgical treatment or assistance as a result of injury or
sickness contracted during the Period of Insurance as per the Schedule of Benefits. The benefits are
subject to policy definitions, exclusions, limitations and conditions. The Company reserves the right
to interpret the terms and conditions of this Policy and to determine the benefits payable subject
to the Premium having been paid by the Policyholder/Insured Member in the manner provided by
and subject to the terms, conditions and limitations of the Policy.
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Benefits and Conditions mentioned hereunder will apply to the Policyholder or the Insured
Members to the extent that these benefits are mentioned in the attached Schedule(s) under the
heading “Schedule of Benefits”. The Company shall compensate the Policyholder or the Insured
Persons as per details given on the Schedule of Benefits for any claim reported and admissible
under the Policy. The payment by the Company for any admissible claim reported under the Policy
will be limited to the overall limits shown on the Schedule of Benefits. Benefits mentioned
hereunder but not mentioned in the attached Schedule(s) will not apply to the
Policyholder/Insured Member.
1. Inpatient Benefits
Inpatient benefits refer to expenses incurred relating to any medical treatment or surgical
Procedure, excluding maternity and which requires the occupation of bed within a hospital. The
inpatient benefits also include expenses related to surgical operations including surgeons’,
assistants’ and anaesthetists’ fees, deep X-ray therapy and approved physiotherapy, blood
transfusions, serum, pathological and radiological services, theatre room, oxygen and drugs for the
operation and other Hospital fees pertaining to the operation. All costs incurred in relation to
maternity (pregnancy from conception to child birth and post-natal expenses) shall be exclusively
considered under the limit of the maternity benefits defined hereunder. The inpatient benefit will
include day care procedures/surgeries such as gastroscopy, colonoscopy, chalazion excision, etc.
To benefit from the aforesaid, notification to the Company by the Insured Member should be made
prior or during admission to public hospital, failing which the Company may opt not to effect any
payments or to restrict payments.
Subject to the above, cover is limited to the amount specified in the Schedule of Benefits and is
payable upon discharge from the public hospital and submission of a detailed medical report (with
mention of the exact diagnosis and treatment undergone) and other relevant documents
ascertaining admission such as length of stay, date and time admitted and discharged.
The Company reserves the right to engage its designated Doctor(s) to visit the Insured Member at
the public hospital prior payment of any cash benefit and in light of observations made, it may at
its sole discretion limit the number of days of cover based on treatment received and/or the
medical report received. Accordingly, the Company shall place a limit on the number of days for
which the cash benefit is offered during hospitalisation.
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3. Medical Benefits
Medical benefits refer to expenses incurred relating to doctors’ and specialists’ services,
consultations, prescribed drugs, injections, therapies, clinical tests (e.g. X-ray). Medical benefits
cover other Hospital fees not involving a surgical Procedure. Medical benefits exclude expenses
related to maternity, optical, hearing and dental treatments.
4. Optical Benefits
Optical benefits refer to expenses incurred in connection to glasses, frames and consultations
relative thereto. The optical benefit is available every twelve (12) months for an eye test and every
twenty four (24) months for frames and lenses unless mentioned otherwise in your schedule of
benefits. Lenses include single vision, bifocal, and multifocal lenses. Any additional optical or
ophthalmological service such as Excimer laser / refractive eye surgery, photo chromatic lenses
(tinted), radium coating and sunglasses are excluded. Unless provided in the Schedule of Benefits,
contact lenses will be approved and refunded only in case of deterioration in sight certified by an
ophthalmologist/optometrist.
5. Maternity Benefits
Maternity benefits refer to expenses incurred in connection with pregnancy from conception until
child delivery including ante-natal, post-natal treatments and any complications of pregnancy.
These expenses will include any cost incurred on normal delivery, delivery by caesarean section or
surgical Procedures related to miscarriages. These benefits shall apply to the Insured Person and
Adult Dependants only. Child Dependants and Parent Dependants are excluded from this benefit.
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a) Root canal treatment, fillings and crowns excluding the cost of precious metal restoration;
b) Tooth extractions and all other types of dental surgery, including those requiring
hospitalisation
c) Initial installation or repair of prosthetic appliances including bridges and full/partial
dentures;
d) Initial installation of orthodontic appliances.
e) Dental implant
7. Hearing Benefits
Hearing benefits refer to expenses incurred in relation to hearing diagnostics, hearing
rehabilitation, hearing aids, or any related treatment.
8. Congenital Benefits
Congenital benefits refer to expenses incurred in treatment of medical condition(s) or disorder(s)
that exist in neonates at or before birth. Such expenses related to this condition are restricted to
the congenital benefit and these benefits apply solely to neonates subject to:-
(a) the natural mother having been under this insurance cover and having fulfilled the waiting
period for maternity benefits.
9. Funeral Benefits
Funeral benefits are payable to designated beneficiary/ies on death of the Insured Person and/or
Adult Dependant during the policy period. For Individual Policyholder, in case no beneficiary/ies
are designated, the funeral benefit will be payable to the succession of the Policyholder.
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1. If the Catastrophe Cover is mentioned in the attached Schedule(s), the Catastrophe Cover takes
effect only after the Inpatient Benefit has been exhausted.
2. In addition to the conditions and benefits mentioned above, any treatment on congenital
problems, infirmities and malformations will be excluded from the scope of this cover.
3. Immediate notification should be given to the Company about claim under Catastrophe Cover
and claim documents should be submitted to the Company within 30 days from the date of
discharge from a Hospital.
4. Any excess applicable on the catastrophe benefit is specified on the catastrophe table of
benefits.
1. Claims
1. Claims shall be made through Claim Forms to be furnished by the Company and shall contain
answers to every question asked to the claimant and physicians, as may be applicable.
2. Claims must be signed and certified as correct and must be submitted to the Company within
thirty (30) days following the date on which the service was rendered. The Company will notify
the claimant of any missing documents such as invoices, receipts, doctor’s prescription, doctor’s
report and other similar relevant documents within a maximum of thirty (30) days following
receipt of the claim. Claimants will be allowed thirty (30) days, from the date of notification, to
resubmit the missing documents. In the event the Company does not receive the relevant
documents within the prescribed timeframe, the claim will be rejected on the basis of
incomplete documentation.
3. All claims must be supported by original paid vouchers, information and evidence of any nature
which the Company considers necessary to determine whether an admissible claim exists, and
the amount of any such claim.
4. Admissible claims will be refunded to the policyholder in case of Individual Policyholders and
to the insured Person in case of Corporate Policyholders, up to the limits set out in the Schedule
of Benefits and subject to the Scale of Costs as enclosed within thirty (30) days of submission
of complete set of required documents, provided the premium payments are up to date and
once all the necessary verifications have been made.
5. Claims will be settled to the nearest Mauritian rupee.
6. Subject to paragraph 9 below, where the Company is of the opinion that an account, statement
or claim is erroneous or unacceptable for payment, it shall notify the Insured Person or any
relevant service provider within 30 days after receipt thereof and state the reasons for such an
opinion; the Company shall afford such Insured Person and/or service provider the
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2. Premiums
1. Premiums shall be payable in accordance with the premium payment terms shown in the
Schedule of Premiums.
2. A moratorium of twenty-one (21) days may be allowed at the Company’s discretion for
payment of premiums.
3. On the expiry of any moratorium, the Company reserves the right to issue a Mise en Demeure
in accordance with Article 1983-21 of the Civil Code. If premiums are not settled within 20 days
following the issue of the Mise en Demeure, the Company shall suspend the insurance cover
and not entertain any claim under this Policy until the full amount of premiums due has been
paid and policy reinstated.
4. Article 1983-21 of the Civil Code provides as follows:
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A défaut de paiement d’une prime ou d’une fraction de prime, la garantie ne peut être suspendue que
vingt jours après l’expédition, par lettre recommandée, de la mise en demeure de l’assure.
La garantie suspendue reprend pour l’avenir ses effets, à midi le lendemain du jour ou ont été payes a
l’assureur ou au mandataire désigné par lui a cet effet, la prime arriérée ainsi que, éventuellement, les
frais de poursuites et de recouvrement.
L’assureur a le droit de résilier le contrat dix jours après l’expiration du délai fixe par l’alinéa 2 du
présent article ou d’en poursuivre l’exécution en justice sous réserve des dispositions de l’article 1983-
84.
Est nulle toute clause réduisant les délais fixes par les dispositions du présent article ou dispensant
l’assureur de la mise en demeure”.
The Company reserves the right to apply the procedures of the Civil Code with effect from the due
date of each unpaid premium. If the said premium remains unpaid beyond the delay period
prescribed by the law (30 days following the Mise en demeure) , the Company reserves the right
either to terminate the contract or have recourse to judicial proceedings.
5. For all Insured Members admitted during the course of the Policy, premiums will be calculated
in proportion to the period of the membership from the Admission Date to the expiry date of
the Policy. This is equally applicable in respect of any change in benefits occurring during the
period of insurance.
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5. Change of Address
It shall be the responsibility of the Policyholder to notify the Company in writing of any change of
address of the Policyholder to avoid non-delivery or late delivery of any communication from the
Company.
6. Termination
1. This Policy will terminate on the earlier happening of any one of the following:
a) Detection of a fraud in the submission of any claim under this Policy;
b) Termination of the Policy in accordance with Article 1983-21 of the Civil Code;
c) Cancellation of this Policy in accordance with Article 1983-35 of the Civil Code;
d) Expiry of this Policy as stipulated in the attached Schedule(s).
2. In the events set out in Article 1983-35 of the Mauritius Civil Code whenever a party purports
to cancel the present contract, he/she shall give notice thereof to the other party by way of a
registered letter (“avec demande d’avis de reception”) in accordance with the provisions of
Article 1983-36.
7. Renewal of Policy
1. This Policy shall expire on the expiry date mentioned on the Schedule(s) attached. In no cases,
shall the Policy be renewed by way of “tacite réconduction”.
This Policy is renewable at the end of the policy period only by mutual agreement in writing
between the Policyholder and the Company.
2. Renewal, if any, of the insurance cover shall be subject to underwriting requirements effective
at the date of renewal and shall at all-time be subject to paragraph 5 below.
The Company reserves the right to review the terms of the Policy, including applicable premiums,
in the event of Policy renewal. The Company may also include capping of benefit limits, apply
exclusions or any excess in light of the outcomes of medical underwriting and claims experience.
The Company does not guarantee, under any circumstance, that the premium rates applicable
under this Policy will be maintained on the renewed Policy. Premiums shall be subject to annual
reviews.
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GENERAL CONDITIONS
1. Benefit Section
1. To the extent permitted by law and provided that no “bénéficiaire déterminé et irrévocable”
has been appointed by the Policyholder, the Policyholder may change the beneficiary by giving
us written notice, provided the new beneficiary can demonstrate insurable and/or fiduciary
interest.
2. If the age of an Insured Member falls outside the predetermined age limits for entering into a
contract as set in this Policy, no benefits shall be payable under this Policy and premiums paid
for that Insured Member shall be refunded on a prorated basis to the Policyholder deducting
processing and documentation charges.
3. The Company shall entertain the claims arising from an event in respect of which an Insured
Person or Dependant has received or is likely to receive compensation from any source
whatsoever, only to the portion not covered by the other source(s). These claims shall at all
times be subject to the excess applicable to the respective benefits of this Policy.
4. Insured Persons and their Dependants admitted during the course of the Policy are entitled to
the benefits set out in the relevant benefit(s) chosen, with the maximum benefits being adjusted
in proportion to the period of membership calculated from the Admission Date to the expiry
date of the Policy.
5. Upon payment of any claim, the Company shall be subrogated into all the rights, actions and
privileges of the Insured Person. The Company shall be entitled to take over and conduct in its
own name or in the name of the Insured Person, defence of any claim and to prosecute for its
own benefit any claim against any third party and shall have full discretion in the conduct of
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The Insured Person shall at the expense of the Company, do and concur in doing and permit to be
done all such acts and things as may be necessary or reasonably required by the Company for the
purpose of enforcing any rights and remedies or obtaining relief or indemnity from other parties
to which the Company shall or would become entitled or subrogated, upon paying for or making
good any loss or damage under this Policy, whether such acts and things shall become necessary or
required before or after Insured Person’s indemnification by the Company.
3. Provided that the surgical and/ or medical intervention is performed overseas, as approved by
the Company, the return air fares in Economy class of the Insured Member, undergoing
treatment, shall be covered within the cover limit. Cover will be available for air ticket for the
Insured Person or Dependant undergoing treatment only. Any other travelling expense
including costs in relation to any accompanying person will be excluded.
5. Where treatment and operation is available in Mauritius, the Company may consider
reimbursement of expenses as per the Scale of Costs as enclosed or limited to the approximate
cost in force with clinics and doctors in Mauritius. Moreover, expenses incurred in relation to
cost of air tickets and accommodation costs shall not be refunded under policy.
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5. Waiting Period
1. Subject to specific waiting periods mentioned elsewhere in this Policy, all benefits for any
illness will have a waiting period of ninety (90) days from Admission Date. However, this
limitation will not be applicable to accidents.
2. Expenses related to optical benefits, dental benefits and hearing benefits will have a waiting
period of six (6) months from Admission Date.
3. Expenses related to maternity benefits will have a waiting period of ten (10) months from
Admission Date.
4. The following conditions will have a waiting period of twenty-four (24) months of continuous
insurance coverage with the Company from the initial Admission Date:
a) Adenoidectomy
b) Joint pain of any kind including but not limited to Arthritis, Gout, Rheumatism
c) Spinal disorders
d) Varicose veins
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5. Pre-existing condition
a) A pre-existing condition is a disease or sickness or injury which is known to an Insured
Member and/or diagnosed and in receipt of medical advice, consultation or treatment from
a Doctor during the twelve (12) months prior to the Admission Date or which in the opinion
of a Doctor exhibited or caused symptoms during the twelve (12) months prior to the
Admission Date, warranting to compel an ordinary and prudent person to seek medical
assistance or help.
b) Subject to paragraph 5(c)below, no pre-existing condition is covered under this Policy until
such time that the Insured Member would have completed the waiting period of forty-eight
(48) months of continuous insurance coverage with the Company.
c) The medical/surgical conditions appearing at paragraph 4(a) to 4(t) above will not be
covered under this Policy if they are pre-existing at the time Insured Member first joined
the insurance cover.
d) An Insured Member suffering from any physical defect or infirmity prior to taking a Policy
will be considered as person suffering from a pre-existing condition for the purpose of this
Policy.
6. Should an Insured Member wish to increase his/her limit at any time, a waiting period as
applicable for the relevant benefit as prescribed above will apply to the difference between the
increased and initial limits as from the date of approval by the Company of the increased limit
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The Company shall not be liable for expenses incurred in respect of the following exclusions and
limitations:-
1. Exclusions
1.1. General
1.2. External aids, unless related to the treatment being claimed for
1. Walking aids
2. Knee brace, crepe bandages, stockings or leggings
3. Lumbosacral belt, visco belts, abdominal belts or cervical collar
4. Band-aid
5. Alpha bed, air bed or water bed
6. Other aids related or similar to the above
1. Charges and utilities for newborn during and post delivery, including vaccination
charges, baby utilities, other charges/utilities or similar to the above.
1. Attendant bed, attendant food and attendant pass, any charge related to guest(s),
special attendant or special nursing charges and other charges related or similar to the
above.
1.6. Miscellaneous
1. Food charges and/or food supplements other than prescribed diet - not forming part
of treatment, blood grouping, cross matching of Donor samples.
2. Screening tests of any type not forming part of immediate and subsequent treatment,
Blood reservation charges and ante-natal booking charges, ward and theatre booking
charges, preventive treatment/procedures/blood test and Gender re assignment (also
known as sex change)
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GENERAL PROVISIONS
1. Only the mandated authorised representatives of the company have the authority to make or
alter the terms and conditions of this Policy.
2. If, at the Policy Date, any provision of this Policy conflicts with the law of the country of issue,
that provision is understood to be amended to conform to that law.
3. This Policy does not participate in the profits of the Company.
4. If for any reason the Policyholder is not satisfied with this Policy, the Policyholder may return
it to the Company for cancellation within thirty (30) days from the date of receipt of the Policy,
in which case all premiums paid net of all claims already settled will be returned. Accordingly,
in the event that the claims settled exceed the premium already paid, the Policyholder shall
return the excess amount paid by the Company. The company will also deduct all processing
and documentation charges from the refund value.
5. Applicable for Individual Policyholder, the Company may cancel this policy by sending a
registered letter with thirty days’ notice to the Policyholder at the last known address. In such
a case, the Company will return to the Policyholder the premium paid net of claims already
settled, less pro rata portion thereof for the period the policy was in force and all processing
and documentation charges.
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Admission Date: It is the date on which the Insured Member joins the Policy.
Adult Dependant: Lawfully married spouse of the Insured Person or a person of the opposite sex
who lives together with the Insured Person under the same roof as husband and wife. There cannot
be more than one Adult Dependant per Insured Person. Parents and/or other dependants of the
Insured Person are excluded.
Child Dependant: Child, stepchild or lawfully adopted child, of the Insured Person, under the age
of 18 but may include children up to 23 years if dependant and pursuing full-time education and/or
unemployed. Child dependant excludes any married child or any child in full-time employment.
Chronic Condition:
Chronic disease is defined as a disease, illness or injury that has one or more of the following
characteristics:
Claim: A demand from the Insured Person or Dependant, directly or through the Policyholder, to
the Insurer for payment of benefits under the Policy.
Claim form: An application completed by Insured Person or Dependant for payment of benefits
under the Policy.
Claims Ratio: Claim Ratio is defined as (Total Claims Paid ADD Outstanding Claims) DIVIDED BY
Total Premiums Booked for the period of cover:
Outstanding Claims shall include claims reported for the period but not yet settled and a provision
of claims incurred but not yet reported to the Insurer.
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Dependants: Dependants refer to Adult Dependants and/or Child Dependants defined herein.
Diagnosis: The process of determining and identifying the nature of a disease or disorder and
distinguishing it from other possible conditions.
Dialysis: It is a method of extra-corporal removal of waste products such as creatinine and urea, as
well as free water from the blood when the kidneys are in failure
Disease: It is an abnormal condition of the body and/or mind that causes discomfort, dysfunction,
or distress to the person afflicted. Sometimes, the term is used broadly to include injuries,
disabilities, syndromes, symptoms and deviant behaviours.
Doctor: A person, licensed or authorised by law to practise and duly registered with the Medical
Council of Mauritius or overseas equivalents, and who diagnoses physical and mental illnesses,
disorders, injuries, and prescribes medications and treatments to promote or restore good health.
Documentation fee: Fee charged by the Company for issuing the policy
Donor: A natural person that donates blood, biological tissues, sperm, ova and/or an organ of the
human body, for the purpose of saving or promoting health or life.
Drug abuse: Solvent abuse, alcohol abuse or any kind of chemical abuse leading to illness or injury.
Emergency: The sudden and, at the material time, unexpected onset of a health condition that
requires immediate medical or surgical treatment, where failure to provide treatment would result
in serious impairment to bodily functions or bodily organs, or would place the person’s life in
serious jeopardy.
Event: An occurrence of a health condition/ treatment/ surgery. If a benefit is payable per event
per year, any condition, treatment or surgery which is related to a condition, treatment or surgery
which has already occurred during a policy year, will be payable from the remaining limit of the
benefit.
Excess: Excess is an amount to be borne by the Insured Person and is not payable under the Policy.
Exclusions: Health care services or benefits that are not covered under this Policy.
Family: Refers to family members related by blood or marriage. This includes father, mother,
spouse, child, brother and sister.
Hospitalisation: It shall mean the necessary admission to a Hospital as an inpatient on the order
of and under the supervision of a Doctor. Necessary admission is admission which in the opinion of
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Inpatient treatment: Treatment that requires a justified admission into a private hospital/ clinic
for one or more days of overnight stay, as per available limits in line with the provisions of your
policy.
Insurance Agent: Insurance Agent means a person who with the authority of an Insurer and not
being an employee of the Insurer, acts on behalf of the Insurer in the initiation of the insurance
business, the receipt of proposals, the issue of policies, the collection of premiums or the settlement
of claims.
Insurance Broker: Insurance Broker means a person who arranges insurance business with
insurers on behalf of prospective Policyholders or as representatives of a Policyholder, and
includes a reinsurance broker carrying on reinsurance brokering for an insurer.
Insurance Salesperson: Insurance salesperson means a natural person who solicits proposals for
and negotiates insurance on behalf and with the authority of an insurer or an Insurance Agent, not
being its employee or officer.
Insured Member: Insured Person and Dependant(s) if any either for an Individual Policyholder or
Corporate Policyholder.
Insured Person: Any person included in the Schedule of Insured Members annexed to this Policy
and/or who is an employee of the Policyholder in case the Policyholder is a corporate.
Insurer: The word “Insurer” refers exclusively to NIC General Insurance Co. Ltd under the terms
and conditions of this contract and all subsequent documents related to this contract.
Medical expenses: The cost of diagnosis, treatment for any illness, injury or disease. They include
pharmaceuticals, medical and surgical supplies, medical devices and equipment and other products
needed to support doctors, nurses and other service providers.
Naturopathy: Naturopathy is a system of treatment of any disease that avoids drugs and surgery
and emphasises use of natural agents like air, water and herbs as treatment.
Nurse: A person who cares for the sick and/or for someone who is physically or mentally disabled.
The person should be a licensed healthcare professional who practises independantly or is
supervised by a physician, surgeon, or dentist and who is skilled in promoting and maintaining
good health.
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Outpatient treatment: Treatment that does not require a patient (Insured Member) to stay
overnight at a Hospital.
Policy Benefits: Policy Benefits mean one or more sums of money, services or other benefits.
Policyholder: The corporate or person so designated in the Schedule(s) as owner of this Policy,
who has contracted the health cover and who is responsible for payment of the Premium to the
Company.
Pregnancy: It is a process and series of changes that take place in a woman’s organs and tissues as
a result of a developing foetus. The entire process from fertilisation to birth takes about nine (9)
months.
Premium: It is the consideration given or to be given in return for an undertaking to provide Policy
Benefits under specified circumstances.
Private Hospital/ Clinic: It shall mean a facility which meets all of the following standards:
Rest home
Long term nursing care facility
Home for the aged
Any facility which primarily affords remedial, rehabilitative, or convalescent care
Any facility primarily for the confinement or treatment of drug abuse or addiction or
alcoholism.
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Public Hospital: A public hospital is a hospital owned by the Government and where care/
treatments are available free of charge.
Root filling: Root filling involves removing damaged or dead nerves and filling the space. This
allows the dentist to repair the teeth that are left.
Risk: It means a possibility that a particular event may occur during the period for which an
insurance policy is in force.
Scale of Cost: It is the maximum cost the company will settle for listed procedures, surgeries, room
rents and doctor’s fees. The scale of cost shall be reviewed annually in line with the industry
practice and the last one issued shall always precede the others. The insured shall be notified of the
effective date of the new release.
Standard room: It means an individual air-conditioned room with attached bathroom. This room
may have a television, telephone and couch. This does not include deluxe room / suite or room with
additional facilities other than those stated herein
Surgeon: A Doctor who specialises in the treatment of injuries, diseases, and deformities through
surgical Procedures.
Tooth extraction: It is the removal of a tooth from its socket in the bone.
Waiting period: The time period before one is eligible to receive benefits under the Policy and is
also known as elimination period.
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